A pituitary or hypothalamic tumor would be a rare finding in these patients who were all screened with prolactin levels at the beginning of the diagnostic evaluation. Patients with normal prolactin levels and normal imaging studies have hypothalamic amenorrhea of uncertain etiology. If the amenorrhea and lack of withdrawal bleeding persists, prolactin levels should be measured annually since a small microadenoma could be present that is escaping laboratory and radiographic detection. Psychiatric counseling is indicated in most, if not all cases. If the state is persistent, hormone replacement therapy should be considered for protection against osteoporosis.
Secondary amenorrhea is a symptom that can be caused by many pathological states.
The diagnostic evaluation should lead to the correct diagnosis without undue delay if the problem is attacked logically in a stepwise manner. Clinical Gynecologic Endocrinology and Infertility, 5th ed. Baltimore, Williams and Wilkins, 1994. Boston, Blackwell Scientific Publications, 1991. Washington DC, ACOG, 1989.