What is the next step in making the diagnosis?

Before proceeding on to the full battery of tests any precipitating factor for hypothalamic amenorrhea or any other cause of amenorrhea has to be elicited in the history. To elicit the history if lately there has been any stress, change in weight, diet or exercise habits, or illness that might result in hypothalamic amenorrhea (HA). Is the woman taking any drugs that might cause or be associated with amenorrhea? The drug might have been taken for a systemic illness that can itself cause hypothalamic amenorrhea. If the patient is on any contraceptives or has recently discontinued them which can be associated with several months of amenorrhea. Ingestion of androgenic drugs or high-dose progestin can cause amenorrhea. Intake of drugs which increase serum prolactin concentrations should also be carefully looked for in the records. If the women complain of acne, hirsutism, or deepening of the voice it can be a pointer towards testosterone excess state ranging from polycystic ovary syndrome to increased androgen production because of the tumor. If the patient has symptoms suggestive of hypothalamic—or pituitary disease, including headaches, visual field defects, fatigue, or polyuria and polydipsia. If the patient has symptoms of estrogen deficiency, including hot flashes, vaginal dryness, poor sleep, or decreased libido and may point towards ovarian insufficiency.

An exception is women with hypothalamic amenorrhea who do not usually have these symptoms despite the presence of similarly low serum estrogen concentrations. Any history of postpartum hemorrhage and failure of lactation may point towards a possibility of Sheehan’s syndrome.

History and examination of a patient with secondary amenorrhea (important points)

• Exercise, weight loss, chronic illness—pointers towards hypothalamic amenorrhea

• History of any drug use like oral contraceptive pills or injectable hormonal therapy

• History of any previous chemotherapy or radiation exposure

• Previous pelvic radiation

• Vasomotor symptoms-premature ovarian failure

• BMI—can help in diagnosing PCOS (though they can be lean also)

• Acne, hirsutism-suggest hyperandrogenemia and all relevant causes to be ruled out

• Virilization—can point towards androgen or ovarian tumors or congenital adrenal hyperplasia or ovarian hyperthecosis

• If BMI very low <18 kg/m2—can point towards eating disorders like anorexia nervosa

• Acanthosis nigricans, skin tags—markers of insulin resistance

• Breast examination for galactorrhea

• Vulvovaginal examination—to look for signs of estrogen deficiency

• Parotid gland swelling or dental enamel erosion—bulimia

• Primary hypothyroidism or hyperthyroidism—signs and symptoms

• Any markers of Cushing’s syndrome

• Symptoms suggestive of any pituitary tumor or pathology.