Menstruation and Secondary Amenorrhea

Secondary amenorrhea occurs in 3–5% of women and is defined as the absence of menses for three cycles or 3–6 months in previously menstruating women. After excluding pregnancy, the most common causes include hypothalamic suppression, polycystic ovary syndrome, primary ovarian insufficiency, hyperprolactinemia, and thyroid dysfunction. All women presenting to primary care with secondary amenorrhea should be evaluated with a history and physical exam targeted to potential physiologic, anatomical, gynecologic, and endocrine causes of their symptoms. A first-line workup should include pregnancy testing along with serum FSH, TSH, and prolactin. Additional testing, including a progestin withdrawal challenge, androgens, and imaging, should be based upon suspected etiology. Treatment centers on addressing the underlying condition with involvement of specialists for medical, procedural, or surgical management as appropriate.