Outpatient / Endocrinology and Reproductive Medicine

Secondary Amenorrhea

Last Updated: 5/7/2023

# Secondary Amenorrhea


-- LMP: ***

-- Previous Menses: *** cycle length, flow 

-- Sexual Hx: *** currently having sex, partners, birth control use

-- Symptoms: *** weight change, hot flashes, galatorrhea, hirsutism, acne

-- Stressors: *** 

-- Red Flags: ***

DDx: pregnancy, hypothalamic (malnutrition, stress, illness), pituitary (hyperprolactinemia from adenoma, breastfeeding, apoplexy), ovarian (primary insufficiency, PCOS), uterine (Asherman syndrome), thyroid, DM, Cushing’s



-- b-HCG

-- FSH, TSH, E2, prolactin, testosterone

-- If prolactin elevated on two checks or low/normal TSH and low E2, get pituitary MRI

-- If c/w menopause - no need to check labs


-- PCOS - weight loss, exercise, combined OCP, spironolactone, metformin if needed

-- Menopause - SSRI/SNRI (paroxetine) for hot flashes, hormonal therapy if <60 and lower risk for CVD, VTE, breast/endometrial cancer

Template PDF coming soon!

Patient Guidance and Information

Workup for Secondary Amenorrhea

Based on the timing of your periods, you have secondary amenorrhea. To determine the cause of this change, we will perform a series of blood tests to check your hormone levels, including thyroid hormones, prolactin, and follicle-stimulating hormone (FSH), as imbalances in these can lead to amenorrhea. Depending on the results, we may also conduct imaging studies, such as an ultrasound to examine your reproductive organs for any structural abnormalities.

Once we have gathered some more information, we can regroup and determine the most appropriate next steps. If you have any questions, please don't hesitate to reach out.

If You Remember Nothing Else

Make sure the patient isn't pregnant. Send FSH, TSH, E2, prolactin, testosterone and follow a step-wise approach to eliminate etiologies based on the results of the labwork.

Clinical Pearls

  • Secondary Amenorrhea is cessation of regular menses for 3 months OR cessation of irregular menses for 6 months
  • Menopause is 12 months of amenorrhea without alternative etiology - average age of onset is 51 years
  • Prolactin elevated on two checks - hyperprolactinemia
  • FSH elevated and low E2 - primary ovarian insufficiency (often hot flahses and vaginal dryness)
  • Low/normal FSH, Low E2 - hypogonadic hypogonadism - consider MRI to rule out sellar mass
  • Hyperandrogenism - PCOS
  • All labs normal - progestin withdrawal test (goal to simulate a period in response to withdrawal of progestin (commonly Provera) after receiving for 5-10 days; Posiitve if bleeding occurs - implies patient has estrogen and functioning endometrial lining - amenorrhea might be due to anovulation; if no withdrawal bleeding, either not enough estrogen or non-functional endometrium (like in Asherman Syndrome)
  • PCOS - 2 of 3: oligo/anovulation, hyperandrogenism, polycystic ovaries on pelvic US

Trials and Literature

Other Resources