Secondary Amenorrhea: An Unusual Twist

Abstract

A 15-year-old adolescent female was referred to the gynecology clinic for evaluation of secondary amenorrhea and 10 kg weight gain of 14 months duration. The patient was the 2.2-kg product of a 36-week pregnancy and spontaneous vaginal delivery to a homeless G/5P/4003 mother. The mother’s past obstetrical history was notable for a full-term intrauterine fetal demise attributed to unknown etiology. The prenatal history was remarkable for illicit drug addiction with subsequent methadone therapy with additional drug abuse during the pregnancy denied. There was no history of in-utero androgen exposure. The neonatal course was complicated by methadone withdrawal requiring 3 weeks of NICU hospitalization. Clitoromegaly sexual ambiguity or additional signs of androgen excess were not identified on physical examination. Early developmental milestones were appropriate and included crawling at 6 months walking at one year and development of normal language skills. Breast budding and pubic hair were achieved at age 10 years 8 months. Menarche began at age 13 years and was followed by three consecutive apparently normal menstrual periods that occurred 21 days apart. However over the subsequent 14 months the patient did not menstruate and gained 10 kg. She sought initial evaluation by a primary care physician for the secondary amenorrhea. At the time of evaluation the patient denied sexual activity and the routine pregnancy test was negative. Physical examination revealed a normal habitus adolescent female with no significant acne or excess hair growth. A pelvic examination was not performed and Tanner stages were not recorded. The patient was prescribed progesterone therapy to induce menstruation. When the expected withdrawal bleeding did not commence the patient was referred to a gynecology clinic for additional evaluation and testing. (excerpt)