Easy Bruising in a Patient with Secondary Amenorrhea

Abstract

A 33-year-old woman presented with amenorrhea and weight gain of 27.2-31.8 kg, despite diet and exercise, as well as progressively worsening acne. Symptoms began subsequent to a spontaneous abortion 5 years earlier and had become especially concerning during the past year. There was no notable family medical history. The patient did not report taking any prescription or over-the-counter medication and denied tobacco, alcohol, or illicit drug use. She had a blood pressure of 144/86 mmHg, heart rate of 88 beats/min, temperature of 37.1°C, and was 1.8 m tall and weighed 105.7 kg (body mass index, 33.4). The results of a physical examination were otherwise normal.Initial laboratory evaluation results included a negative point-of-care urine human chorionic gonadotropin test and concentrations within reference intervals for thyroid-stimulating hormone (TSH), 2 prolactin, leutinizing hormone (LH), and follicle-stimulating hormone (FSH) ( Table 1). Further testing revealed a low estradiol concentration (20 pg/mL, reference interval, 24 -706 pg/mL), as well as increased total testosterone [96 ng/dL (DPC, Siemens, Malvern PA), reference interval, 10 -80 ng/dL] and dehydroepiandrosterone-S (DHEA-S) (594 g/dL, reference interval, Ͻ340 g/ dL) ( Table 1). She was diagnosed with polycystic ovary syndrome (PCOS) and treated with metformin, which she did not tolerate, and local creams for her acne were ineffective.Approximately 1 year later, the patient presented with continuing amenorrhea and complained of mood swings and depression as well as easy bruising and hirsutism. She was referred to an endocrinologist for further evaluation. Laboratory testing at this time included a basic metabolic panel. All measurands were within reference intervals, as were concentrations of TSH, LH, and FSH (Table 1). A random 17-hydroxyprogesterone (17-OHP) was within reference intervals, and estradiol was at the lower limit of the reference interval (28 pg/mL). Prothrombin time and partial thromboplastin time were both within reference intervals. Total testosterone (132 ng/dL) and DHEA-S (812 g/dL) remained increased. DISCUSSION OVERVIEW OF SECONDARY AMENORRHEAAmenorrhea is classified as either primary (failure to achieve menarche) or secondary, which is the cessation of menses for 3 months or more. Secondary amenorrhea is not, in itself, a cause for concern; however, it can be a symptom of other pathological states. Secondary amenorrhea will affect approximately 5% of women of reproductive age and those who are affected often will not demonstrate an obvious etiology for their symptoms. Therefore, a systematic evaluation is required to establish a definitive diagnosis (1 ).The most common underlying cause of secondary amenorrhea is pregnancy. Once pregnancy is ruled out, TSH and prolactin can be measured to investigate other causes such as hypothyroidism and hyperprolactinemia. In the absence of hypothyroidism and hyperprolactinemia, secondary amenorrhea is likely due to either outflow tract obstruction or hypogonadism. The low estrogen concentr...