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Secondary amenorrhoea – a consultation
  1. Annette Thwaites1,2,
  2. Rachel Westwick3,
  3. Katharine Logan4
  1. 1 Institute for Women's Health, University College London, London, UK
  2. 2 Sexual and Reproductive Health, King's College Hospital NHS Foundation Trust, London, UK
  3. 3 Sexual and Reproductive Health, Great Western Hospitals NHS Foundation Trust, Swindon, UK
  4. 4 Psychiatry, NHS Lothian, Edinburgh, UK
  1. Correspondence to Dr Annette Thwaites, Institute for Women's Health, University College London, London WC1E 6BT, UK; annettethwaites{at}doctors.org.uk

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Key messages

  • Secondary amenorrhoea has a wide range of differential diagnoses, and determination of the underlying cause requires prompt assessment with thorough history, focused examination and often specialist referral.

  • Sexually active women require effective contraception despite amenorrhoea as it is not possible to predict when ovulation and unintended pregnancy may occur.

  • Clinicians providing sexual and reproductive healthcare should retain a high index of suspicion for the presence of eating disorders in patients in the context of menstrual disturbance regardless of weight.

Evelyn, a 20-year-old student, attends her university general practitioner (GP) practice for the first time with a history of her periods becoming further apart and then stopping. Her periods had been regular previously, when living at home, but they have become more irregular in the last 12 months. Her body mass index (BMI) is 19 kg/m2 (weight 45 kg, height 1.53 m).

Background

Although definitions vary, secondary amenorrhoea should be suspected if a woman has not had a period for 3–6 months with previous regular periods or 6–12 months in a woman with preceding oligomenorrhoea. Secondary amenorrhoea has a prevalence of 3%–4% in women of reproductive age1 and can present a diagnostic challenge, with a wide range of underlying causes, often with minimal or subtle signs (figure 1). In the context of a normal puberty, the most common causes in this age group are pregnancy, hypothalamic dysfunction, polycystic ovary syndrome (PCOS), hyperprolactinaemia and drugs (including hormonal contraception and recreational drugs).

Figure 1

Causes of secondary amenorrhoea.

History

A detailed menstrual history, from menarche to the last menstrual period, is required to verify secondary amenorrhoea and elicit relevant timescales and any associated factors. A sexual and contraceptive history should then be used to assess pregnancy risk and exclude causes related to hormonal contraception. In this case, Evelyn reports “about ten” casual partners during her current university …

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Footnotes

  • Contributors AT wrote the paper and had final responsibility for the decision to submit for publication. RW and KL provided input and helped revise the manuscript.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

  • Patient consent for publication Not required. The details of this case are fictitious. Any resemblance to actual persons, living or dead, or actual events is coincidental.

  • Provenance and peer review Commissioned; externally peer reviewed.

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