From the Guidelines
Secondary amenorrhea is most commonly caused by polycystic ovary syndrome (PCOS), functional hypothalamic amenorrhea (FHA), and other hormonal imbalances, with FHA being responsible for approximately 20-35% of cases, as noted in a recent study 1. The causes of secondary amenorrhea can be diverse, including:
- Hormonal imbalances, such as PCOS, characterized by elevated androgens and insulin resistance
- Functional hypothalamic amenorrhea (FHA), which occurs when the brain's signaling to the ovaries is disrupted, often due to excessive exercise, significant weight loss, eating disorders, or severe stress, as discussed in a narrative review 1
- Thyroid dysfunction, including both hypo- and hyperthyroidism, which can interrupt normal menstrual cycles
- Premature ovarian insufficiency, occurring before age 40, resulting from depleted ovarian follicles
- Structural problems, such as Asherman's syndrome (uterine scarring) or cervical stenosis, which can prevent menstrual flow
- Certain medications, including hormonal contraceptives, antipsychotics, chemotherapy drugs, and some antidepressants, which may cause amenorrhea
- Hyperprolactinemia from pituitary tumors or medications, which can suppress ovulation
- Chronic conditions, such as uncontrolled diabetes, celiac disease, or inflammatory disorders, which may also contribute to menstrual cessation A recent study published in 2025 found that FHA is responsible for approximately one-third of the cases of secondary amenorrhea in women of reproductive age 1. Proper diagnosis of secondary amenorrhea typically requires a thorough medical history, physical examination, pregnancy test, and hormone level assessments to determine the underlying cause and guide appropriate treatment, as emphasized in recent research 1.
From the Research
Causes of Secondary Amenorrhea
The causes of secondary amenorrhea can be categorized into several groups, including:
- Outflow tract abnormalities
- Primary ovarian insufficiency
- Hypothalamic or pituitary disorders
- Other endocrine gland disorders
- Sequelae of chronic disease
- Physiologic causes
- Induced causes 2
Evaluation of Secondary Amenorrhea
When evaluating secondary amenorrhea, clinicians should consider the patient's medical history, including:
- Menstrual onset and patterns
- Eating and exercise habits
- Presence of psychosocial stressors
- Body weight changes
- Medication use
- Galactorrhea
- Chronic illness 2 Additional questions may target neurologic, vasomotor, hyperandrogenic, or thyroid-related symptoms.
Diagnostic Testing
Diagnostic testing for secondary amenorrhea may include:
- Pregnancy test
- Assessment of serum follicle-stimulating hormone, luteinizing hormone, prolactin, and thyroid-stimulating hormone levels
- Karyotyping
- Serum androgen evaluation
- Pelvic or brain imaging 2 These tests should be individualized based on the patient's symptoms and medical history.
Treatment
Treatment for secondary amenorrhea should address the underlying cause 2. Patients with primary ovarian insufficiency may require hormone replacement therapy, contraception, or infertility services. Functional hypothalamic amenorrhea may indicate disordered eating and low bone density, and treatment should address these underlying issues. Patients with polycystic ovary syndrome should undergo screening and intervention to attenuate metabolic disease and endometrial cancer risk.