Vol. 81, No. 2 Printed in U.S.A.
Hospital Center, and
Departments of Obstetrics and Gynecology and Medicine, St. Luke&Roosevelt Columbia College of Physicians and Surgeons, New York, NewYork 10019
HE EVALUATION of secondary amenorrhea is conceptually organized around disruption of the menstrual cycle at three critical levels. These levels, the hypothalamus, the pituitary, and the ovary, are the main target organs for the complex feedback interactions that maintain the normal menstrual cycle. The feedback interactions have been the object of intense study in the last 2 decades,and the evaluation of secondary amenorrhea has benefited from the precise measurement of hormonal levels in the blood as well as the understanding of their interactive signals. The ovary produces the most important ovarian steroid, estradiol, which is critical for the normal functioning of the uterus. As estradiol is ineffective if the uterus is unresponsive or absent, the uterus as an end organmust also be considered in the evaluation of secondary amenorrhea. Secondary amenorrhea is present when the patient has menstruated in the past, but has stopped for at least 6 months (1). Although most studies define secondary amenorrhea for epidemiological purposes as 3 months without menses, intermittent cycles occurring every 3 months usually signifies a different clinical problem than an abruptchange in pattern. One textbook defines secondary amenorrhea as the absence of periods for a length of time equivalent to a total of at least 3 of the previous cycle intervals, or 6 months of amenorrhea (21. The prevalence of secondary amenorrhea depends on the age group studied. A group of women aged 13-18 with 3 months of secondary amenorrhea was found to have a prevalence of 8.5% in one study,whereas another study reported a prevalence of 7.6% in a 15- to 24-yr-old group and 3.0% and 3.7% in women aged 25-34 and 35-44, respectively (3). Clinically and conceptually, it is helpful to separate patients with secondary amenorrhea into those with and without hirsutism or signs of androgen excess. Initially, the separation into one of these two groups can be made clinically by the presence ofthe classic clinical signs either from the patient’s history or by observation. Further confirmation should be made by several standard tests.
Received February 27, 1995. Revision received September 15, 1995. Rerevision received October 30, 1995. Accepted November 6,1995. Address all correspondence and requests for reprints to: Michelle P. Warren, M.D., St. Luke’s-Roosevelt Hospital, 1000 TenthAvenue, New York, New York 10019.
Classically, the patient with androgen excesswill present with, in addition to secondary amenorrhea, hirsutism; particularly on the face, chest, abdomen, and thighs; acne; and generally obesity. There may be alopecia as an additional complaint or hair loss on the head in a male pattern distribution. Acanthosis nigricans should belooked for. These areas of hyperpigmentation occur most commonly on the neck and in the axillae and are associated with insulin resistance.The acne may be so severeas to be cystic in character and may be the major complaint. Alternatively, these symptoms can be so mild that they are only elicited by the history, and the patient is aware only of the menstrual disturbance or the anovulation that isclassically present and may lead the patient to seek help for infertility. The physical examination is important, as some of these symptoms may be present when they are not noted by the patient; in particular, clitoromegaly must be looked for, asit is a classicalsign of overt hyperandrogenism. Rarely, folliculitis or hidradenitis may lead to repeated infections in the axillae or groin. The ovaries of...