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Primary vs Secondary

16 year old female Patient concerns or questions: Amenorrhea and Headaches. 1) Loss of Period (r/o Secondary Amenorrhea) Menarche: ~11yo. LMP: over 4 months ago Cycles were very regular (started on the 7th or 14th every month), lasted 7 days, medium flow, never kept her home or affected daily life, no dizziness Has never had preceding ovulatory symptoms (abdominal pain, breast tenderness, mood changes) nor changes during the time of her period Has had increased exercise(playing JV soccer), continues poor eating habits

(rarely eats breakfast/lunch, occasionally eats dinner) Mildly more stress in her life, but fairly benign. This stems from starting school and having harder classes, though still doing well and her guardian believe this is being handled very well .

2) Headaches Left sided. Occurring less frequently. Given a headache log calendar
No reported weight loss or weight gain over time. No change in pant size. Denies

wanting to lose weight, poor body image, etc.

however according to her growth chart she had been tracking on the 32% and then went up to 48% last visit (May 2012) and now back down to 35%.

Other ROS normal

PMHx, Meds, Allergies

PAST MEDICAL HISTORY: Alleged child sexual abuse Post Traumatic Depression s/p V2 facial hemangioma resection prior to 2001 and in 2002 MEDICATIONS: Quetiapine Fumarate (SEROQUEL) : 150mg qHS Lamotrigine SR (LAMICTINE): 50mg qHS

Social Hx, Family Hx

SOCIAL HISTORY: Born in Mexico, Moved to Utah at young age. In DCSF custody ~10 months

Sexual History: No wanted Partners; Raped in current year Substance use: She denies smoking tobacco and using alcohol or illicit substances She is a Jr in high school; good performance and attendance Mood symptoms/suicidal ideation: Good mood, no SI, HI Increased stressors with school

FAMILY HISTORY: Not much information available,

Physical Exam


BP 111/74 | Pulse 60 | Temp 98.2 F (36.8 C) | Wt 51.7 kg ( 34%ile) C) | Ht 155cm (13%ile) | BMI 21

GEN: Alert, Active, NAD, normal color and normal perfusion HEENT: Scar over Left cheek otherwise Normocephalic and atraumatic; Red reflex present bilaterally, EOMI, pupils equal round and reactive to light and accommodation and fundi normal, Nares, Ears, Throat normal. Dentition normal. No parotid gland felt. NECK: supple, full range of motion, no masses and no lesions CHEST: Breasts normal appearing, (Tanner IV) , Clear to auscultation bilaterally, good aeration, normal respiratory rate and chest symmetrical CV: Regular rate and rhythm, PMI normal, regular rate, regular rhythm, no murmur, femoral pulses bilaterally and good peripheral pulses. ABD: soft, nontender, nondistended, no HSM, normal bowel sounds. No masses. No uteral fundus felt. SKELETAL: back straight, normal gait, no sacral dimple, upper extremities with full range of motion, lower extremities with full range of motion and no cyanosis, clubbing or edema in all 4 extremities SKIN: normal color, normal perfusion, no rash and no birthmarks. No acne. No hirsutism. NEURO: Cranial nerves II-XII intact, normal strength, normal tone, normal coordination, DTR 2+ and symmetric and normal behavior GU: deferred

DDx of 16 yo with secondary amenorrhea

DDx of 16 yo with secondary amenorrhea


Hypothyroid Late Onset Congenital Adrenal Hyperplasia Functional hypothalamic amenorrhea

Hyperandrogenism (21-hydroxylase deficiency) Stress; Weight Loss (diet,exercise); Poor Nutrition Systemic illnesses (CELIAC)



Anorexia/Bulemia PCOS



Prolactinoma Pituitary Adenoma, Craniopharyngioma (Sellar Tumors) Adrenal Tumor Ovarian Tumor Antipsychotics (cause hyperprolactinemia) Illicit Drug Use

What we sent
Urine Hcg: Neg
TSH: 1.91 Prolactin: 6.1

CBC: Normal; WBC: 5.3 ANC: 2740; Hct 42 Plt: 225

BMP : Normal; K: 4.7 Cl: 105 HCO3: 24 All within normal limits.

Primary Amenorrhea
delayed menarche
(defined as any one of the following:)

1) the absence of menarche by 16 years of age in the

presence of normal pubertal growth and development

2) the absence of menarche by 14 years of age in the

absence of normal pubertal growth and development

3) the absence of menarche 2 years after completed sexual


Secondary amenorrhea
loss of period
(defined as all of the following:)

Cessation of previously normal menstruation Has a gynecological age of at least 24 mos Gynecological age-time in months since menarche Time in months is best indicator a normal pattern should have been established Has not menstruated for three or more cycles

So what was the cause?

I advised her to come back in two weeks after improving

nutrition, hydration and to follow headaches.

Magically; it resolved.

However, her headaches were worse

Physical or emotional stress (Functional production of GnRH produces low FSH and LH Female athletes less leptin in fat (helps trigger GnRH secretion)
lose pulsatile LH release because of reduced


low intake, high expenditure

Secondary must have a regular cycle and have had period

for 24 months
Most common are derangements of the
hypothalamus and pituitary
most often related to emotional or physical stress Dont forget pregnancy and medications

Discover the causediscover the treatment