What is the workup for a 36-year-old female with secondary amenorrhea (absence of menstruation) for the past 3 years following 10 years of Depo-Provera (medroxyprogesterone acetate) use?

Workup for Secondary Amenorrhea Following Depo Provera Use

For a 36-year-old female with secondary amenorrhea for 3 years after 10 years of Depo Provera use, the workup should first rule out pregnancy and then evaluate for underlying gynecological conditions, as amenorrhea following DMPA discontinuation typically resolves within 9-18 months. 1

Initial Assessment

• Pregnancy test to rule out pregnancy if clinically indicated, especially if the regular bleeding pattern changed abruptly to amenorrhea 2
• Detailed menstrual history including:
  • Pattern of amenorrhea (immediate vs. gradual onset after discontinuation)
  • Any spotting or irregular bleeding episodes during the 3-year period 2
• Medical history focusing on:
  • Weight changes since discontinuation of Depo Provera 1
  • Other medications that might interact with hormonal function 2
  • Symptoms of thyroid disorders, hyperprolactinemia, or polycystic ovary syndrome 2

Laboratory Evaluation

• TSH and free T4 to rule out thyroid dysfunction 2
• Prolactin level to rule out hyperprolactinemia 2
• FSH and estradiol to assess ovarian function 2
• Consider testing for:
  • Androgens (total/free testosterone, DHEAS) if clinical signs of hyperandrogenism are present 2
  • Fasting glucose and insulin to evaluate for insulin resistance if PCOS is suspected 2

Imaging Studies

• Pelvic ultrasound to evaluate:
  • Endometrial thickness
  • Ovarian morphology (to assess for PCOS or ovarian failure)
  • Uterine pathology (fibroids, polyps) that might have developed 2, 3

Special Considerations for Post-Depo Provera Amenorrhea

• Prolonged amenorrhea following Depo Provera is well-documented, with return to fertility typically taking 9-18 months after discontinuation 1
• If amenorrhea persists beyond 18 months, further evaluation is warranted as this exceeds the expected timeframe for recovery 1
• Bone mineral density assessment may be considered if the patient used Depo Provera for more than 2 years, as prolonged use is associated with decreased bone mineral density 1, 4

Management Options

• If no underlying pathology is found:

  • Reassurance that amenorrhea following Depo Provera is common and generally not harmful 2
  • Consider a progestin challenge test (medroxyprogesterone acetate 10 mg daily for 10 days) to assess estrogen status and endometrial responsiveness 2
  • If the patient desires return of menses, consider short-term hormonal treatment with low-dose combined oral contraceptives 2

• If underlying pathology is identified:

  • Treat the specific condition or refer for specialized care 2
  • NSAIDs may be considered for management of irregular bleeding if it occurs during recovery 2

Common Pitfalls to Avoid

• Assuming amenorrhea is solely due to prior Depo Provera use without ruling out other causes, especially after 3 years 2
• Failing to consider bone health implications of long-term Depo Provera use (>2 years) 1, 4
• Not addressing patient concerns about fertility if pregnancy is desired 1
• Overlooking the psychological impact of prolonged amenorrhea on the patient 5

If amenorrhea persists despite normal workup and the patient finds it unacceptable, counseling on alternative methods to restore regular cycles should be offered 2.