Case Study #2

Amenorrhea: A Case Study

by: Rie Torimaru

​Learning outcomes

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​1) List differential diagnoses of secondary amenorrhea

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​2) Elicit a history with amenorrhea as a presenting complaint

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​3) Outline relevant investigations for secondary amenorrhea

The case...

A 24 year old woman presents with absent periods for the past 9 months.

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Fill in the Blanks

Differential diagnoses of secondary amenorrhea

​Differentials

​Hypothalamic

​- chronic illness

​- anorexia

​- excessive exercise

​- stress

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​Pituitary

​- hyperprolactinaemia (e.g. drugs, tumour)

​- hypothyroidism

​- breastfeeding

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​Ovarian

​- Polycystic ovarian syndrome

​- Premature ovarian failure 

​- Iatrogenic (chemotherapy, radiotherapy, oophorectomy)

​- long-acting progesterone contraception

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​Uterine

​- pregnancy 

​- Asherman's syndrome

​- cervical stenosis 

What questions would you ask?​

​She started her periods at age 13, and had a regular 28-day cycle until 18 months ago. The periods then became irregular occurring every 2-3 months until they stopped completely. She has also had headaches for the last few months and is not sure if this is related. 

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​She has a regular sexual partner and uses condoms for contraception. She has never been pregnant. There is no previous medical history of note.

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​She works as a primary school teacher and drinks approximately 4 units of alcohol per week. She does not smoke or use recreational drugs. She jogs and swims in her spare time. 

​Examination

​The woman is of average build. The blood pressure and general observations are normal. The abdomen is soft and non-tender and speculum and bimanual examination are unremarkable.

Fill in the Blanks

What investigations would you order?

​Investigations

​Investigations cont.

Fill in the Blanks

What is the diagnosis?

​The investigations show a high-prolactin and a space-occupying lesion in the pituitary fossa in the region of the anterior pituitary. 

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​This is consistent with a pituitary adenoma (prolactinoma).

​MRI

​Arrow shows a small asymmetrical enlargement of pituitary gland, representative of a small pituitary adenoma (prolactinoma).

How would you manage this patient?​

​Management

​ - Refer to an endocrinologist

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​ - Most prolactinomas respond to medical treatment with bromocriptine or cabergoline.

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​- Maintaining the prolactin level below 1000 mu/L causes menstruation and ovulation to return to most women

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​- Surgical removal is indicated if visual field defects are present

​Bonus Questions!

Multiple Choice

Which is NOT a cause of secondary amenorrhea?

• Asherman's syndrome 

• Turner's syndrome

• Sheehan's syndrome

• Polycystic ovarian syndrome 

Multiple Select

Which of the following drugs cause hyperprolactinemia? (pick all that apply)

• metoclopramide

• haloperidol

• methyldopa

• spironolactone

​~The End~

​Complications

​Pituitary apoplexy

​- Acute hemorrhage and/or infarction in a pre-existing pituitary adenoma

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Signs and symptoms

​- Sudden headache

​- Rapidly worsening visual field defect or double vision

​- Acute symptoms due to sudden hormone deficiency, usually adrenal insufficiency

​cont.

​Risk factors include:

​- Pregnancy (pituitary enlarges)

​- Hypertension

​- Previous major surgeries e.g. coronary artery bypass graft

​- Coagulopathies

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​Treatment - hormone supplementation +/- surgical decompression