Assessment of secondary amenorrhoea

FSH assays have wide ranges, depending not only on cycle time but also on patient age. Results are unreliable if patient is taking any form of hormonal therapy.

Results are unreliable if patient is taking any form of hormonal therapy.

May obviate need for progestogen challenge.

High LH levels suggest alternate diagnoses. Results are unreliable if patient is taking any form of hormonal therapy.

A prolonged hypo-oestrogenic state can result in osteopenia or osteoporosis. The female athlete triad consists of amenorrhoea, osteoporosis, and eating disorder.

Depends on the primary aetiology and presence or absence of low levels of circulating oestrogen.

FSH assays have wide ranges, depending not only on cycle time but also on patient age. Results are unreliable if patient is taking any form of hormonal therapy.

Results are unreliable if patient is taking any form of hormonal therapy.

May obviate need for progestogen challenge.

High LH levels suggest alternate diagnoses. Results are unreliable if patient is taking any form of hormonal therapy.

A prolonged hypo-oestrogenic state can result in bone loss.

Depends on the primary aetiology and presence or absence of low levels of circulating oestrogen.

FSH assays have wide ranges, depending not only on cycle time but also on patient age. Results are unreliable if patient is taking any form of hormonal therapy.

Results are unreliable if patient is taking any form of hormonal therapy.

May obviate need for progestogen challenge.

High LH levels suggest alternate diagnoses. Results are unreliable if patient is taking any form of hormonal therapy.

A prolonged hypo-oestrogenic state can result in bone loss.

Depends on the primary aetiology and presence or absence of low levels of circulating oestrogen.

Persistently elevated levels warrant further evaluation to rule out primary hypothyroidism or prolactinoma. Mildly elevated levels may indicate another structural central nervous system lesion.[1]Practice Committee of the American Society for Reproductive Medicine. Current evaluation of amenorrhea: a committee opinion. Fertil Steril. 2024 Jul;122(1):52-61. https://www.fertstert.org/article/S0015-0282(24)00082-7/fulltext http://www.ncbi.nlm.nih.gov/pubmed/38456861?tool=bestpractice.com ​​

Prolactin has a suppressive influence on the hypothalamus, resulting in hypogonadotrophic hypogonadism. FSH assays have wide ranges, depending not only on cycle time but also on patient age. Results are unreliable if patient is taking any form of hormonal therapy.

Prolactin has a suppressive influence on the hypothalamus, resulting in hypogonadotrophic hypogonadism. Results are unreliable if patient is taking any form of hormonal therapy.

Elevation suggests hyperprolactinaemia is related to primary hypothyroidism.

May obviate need for progestogen challenge.

Prolactin has a suppressive influence on the hypothalamus, resulting in hypogonadotrophic hypogonadism. Results are unreliable if patient is taking any form of hormonal therapy.

Depends on presence or absence of low levels of circulating oestrogen.

FSH assays have wide ranges, depending not only on cycle time but also on patient age. Results are unreliable if patient is taking any form of hormonal therapy.

Results from peripheral androgen conversion and decreased sex hormone-binding globulin (influence of excess androgen). Results are unreliable if patient is taking any form of hormonal therapy.

Well standardised among differing laboratories; however, does not necessarily reflect the degree of clinical hyperandrogenism. Results are unreliable if patient is taking any form of hormonal therapy.

Results are unreliable if patient is taking any form of hormonal therapy.

The diagnosis of 21-hydroxylase deficiency is confirmed by an exaggerated response to high-dose adrenocorticotropic hormone (250 micrograms).

Insulin dysregulation is common and screening for type 2 diabetes is also warranted.[28]Moran LJ, Misso ML, Wild RA, Norman RJ. Impaired glucose tolerance, type 2 diabetes and metabolic syndrome in polycystic ovary syndrome: a systematic review and meta-analysis. Hum Reprod Update. 2010 Jul-Aug;16(4):347-63. http://www.ncbi.nlm.nih.gov/pubmed/20159883?tool=bestpractice.com

Patients with PCOS are at risk for hyperlipidaemia and cardiovascular events.

Hypertrophy of ovarian stroma, resulting in ovarian androgen production. Due to pulsatile secretion of LH. Levels may not confirm or exclude PCOS. Results are unreliable if patient is taking any form of hormonal therapy.

Chronic anovulation results in unopposed oestrogenic influence on the endometrium. Progestogen challenge may be therapeutic as well as diagnostic.

Two elevated levels at least 1 month apart are necessary to diagnose gonadal failure. FSH assays have wide ranges, depending not only on cycle time but also on patient age. Results are unreliable if patient is taking any form of hormonal therapy.

Results are unreliable if patient is taking any form of hormonal therapy.

May obviate need for progestogen challenge.

Results are unreliable if patient is taking any form of hormonal therapy.

Ovarian failure (reduced inhibition of FSH secretion from pituitary).

Must assess for Y chromosome, risk for gonadal neoplasm.

Two elevated levels at least 1 month apart are necessary to diagnose gonadal failure. FSH assays have wide ranges, depending not only on cycle time but also on patient age. Results are unreliable if patient is taking any form of hormonal therapy.

Results are unreliable if patient is taking any form of hormonal therapy.

May obviate need for progestogen challenge.

Results are unreliable if patient is taking any form of hormonal therapy.

Two elevated levels at least 1 month apart are necessary to diagnose gonadal failure. FSH assays have wide ranges, depending not only on cycle time but also on patient age. Results are unreliable if patient is taking any form of hormonal therapy.

Results are unreliable if patient is taking any form of hormonal therapy.

May obviate need for progestogen challenge.

Results are unreliable if patient is taking any form of hormonal therapy.

Ovarian failure (reduced inhibition of FSH secretion from pituitary).

If abnormal, must assess for Y chromosome, risk for gonadal neoplasm.

FSH assays have wide ranges, depending not only on cycle time but also on patient age. Results are unreliable if patient is taking any form of hormonal therapy.

Results from peripheral androgen conversion and decreased sex hormone-binding globulin (influence of excess androgen). Results are unreliable if patient is taking any form of hormonal therapy.

Well standardised among differing laboratories; however, does not necessarily reflect the degree of clinical hyperandrogenism. Results are unreliable if patient is taking any form of hormonal therapy.

A basal morning level >6 nanomol/L (>200 nanograms/dL) drawn in the early follicular phase is strongly suggestive of 21-hydroxylase deficiency. The diagnosis is confirmed by an exaggerated response to high-dose adrenocorticotropic hormone (250 micrograms).

Results are unreliable if patient is taking any form of hormonal therapy.

Results are unreliable if patient is taking any form of hormonal therapy.

Chronic anovulation results in unopposed oestrogenic influence on the endometrium.

TSH is a useful screening tool for thyroid dysfunction. TSH is low in secondary hypothyroidism.

May be low in secondary hypothyroidism associated with pituitary failure. FSH assays have wide ranges, depending not only on cycle time but also on patient age. Results are unreliable if patient is taking any form of hormonal therapy.

Prolactin may be secondarily elevated.

Results are unreliable if patient is taking any form of hormonal therapy.

May be low in secondary hypothyroidism associated with pituitary failure. Results are unreliable if patient is taking any form of hormonal therapy.

Low free thyroxine confirms overt hypothyroidism. The thyroxine level may be normal in subclinical hypothyroidism.

FSH assays have wide ranges, depending not only on cycle time but also on patient age. Results are unreliable if patient is taking any form of hormonal therapy.

Results are unreliable if patient is taking any form of hormonal therapy.

May obviate need for progestogen challenge.

High LH levels suggest alternate diagnoses. Results are unreliable if patient is taking any form of hormonal therapy.

A prolonged hypo-oestrogenic state can result in osteopenia or osteoporosis (part of the female athlete triad).

Depends on the primary aetiology and presence or absence of low levels of circulating oestrogen.

FSH assays have wide ranges, depending not only on cycle time but also on patient age. Results are unreliable if patient is taking any form of hormonal therapy.

Results are unreliable if patient is taking any form of hormonal therapy.

May obviate need for progestogen challenge.

Results are unreliable if patient is taking any form of hormonal therapy.

Depends on presence or absence of low levels of circulating oestrogen.

FSH assays have wide ranges, depending not only on cycle time but also on patient age. Results are unreliable if patient is taking any form of hormonal therapy.

Results are unreliable if patient is taking any form of hormonal therapy.

May be normal when hypogonadism temporally precedes hypothyroidism.

May be normal when hypogonadism temporally precedes hypothyroidism.

May be normal when hypogonadism temporally precedes hypothyroidism and/or hypoadrenalism. Adrenal crisis may be an initial presentation, if triggered by a stressor.

Test is to be completed if secondary diabetes insipidus develops.

May be normal when hypogonadism temporally precedes hypothyroidism and/or hypoadrenalism. Adrenal crisis may be an initial presentation, if triggered by a stressor.

This is the imaging modality of choice.

May obviate need for progestogen challenge.

Results are unreliable if patient is taking any form of hormonal therapy.

May be normal when hypogonadism temporally precedes hypothyroidism and/or hypoadrenalism.

FSH assays have wide ranges, depending not only on cycle time but also on patient age. Results are unreliable if patient is taking any form of hormonal therapy.

Results are unreliable if patient is taking any form of hormonal therapy.

May obviate need for progestogen challenge.

Results are unreliable if patient is taking any form of hormonal therapy.

Depends on presence or absence of low levels of circulating oestrogen.

FSH assays have wide ranges, depending not only on cycle time but also on patient age. Results are unreliable if patient is taking any form of hormonal therapy.

Results from peripheral androgen conversion and decreased sex hormone-binding globulin (influence of excess androgen). Results are unreliable if patient is taking any form of hormonal therapy.

The diagnosis of 21-hydroxylase deficiency is confirmed by an exaggerated response to high-dose adrenocorticotropic hormone (250 micrograms).

Results are unreliable if patient is taking any form of hormonal therapy.

Increased LH:FSH ratio may be seen in patients with polycystic ovary syndrome, but is not diagnostic. Results are unreliable if patient is taking any form of hormonal therapy.

Results are unreliable if patient is taking any form of hormonal therapy.

Marked DHEAS elevations warrant adrenal evaluation.

Chronic anovulation results in unopposed oestrogenic influence on the endometrium.

Two elevated levels at least 1 month apart are necessary to diagnose gonadal failure. FSH assays have wide ranges, depending not only on cycle time but also on patient age. Results are unreliable if patient is taking any form of hormonal therapy.

Results are unreliable if patient is taking any form of hormonal therapy.

Autoimmune thyroiditis is the most common autoimmune disease associated with premature ovarian failure.[24]Committee opinion no. 605: primary ovarian insufficiency in adolescents and young women. Obstet Gynecol. 2014 Jul;124(1):193-7. https://journals.lww.com/greenjournal/Fulltext/2014/07000/Committee_Opinion_No__605__Primary_Ovarian.36.aspx http://www.ncbi.nlm.nih.gov/pubmed/24945456?tool=bestpractice.com Graves' disease is less common.

May obviate need for progestogen challenge.

Results are unreliable if patient is taking any form of hormonal therapy.

Presence suggestive of Addison's disease.[29]Nelson LM. Clinical practice. Primary ovarian insufficiency. N Engl J Med. 2009 Feb 5;360(6):606-14. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2762081 http://www.ncbi.nlm.nih.gov/pubmed/19196677?tool=bestpractice.com

Ovarian failure (reduced inhibition of FSH secretion from pituitary).

If abnormal, must assess for Y chromosome, risk for gonadal neoplasm.

Should perform if need to confirm adrenal insufficiency (request if anti-adrenal antibodies are present).

FSH assays have wide ranges, depending not only on cycle time but also on patient age. Results are unreliable if patient is taking any form of hormonal therapy.

Results from peripheral androgen conversion and decreased sex hormone-binding globulin (influence of excess androgen). Results are unreliable if patient is taking any form of hormonal therapy.

The diagnosis is confirmed by an exaggerated response to high-dose adrenocorticotropic hormone (250 micrograms).

Results are unreliable if patient is taking any form of hormonal therapy.

Increased LH:FSH ratio may be seen in patients with polycystic ovary syndrome, but is not diagnostic. Results are unreliable if patient is taking any form of hormonal therapy.

Results are unreliable if patient is taking any form of hormonal therapy.

Chronic anovulation results in unopposed oestrogenic influence on the endometrium.

FSH assays have wide ranges, depending not only on cycle time but also on patient age. Results are unreliable if patient is taking any form of hormonal therapy.

Results are unreliable if patient is taking any form of hormonal therapy.

Results are unreliable if patient is taking any form of hormonal therapy.

This test is more specific than serum ACTH level and is completed if the source of ACTH elevation cannot be determined, or to confirm whether elevation is in fact real. The low-dose dexamethasone suppression test helps to differentiate patients with Cushing's syndrome of any cause from those without Cushing's syndrome. The high-dose dexamethasone suppression test distinguishes patients with Cushing's syndrome caused by pituitary hypersecretion (Cushing's disease) from those with ectopic ACTH secretion or adrenal tumours.

Used to verify dexamethasone suppression test results and increase sensitivity and specificity.

Macroadenoma should be ruled out in patients presenting with amenorrhoea and acromegaly. Cushing's syndrome can result from an ACTH-producing pituitary tumour, adrenal tumour,[30]Wellons MF, Weeber KM, Rebar RW. Amenorrhea. In: Falcone T, Hurd WW, eds. Clinical reproductive medicine and surgery: a practical guide. 3rd ed. Heidelberg: Springer International Publishing; 2017:109-22. ectopic ACTH production, or adrenal hyperplasia.

FSH assays have wide ranges, depending not only on cycle time but also on patient age. Results are unreliable if patient is taking any form of hormonal therapy.

Results are unreliable if patient is taking any form of hormonal therapy.

Process may occur as a result of a genital infection such as tuberculosis.

May lack typical trilaminar appearance of endometrial echo found during normal proliferative phase.

Results are unreliable if patient is taking any form of hormonal therapy.

FSH assays have wide ranges, depending not only on cycle time but also on patient age. Results are unreliable if patient is taking any form of hormonal therapy.

Results are unreliable if patient is taking any form of hormonal therapy.

May obviate need for progestogen challenge.

High LH levels suggest alternate diagnoses. Results are unreliable if patient is taking any form of hormonal therapy.

A prolonged hypo-oestrogenic state can result in bone loss.

A urine drug screen should be ordered if there is a clinical suspicion of cocaine or opioid use.