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Secondary amenorrhea is defined as absence of menstruation for 3 normal cycles or for 6 months or more in a woman with previous normal menstrual pattern in absence of pregnancy...


Important causes of Secondary Amenorrhea (Compartment wise)

Compartment I Disorder of outflow tract / uterus)

• Acquired obstruction (gynatresia) of cervical canal causing severe stenosis or atresia following electrocauterization, chemical burns, cervical amputation in Fothergill's repair, conization, CIN, or genital tuberculosis.

• Asherman's syndrome

 Following excessive curettage or endometrial tuberculosis

• V V F (cause unknown)

Compartment II (Disorders of Ovary)

• Ovary Tumor - Masculinizing tumors/PCOOO

• Trauma - Surgical extipiration/Radiotherapy

• Infections - Mumps, Tuberculosis rarely pyogenic infections

• Premature ovarian failure

Compartment III (Pituitary)

• Hyperprolactinemia prolactin tumor/prolactinoma

• Insufficiency as in Simmond's disease, Sheehan's syndrome

• Empty sella syndrome

• Infiltrative disease

Compartment IV (Hypothalamus)

• GnRH deficiency

• Vigorous exercise/excessive stress

• Weight loss

• Eating disorders - anorexia and Bulimia

• Tumor (including craniopharyngioma, germinoma, endodermal sinus tumor, eosinophilic granuloma, and glioma)

• Radiation

• Pseudocyesis

• Infection (TB)

• Infiltrative disease (sarcoidosis)

Besides these some other causes of secondary amenorrhea are

  • Pregnancy-M / C cause of secondary amenorrhea
  • Hypothyroidism (V. Imp. cause, should be ruled out in every case)
  • Hyperprolactinemia
  • Diabetes
  • Tuberculosis
  • Renal disease/liver disease
  • Addison disease/Cushing's syndrome/acromegaly
  • Drugs (phenothiazines, reserpine, antidepressants, OCPs).
  • Malabsorption syndrome
  • AIDS

Sheehan's Syndrome

  • It is the syndrome which results from ischemic necrosis of most of the anterior pituitary due to spasm in its arterioles occurring at the time of severe hemorrhage or shock complicating childbirth.
  • Only the anterior pituitary is affected because in parturient woman, blood supply to the pituitary gland is modified to the advantage of the posterior lobe and disadvantage of the anterior lobe so, when spasm occurs, posterior lobe is protected.
  • When 75% of anterior pituitary is destroyed, manifestations of Sheehan's syndrome appear and when 95 % is destroyed - fully developed Simmond's syndrome is seen.
  • Hormones of anterior pituitary are affected in order of frequency = CH, FSH, and LH, TSH and ACTH.

Clinical Features



  • Failure of lactation after delivery (due to Prolactin)
  • Secondary amenorrhea ( LH/ FSH)
  • Loss of libido
  • Increased sensitivity to cold (hypothyroidism) ( TSH)


  • Loss of axillary and pubic hair (Signs of adrenal cortical failure)
  • Decrease in skin pigmentation
  • Anemia due to lack of pituitary erythropoeitic factor
  • Weakness, lethargy
  • Hypothyroidism and hypothermia
  • Hypoglycemia (due to decreased insulin tolerance)
  • All genital organs show atrophy, uterus is smaller than in postmenopausal women as there is decrease in FSH, LH and estrogen although dormant ovaries retain their ova till menopause

Lab Investigation


Most common is prolactin deficiency along with decreased levels of FSHQ, LHQ, TSHQ, ACTHQ, oestrogens, and urinary 17-keto steroids.



The treatment of Sheehan's syndrome includes: Life-long hormone substitute of estrogen, progesterone, thyroid, and adrenal hormone.

Stein Leventhal Syndrome


Another name for PCOS (dealt in detail earlier).

Premature Menopause


Is defined as secondary amenorrhea before 40 years of age, due to ovarian failure.


It is clinically defined as secondary amenorrhea for at least 3 months with raised FSH, raised FSH/LH ratio and low E2 levels in a women under 40 years of age.


Work up for a case of Secondary Amenorrhea

Purpose: To assess the level of endogenous estrogen and competence of outflow tract.

Method: Progesterone totally devoid of estrogenic activity (like MDPA, micronized progesterone) is given for 5 days and then withdrawn.


Extra Edge:


Secondary amenorrhea is defined as absence of menses for 6 consecutive months (or length of time equivalent to total of three previous cycles) in a female who had previously 'regular menses.

  • Pregnancy is the MC cause of secondary amenorrhea.
    Steps to be followed in evaluation of secondary amenorrhea:
  • Rule out pregnancy (urine pregnancy test/Sr. ï-hCG)
  • TSH and Prolactin estimation (easily correctable hormonal conditions causing amenorrhea)
  • Progesterone challenge test (PCT)
  • Falsely negative estrogen + progesterone (E + P) challenge test is seen in outflow tract obstruction like imperforate hymen, transverse vaginal septum, cervical atresia, etc.



  • Infertility is defined as an inability to conceive in spite of 1 year of regular unprotected intercourse
  • Primary = never conceived
  • Secondary = conceived in the past (irrespective of outcome of that pregnancy)
  • Fecundity = probability of achieving a live birth within a single cycle
  • Fecundability = probability of achieving pregnancy within a single menstrual cycle

Causes of Infertility

  • Male factor
  • Female factor
  • Unexplained infertility
  • Combined factors

Causes of Male and Female factor

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