Evaluation and Management of Secondary Amenorrhea

Initial Assessment and Laboratory Testing

• The British Journal of Sports Medicine recommends assessing weight changes and nutritional status in patients with secondary amenorrhea 1
• The British Journal of Sports Medicine suggests evaluating exercise habits, especially excessive exercise, in patients with secondary amenorrhea 2, 1
• The Human Reproduction Update recommends considering psychological stressors in the evaluation of secondary amenorrhea 3, 4
• The British Journal of Sports Medicine advises assessing body mass index (BMI) and weight trends in patients with secondary amenorrhea 2
• The British Journal of Sports Medicine recommends performing a breast examination for galactorrhea, which may indicate hyperprolactinemia, in patients with secondary amenorrhea 1
• The British Journal of Sports Medicine suggests a pelvic examination to rule out outflow tract obstruction in patients with secondary amenorrhea 2
• Measuring prolactin level is recommended as a first-line laboratory test for secondary amenorrhea, according to the British Journal of Sports Medicine 1
• The British Journal of Sports Medicine recommends measuring FSH and LH levels as first-line laboratory tests for secondary amenorrhea 2
• The British Journal of Sports Medicine advises measuring TSH level as a first-line laboratory test for secondary amenorrhea 1

Imaging Studies and Special Tests

• Transvaginal ultrasound is recommended to evaluate endometrial thickness and ovarian morphology in patients with secondary amenorrhea, according to the Journal of the American College of Radiology 6, 7
• The Human Reproduction Update suggests that transvaginal ultrasound helps identify polycystic ovarian morphology in patients with secondary amenorrhea 3, 4
• The Human Reproduction Update recommends using transvaginal ultrasound to assess endometrial thickness as an indicator of estrogen status in patients with secondary amenorrhea 5
• The Journal of the American College of Radiology advises considering MRI when ultrasound is inconclusive or to evaluate pituitary abnormalities in patients with secondary amenorrhea 6, 7
• The British Journal of Sports Medicine recommends a DXA scan for bone mineral density assessment in patients with amenorrhea lasting >6 months 1
• The British Journal of Sports Medicine suggests a DXA scan for patients with a history of eating disorders or BMI <18.5 kg/m² 2
• The British Journal of Sports Medicine advises a DXA scan for patients with late menarche (≥16 years) 2
• The Human Reproduction Update recommends a progesterone challenge test to determine estrogen status in patients with secondary amenorrhea 5

Diagnostic Algorithm and Management

• The Human Reproduction Update suggests a diagnostic algorithm for secondary amenorrhea, starting with a pregnancy test, followed by measuring FSH, LH, prolactin, and TSH levels 5, 2
• The Human Reproduction Update recommends considering primary ovarian insufficiency if FSH/LH levels are high, and performing karyotype analysis and measuring AMH level 3
• The Human Reproduction Update advises considering functional hypothalamic amenorrhea if FSH/LH levels are normal/low, and performing estradiol level and bone density testing 5
• The Human Reproduction Update suggests considering polycystic ovary syndrome (PCOS) if LH:FSH ratio is elevated, and performing androgen profile and metabolic screening 5
• The Human Reproduction Update recommends considering hyperprolactinemia if prolactin level is elevated, and performing pituitary imaging 4
• The British Journal of Sports Medicine advises considering thyroid dysfunction if TSH level is abnormal, and performing additional thyroid testing 2