32 year old female presented to her GP following a first trimester miscarriage which consequently resulted in her experiencing secondary amenorrhoea for more than 9 months. Secondary amenorrhoea is defined as cessation of regular menses for 3-6 months or the cessation of irregular menses for 6-12 months. Her main concern was around her subfertility and dry skin. She started menarche at the age of 10 with regular monthly menses until her copper coil insertion 4 years ago. She had conceived spontaneously 2 months after removal of her copper coil. Her BMI has always ranged been 17-19 kg/m2 since the age of 16. She visits the gym regularly and eats <1500 calories per day. She is not on any medications or supplements. Blood test in clinic (Table 1): An MRI scan was performed and discussed in our MDM which confirmed no pituitary defect. DEXA bone scan showed bone mineral density to lie in normal range for age of patient. Despite improving her BMI (19.5 kg/m2) clinically she remained unchanged. There are multifactorial causes linked to secondary amenorrhoea. Functional hypothalamic amenorrhoea is a diagnosis of exclusion and accounts for 30% of cases. Current guidance focuses on nutrition and hormone replacement. During nutritional recovery the luteal phase is short with prolonged follicular phase resulting in longer menstrual cycles; this correlates with abnormal folliculogenesis. Interestingly when females modify intense activity and/or improve caloric intake they can also show a triad of symptoms described as female athlete triad (low energy, low bone density and menstrual dysfunction). Among those keen to conceive first line therapy involves pulsatile gonadotrophin-releasing hormone followed by gonadotrophin therapy and induction of ovulation. The choice of oestrogen substrate is unclear. To reduce foetal complications fertility services should only be offered when BMI is >18.5 kg/m2 and nutritional improvement is made. Evidence on cognitive behavioural therapy remains limited. The long-term risk to bone, cardiac function and fertility remains unknown.
|Follicular stage 2.4-12.6 Luteal stage 1.0-11.4
|Follicular stage 3.5-12.5 Luteal stage 1.7-7.7
|9 am cortisol
|Anti Mullerian hormone