Secondary amenorrhea. A protocol for pinpointing the underlying cause.

Secondary amenorrhea presents the primary care physician with a diagnostic challenge because of the many disorders that can cause it. Thus, its evaluation warrants a systematic approach to avoid unnecessary and expensive diagnostic procedures. By using the step-by-step protocol outlined in this article, the clinician can isolate the dysfunctional compartment--outflow tract, ovary, anterior pituitary, CNS, or hypothalamus--and then pursue a more specific workup to pinpoint the cause. Treatment depends on the patient's desire for pregnancy, and the need for long-term follow-up is dictated by the specific diagnosis.

Ovulation induction with pulsatile intravenous GnRH.

Human menopausal gonadotropin has been the treatment of choice for hypogonadotropic hypogonadism patients who fail ovulation induction with clomiphene citrate. Several authors have reported successful ovulation induction with the use of gonadotropin releasing hormone (GnRH). We used commercially available GnRH (Factrel, Ayerst Laboratories) and the Auto Syringe AS6H Infusion Pump for ovulation induction in such patients. Eight patients completed 15 cycles of pulsatile intravenous GnRH therapy. A mean of 12.2 days of therapy was required per cycle. Basal body temperatures and ultrasound documented ovulation of a single, dominant follicle in 12 cycles (80%). There were four singleton pregnancies. The overall corrected pregnancy rate was four pregnancies for ten cycles (40%) in six patients (67%). No complications were observed, and the cost of care was one-third that of human menopausal gonadotropin at our institution.