From the Guidelines
The workup for secondary amenorrhea in a 43-year-old female should commence with a thorough medical history and physical examination, including assessment of menstrual and reproductive history, to identify potential underlying causes such as pregnancy, polycystic ovary syndrome (PCOS), or functional hypothalamic amenorrhea (FHA) 1.
Initial Evaluation
The initial evaluation should include:
- A menstrual history assessing age of menarche, regularity of menses, use of medications, and the presence of other health issues 1
- A physical examination to assess anthropometry, pubertal stage, signs of eating disorders, and secondary causes of amenorrhea 1
- A pregnancy test to rule out pregnancy 1
Laboratory Tests
Laboratory tests should include:
- Follicle-stimulating hormone (FSH) and thyroid-stimulating hormone (TSH) levels to evaluate ovarian function and thyroid status 1
- Prolactin level to check for hyperprolactinemia, and if elevated, further evaluation with a brain MRI may be warranted to rule out a pituitary adenoma 1
Additional Tests
Additional tests such as pelvic ultrasound and endometrial sampling may be indicated to rule out other gynecological pathologies 1.
Diagnosis and Treatment
A diagnosis of FHA should be considered if no other underlying cause is identified, and treatment may involve addressing underlying stressors, nutritional deficiencies, or hormonal imbalances 1. Medications such as dopamine agonists like cabergoline may be considered if hyperprolactinemia is diagnosed.
From the Research
Diagnostic Workup for Secondary Amenorrhea
The diagnostic workup for secondary amenorrhea in a 43-year-old female involves evaluating the hypothalamic-pituitary-ovarian (HPO) axis, as well as other potential causes of amenorrhea 2. The workup may include:
- Hypothalamic etiologies, such as eating disorders and relative energy deficiency in sport
- Pituitary causes, including hyperprolactinemia, empty sella syndrome, Sheehan's syndrome, and Cushing's syndrome
- Ovarian causes, such as polycystic ovarian syndrome and primary ovarian insufficiency
- Other etiologies, including thyroid disease, adrenal disease, and reproductive tract anomalies
Considerations in Perimenopausal Women
In perimenopausal women, such as a 43-year-old female, the approach to secondary amenorrhea must consider the potential for hormonal fluctuations and the transition to menopause 3. The hormone patterns observed in perimenopausal women can vary widely, and may include:
- Ovulatory cycles with low premenopausal levels of FSH
- Transient episodes with high levels of FSH and LH
- Elevations of LH or FSH into the postmenopausal range
Pregnancy Risks in Older Women
While the provided studies do not directly address the workup for secondary amenorrhea, they do highlight the importance of considering pregnancy risks in older women 4, 5, 6. Women aged 43 years or older who become pregnant are at increased risk of:
- Cesarean delivery
- Preterm delivery
- Gestational hypertension
- Preeclampsia These risks are further increased in women who undergo IVF or have twin pregnancies.