Women's Health · Full case

Amenorrhoea

NICE CKSPregnancy first · HPO axisLow BMI / bone risk

Pregnancy until proven otherwiseThe first thought in any woman of reproductive age with absent periods is pregnancy — do a pregnancy test before anything else, regardless of what she says about contraception or sexual activity. It is the commonest cause of secondary amenorrhoea

Primary vs secondaryPrimary amenorrhoea = no periods by 15 (with secondary sexual characteristics) or by 13 (without). Secondary = absence of periods for 3–6 months in a woman who previously menstruated. The framework and causes differ

Think along the HPO axisLocalise the problem: hypothalamus (functional hypothalamic amenorrhoea — stress, low weight, exercise), pituitary (hyperprolactinaemia, tumour), ovary (PCOS, premature ovarian insufficiency), or outflow tract (structural). Hormone profile localises the level

The core blood panelAfter pregnancy test: FSH/LH, oestradiol, prolactin, TSH, and testosterone (+ free androgen index if PCOS suspected). High FSH → ovarian (POI); low/normal FSH+LH → hypothalamic/pituitary; high prolactin → pituitary; high androgens → PCOS

PCOS = commonest secondary cause (non-pregnant)PCOS (Rotterdam: 2 of 3 — oligo/anovulation, clinical/biochemical hyperandrogenism, polycystic ovaries) is the commonest cause of secondary amenorrhoea after pregnancy. Manage symptoms, metabolic risk and endometrial protection

POI under 40 mattersPremature ovarian insufficiency (menopause <40): raised FSH on two occasions + amenorrhoea. Needs HRT (not just contraception) for bone/cardiovascular/symptom protection until ~51, fertility counselling, and a cause work-up

Low oestrogen → boneProlonged hypo-oestrogenism (hypothalamic amenorrhoea, POI) threatens bone density — address oestrogen status, calcium/vitamin D, and consider DXA. In hypothalamic amenorrhoea, restoring energy balance/weight is the treatment, not just the pill

Don't miss the seriousRed flags: hyperprolactinaemia with visual field defects/headache (pituitary tumour), virilisation/rapid androgen rise (androgen-secreting tumour, CAH), eating disorder behind hypothalamic amenorrhoea, and the psychological impact of fertility implications

📋 Clinical Stem — Amenorrhoea

A 26-year-old marathon runner whose periods stopped 8 months ago, training hard on a restricted diet, who is "not worried" but wants to know it's nothing serious

Sophie Carter, 26, hasn't had a period for 8 months. She is training intensively for a marathon, has cut her food intake to "stay lean", and has lost weight; her BMI is now 18. She is stressed at work. She is sexually active but uses condoms and is "sure" she isn't pregnant. She has no galactorrhoea, no excess hair or acne, no headaches or visual symptoms, and no hot flushes. She isn't trying to conceive and is mostly unbothered, but came because her mum nagged her and she wants reassurance. She has had a previous stress fracture in her foot.

This stem tests the ability to: always exclude pregnancy first; classify amenorrhoea (here secondary) and reason along the HPO axis; recognise functional hypothalamic amenorrhoea from low energy availability (intensive exercise + dietary restriction + low BMI + stress — the "female athlete triad" with the prior stress fracture signalling low bone density) while still excluding PCOS, thyroid disease, hyperprolactinaemia and premature ovarian insufficiency with the core blood panel; appreciate the bone-health consequences of hypo-oestrogenism and that the treatment is restoring energy balance, not simply prescribing the pill; sensitively screen for disordered eating; and counsel on fertility and long-term health. The SCA challenge is engaging a patient who minimises the problem, and conveying that "no periods" is a meaningful health signal — especially for her bones — without lecturing.

Scenario A — Functional hypothalamic amenorrhoea (this stem) Low energy availability (exercise/restriction/low BMI/stress); low/normal FSH-LH, low oestradiol. Restore energy balance/weight, screen eating disorder, protect bone (DXA, calcium/vit D), MDT; avoid masking with the pill alone.

Scenario B — PCOS Oligo/amenorrhoea + hyperandrogenism (hirsutism/acne) ± polycystic ovaries; raised free androgens, LH:FSH. Lifestyle, symptom control, endometrial protection, metabolic/CV risk, fertility pathway.

Scenario C — Premature ovarian insufficiency (<40) Amenorrhoea + raised FSH (×2) ± menopausal symptoms. HRT until ~51, fertility counselling, cause work-up (karyotype, autoimmune, fragile X), bone/CV protection.

Scenario D — Hyperprolactinaemia / pituitary Galactorrhoea, headache, visual field defect; raised prolactin. Exclude drugs/pregnancy/hypothyroidism; MRI pituitary; endocrinology (prolactinoma).

Scenario E — Primary amenorrhoea No periods by 15 (with) / 13 (without secondary sexual characteristics). Consider constitutional delay, Turner's, structural/outflow (imperforate hymen, Müllerian agenesis), androgen insensitivity; examine and image.

Key variables to adapt for Pregnancy (always first); primary vs secondary; HPO level (hypothalamic/pituitary/ovarian/outflow); energy availability & eating disorder; PCOS features; POI <40 (HRT); prolactin/pituitary red flags; virilisation; bone health and oestrogen status; fertility wishes; the minimising patient.

Steps:

Step 1

History — Pregnancy · HPO Localisation · Energy/Eating · Red Flags · ICE

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The history excludes pregnancy first, then localises the problem along the hypothalamic–pituitary–ovarian axis with a few targeted questions, screens for the energy-availability/eating issues behind hypothalamic amenorrhoea, and looks for the red flags (visual symptoms, virilisation, menopausal symptoms under 40). Sophie minimises the problem; the skill is to convey that absent periods are a meaningful signal — especially for her bones — without lecturing.

🎓 SCA framing — engage the minimising patient

"I'm glad you came, even if it was your mum's idea. Periods stopping can be the body's way of saying it's under strain — and it can affect things like your bones, which matters for a runner. Let me check a few things, starting with the one we always rule out first."

Sophie wants reassurance and may resist the idea that her training/eating is the cause. Framing it around her own goals (running, bones, performance) is more effective than warning her off exercise.

1A — Pregnancy, localisation and energy/eating

Question	Why it matters	Changes what?
🟢 OPEN QUESTION"Tell me about your periods — when they stopped, what they were like before, and what's been going on in your life."	Establishes primary vs secondary and opens the contextual story. Sophie has secondary amenorrhoea (previously regular, now 8 months). The open frame surfaces the training, dietary restriction, weight loss and stress that point to functional hypothalamic amenorrhoea — while leaving room to localise elsewhere.In SCA: linking the menstrual history to the life context (exercise, eating, stress) is the diagnostic move.	Secondary; context → hypothalamic
🚩 Pregnancy"Is there any chance you could be pregnant? Either way, I'd like to do a pregnancy test today."	Always first. Pregnancy is the commonest cause of secondary amenorrhoea and must be excluded regardless of reported contraception or certainty — condoms fail, and patients are often wrong. A test is mandatory before any work-up.	Positive → antenatal pathway; negative → continue work-up.	Pregnancy test — always
HPO localisation"Any milky discharge from the breasts? Hot flushes or night sweats? Excess hair, acne, or skin changes? Headaches or changes in your vision?"	A handful of questions localise the axis: galactorrhoea → hyperprolactinaemia; hot flushes/night sweats under 40 → premature ovarian insufficiency; hirsutism/acne → PCOS or androgen excess; headache/visual field loss → pituitary tumour. Sophie has none of these, supporting a hypothalamic cause — but they must be asked to exclude the others.	Directs the differential and the blood panel; red flags change urgency.	FSH/LH, oestradiol, prolactin, TSH, androgens
🚩 Energy availability & eating"Tell me about your eating and training — how much are you doing, and how do you feel about food and your body?"	Functional hypothalamic amenorrhoea results from low energy availability — intensive exercise plus inadequate intake (Sophie). Sensitively screen for disordered eating/eating disorder, which frequently coexists and changes management. The combination of amenorrhoea + low energy + the prior stress fracture is the female athlete triad / RED-S, signalling low bone density.	Low energy availability → restore balance; eating disorder → psychological input. Triad → bone risk.	Eating-disorder screen; bone risk
Bone, drug & medical history"You've had a stress fracture — any others? What medicines do you take? Any thyroid problems? Past pregnancies, surgery or treatments?"	A stress fracture at a low BMI flags hypo-oestrogenic bone loss. Drugs (antipsychotics, some antidepressants, metoclopramide, opioids) raise prolactin; thyroid disease causes menstrual disturbance; uterine instrumentation can cause Asherman's. Builds the differential and the risk picture.	Drug-induced hyperprolactinaemia; thyroid; bone health → DXA, calcium/vit D.	Consider DXA; review prolactin-raising drugs
Fertility & contraceptive context"Are you hoping to have children at some point, and what are you using for contraception?"	Fertility wishes shape the conversation (now and future), and the pill — often the reflex prescription — can mask the underlying problem and does not, in hypothalamic amenorrhoea, fix the energy deficit or fully protect bone. Counselling must be honest about fertility implications of the underlying cause.	Fertility wishes → tailored counselling; avoid masking with the pill alone.	Don't just prescribe the pill

1B — Red flags

🚨

Red Flags — the serious causes and consequences

Red flag	Why it matters	Action
Hyperprolactinaemia with headache / visual field defect	Pituitary macroadenoma compressing the optic chiasm — risk to vision.	Urgent prolactin, MRI pituitary, endocrinology; visual field testing
Virilisation / rapid androgen rise (deep voice, clitoromegaly, rapid hirsutism)	Androgen-secreting ovarian/adrenal tumour or non-classical CAH.	Urgent androgens (testosterone, DHEAS, 17-OHP); endocrine/gynae referral
Premature ovarian insufficiency (<40, raised FSH)	Long-term bone/cardiovascular risk and significant fertility/psychological impact.	Repeat FSH; HRT to ~51; cause work-up; fertility counselling; gynae/endocrine
Eating disorder behind hypothalamic amenorrhoea	Serious morbidity/mortality; amenorrhoea may be the presenting sign.	Sensitive assessment; eating-disorder service; don't mask with the pill
Prolonged hypo-oestrogenism + prior fragility/stress fracture	Low bone density and fracture risk (female athlete triad / RED-S).	Address energy balance; DXA; calcium/vitamin D; specialist input
Primary amenorrhoea with absent secondary sexual characteristics / dysmorphic features	Turner's syndrome, structural/outflow anomaly, or other genetic cause.	Examination, imaging, karyotype; paediatric/gynae/endocrine referral

1C — ICE

💭 Ideas

"What do you think has caused your periods to stop?"

Sophie may assume it's "just the running" and harmless, or have a hidden worry about fertility. Surfacing her idea lets you connect the amenorrhoea to energy balance and bone health in terms she cares about, and correct the belief that it's nothing.

😟 Concerns

"Is there anything about it that does worry you, even a little — like having children one day?"

Beneath the "not bothered" stance there may be a real concern about fertility or a fear of being told to stop running. Naming these lets you address them honestly and recruit her into the plan.

🎯 Expectations

"You came for reassurance — what would feel reassuring, and what were you hoping I'd do?"

She wants to be told it's nothing. Naming this lets you honestly reassure (likely benign and reversible) while explaining the tests needed and why simply ignoring it — or just taking the pill — isn't the safe option for her bones.

1D — Psychosocial context

Functional hypothalamic amenorrhoea in athletes is frequently normalised — by the patient and sometimes by sport culture — as a harmless sign of being "fit and lean". In reality it reflects insufficient energy availability and low oestrogen, with real consequences for bone density (the prior stress fracture is a warning) and future health. The consultation works by reframing absent periods as meaningful feedback from the body, by exploring eating and training without judgement, and by aligning the plan with what Sophie values — running well and staying injury-free — rather than simply telling her to do less.

🏃 Performance & bones

Frame energy balance around her goals — under-fuelling harms performance and bones.

"Training hard while under-fuelling actually works against you — it weakens bones (which is why you got that stress fracture) and limits performance. Getting your energy balance right will help your running, not hinder it."

🍽️ Eating, sensitively

Screen for disordered eating without accusation.

"Can I ask a bit about food — not to judge, but because how we fuel matters so much for this. How do you feel about eating and your body at the moment?"

💊 Not just the pill

Explain why the pill alone isn't the fix here.

"It's tempting to just start the pill to bring periods back, but that can mask what's going on and doesn't fully protect your bones. The real fix is restoring your body's energy balance."

👶 Fertility honestly

Reassure that this is usually reversible while taking concerns seriously.

"The good news is this type is usually reversible — when your body's better fuelled, periods and fertility typically return. If you ever have trouble down the line, there's plenty of help."

🎓 SCA Checkpoint — Step 1TasksRelating to OthersGlobal Skills

Key phrases that score

"Either way, I'd like to do a pregnancy test today." — the mandatory first step.

"Any milky discharge, hot flushes, excess hair, or headaches/visual changes?" — localises the axis and screens red flags.

"Training hard while under-fuelling weakens bones — that's likely behind your stress fracture." — links the triad to her goals.

Deductions

Not doing a pregnancy test
Not localising along the HPO axis / not ordering the core panel
Missing the energy-availability/eating-disorder issue and bone risk
Reflexively prescribing the pill to "fix" it

🔴 Red

No pregnancy test; no axis localisation/panel; eating/bone issue missed; pill prescribed as the fix; red flags not screened

🟠 Amber

Pregnancy excluded; some bloods; hypothalamic cause suspected; eating/bone partly addressed; ICE partial

🟢 Green

Pregnancy test first; classifies secondary; HPO localisation + core panel; recognises functional hypothalamic amenorrhoea + triad/bone risk; sensitive eating screen; avoids pill-only; ICE all three

Step 2

Triage — Urgent (Pituitary/Virilisation) · POI & Eating Disorder · Routine

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Amenorrhoea is rarely an emergency, but some causes need prompt action: a pituitary tumour with visual symptoms, rapid virilisation, premature ovarian insufficiency (for timely HRT), and a serious eating disorder. Most causes are worked up routinely in primary care.

🔴 Urgent

Days

Don't delay

Pituitary tumour signsHeadache + visual field defect + high prolactin → urgent MRI/endocrine
Rapid virilisation?androgen-secreting tumour → urgent referral
Severe eating disorder / very low BMIEating-disorder service; medical risk

🟠 Refer / soon

Weeks

Specialist

POI (<40, raised FSH ×2)HRT, cause work-up, gynae/endocrine
Primary amenorrhoeaExamination, imaging, karyotype; specialist
Hyperprolactinaemia (no red flags)Confirm, exclude drugs; endocrine

🟢 Routine

Primary care work-up

Common causes

Functional hypothalamic amenorrhoeaEnergy balance; eating screen; bone protection
PCOSLifestyle, symptom & endometrial management
Thyroid / drug-inducedTreat cause; review medication

🎓 SCA Checkpoint — Step 2Tasks

Triage rationale

"This isn't an emergency, and the likely cause is reversible — but I do want the right blood tests to rule out a few specific things, and to take your bone health seriously given the stress fracture."

Deductions

Missing pituitary/virilisation red flags
Not recognising POI's need for timely HRT

Step 3

Examination — BMI · Androgen Signs · Galactorrhoea · Visual Fields · (Pelvic if indicated)

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Examination is directed by the differential: BMI and signs of low weight, androgen excess, galactorrhoea, thyroid status, visual fields if a pituitary cause is suspected, and (for primary amenorrhoea or structural concern) assessment of secondary sexual characteristics and pelvic/genital examination.

📏 General & endocrine

Check	Why
BMI / weight	Low BMI → functional hypothalamic amenorrhoea / eating disorder (Sophie BMI 18).
Androgen signs	Hirsutism, acne (PCOS); virilisation (tumour/CAH).
Galactorrhoea	Hyperprolactinaemia.
Thyroid exam	Thyroid disease.
Visual fields (confrontation)	Pituitary tumour if prolactin high / headache.

🔎 Primary / structural

Check	Why
Secondary sexual characteristics (Tanner)	Primary amenorrhoea — development/Turner's.
Genital/pelvic exam (if indicated)	Outflow obstruction, Müllerian anomaly (with chaperone/consent).
Dysmorphic features	Turner's syndrome.
Acanthosis nigricans	Insulin resistance/PCOS.

🎓 SCA Checkpoint — Step 3TasksGlobal Skills

Narration that scores

"I'll check your weight and BMI, look for any signs of hormone imbalance like excess hair or breast discharge, and — if needed — check your visual fields. Anything more intimate I'd only do with your consent and a chaperone."

Deductions

Not documenting BMI; missing androgen/galactorrhoea signs
Pelvic exam without consent/chaperone or when not indicated

Step 4

Investigations — Pregnancy Test · Hormone Panel · Imaging · Bone

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Pregnancy test first, then the core hormone panel that localises the HPO axis, with imaging and bone assessment directed by the findings.

🧪 First-line

Test	Interpretation
Pregnancy test (βhCG)	Always first; excludes the commonest cause.
FSH & LH	High FSH → ovarian (POI); low/normal → hypothalamic/pituitary; raised LH:FSH may suggest PCOS.
Oestradiol	Low in hypothalamic amenorrhoea and POI (bone risk).
Prolactin	High → hyperprolactinaemia (exclude drugs, pregnancy, hypothyroidism, macroprolactin).
TSH	Thyroid dysfunction.
Testosterone (± free androgen index, SHBG)	Raised → PCOS; markedly raised → androgen-secreting tumour/CAH.

🩻 Directed / second-line

Test	When
Pelvic ultrasound	PCOS morphology; structural/outflow anomaly; uterine assessment.
MRI pituitary	High prolactin / pituitary symptoms.
Repeat FSH	Confirm POI (raised on two occasions ≥4–6 weeks apart).
Karyotype / further work-up	POI cause, primary amenorrhoea (Turner's, fragile X, autoimmune).
DXA / bone health	Prolonged hypo-oestrogenism, low BMI, prior fragility/stress fracture.

🎓 SCA Checkpoint — Step 4Tasks

Key reasoning

"After a pregnancy test, I'll check a panel of hormones — the pituitary and ovary hormones, prolactin, thyroid and testosterone — which tells us where the problem is. Given the stress fracture, I'll also think about a bone scan."

Deductions

Skipping the pregnancy test
Not knowing how the panel localises the axis
Ignoring bone assessment in a hypo-oestrogenic patient with a stress fracture

Step 5

Diagnosis — Localise the Axis · Name the Cause

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Combine the pattern with the hormone panel to localise the level and name the cause — and, in hypothalamic amenorrhoea and POI, explicitly flag the oestrogen/bone implications.

Diagnosis	Discriminating features
Functional hypothalamic amenorrhoea	Low energy availability (exercise/restriction/stress/low BMI); low/normal FSH-LH, low oestradiol (Sophie). Triad/RED-S with bone risk.
PCOS	Oligo/amenorrhoea + hyperandrogenism ± polycystic ovaries; raised free androgens.
Premature ovarian insufficiency	<40 + raised FSH ×2 ± menopausal symptoms.
Hyperprolactinaemia	High prolactin ± galactorrhoea/visual symptoms (prolactinoma); exclude drugs/hypothyroidism.
Thyroid / drug-induced	Abnormal TSH; prolactin-raising drugs.
Structural / primary causes	Outflow obstruction, Müllerian agenesis, Turner's, androgen insensitivity, Asherman's.

🚩 The discipline — localise, and don't forget the bones

Reasoning by HPO level turns a long differential into a clear answer: pregnancy excluded, then FSH/oestradiol (ovary), prolactin (pituitary), androgens (PCOS), TSH (thyroid). For Sophie the formulation is functional hypothalamic amenorrhoea from low energy availability — low oestradiol with low/normal gonadotrophins — within a female-athlete-triad picture whose prior stress fracture signals low bone density. The treatment is restoring energy balance (not the pill), with eating-disorder screening and active bone protection.

🎓 SCA Checkpoint — Step 5Tasks

Explaining it plainly

"Your periods have stopped because your body isn't getting enough fuel for the amount you're training — so it switches off the reproductive hormones. It's usually reversible, but the low hormone levels can weaken bones, which is why we take it seriously and why feeding yourself properly is the real treatment."

Deductions

Not localising the cause from the panel
Labelling without flagging the bone/oestrogen consequence

Step 6

Referral — Endocrine/Gynae · Eating Disorders · Fertility · Bone

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Referral is directed by cause: endocrinology/gynaecology for POI, hyperprolactinaemia/pituitary, virilisation and primary amenorrhoea; eating-disorder services where relevant; fertility services when conception is the goal; and bone/specialist input for the athlete triad.

Referral	Who / when	Urgency
🔴 Urgent endocrine/neuro	Pituitary tumour with visual symptoms; rapid virilisation.	Urgent
Endocrinology / gynaecology	POI (HRT + work-up), hyperprolactinaemia, PCOS complexity, primary amenorrhoea/structural.	Soon
Eating-disorder service	Disordered eating / eating disorder behind hypothalamic amenorrhoea.	By severity
Fertility services	When conception is desired and not achieved, by cause.	Routine
Sports medicine / dietetics / bone	Female athlete triad / RED-S; DXA-guided bone management.	Routine

🎓 SCA Checkpoint — Step 6Tasks

Right referral, right reason

"For you, the most useful help is dietetic and sports-medicine support to get your fuelling right, plus a bone scan — rather than a hospital hormone clinic. If your bloods threw up something unexpected, we'd involve the specialists."

Deductions

Not referring POI for HRT/work-up
Not involving eating-disorder/dietetic support when indicated

Step 7

Management — Treat the Cause · Bone Protection · Fertility · Endometrial Safety

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Management treats the underlying cause rather than just restoring bleeding: for Sophie, restoring energy availability (with dietetic/eating-disorder support) and protecting bone; for PCOS, lifestyle, symptom control and endometrial protection; for POI, HRT to ~51; for hyperprolactinaemia, treat the cause.

7A — By cause

🎯 Cause-specific

Cause	Management
Hypothalamic (Sophie)	Restore energy availability — increase intake / reduce training load; dietetic + eating-disorder support; bone protection (calcium/vit D, DXA); the pill does not fix the energy deficit and may mask recovery.
PCOS	Lifestyle; combined pill or cyclical progestogen for endometrial protection; manage hirsutism, metabolic/CV risk; fertility pathway if conceiving.
POI	HRT (or COCP) until ~51 for bone/CV/symptoms; fertility counselling; cause work-up; psychological support.
Hyperprolactinaemia	Stop offending drug; dopamine agonist for prolactinoma (specialist); treat hypothyroidism.
Thyroid	Treat the thyroid disorder.

🛡️ Cross-cutting

Element	Detail
Bone health	Address oestrogen status; calcium/vitamin D; DXA where indicated; weight-bearing balance.
Endometrial protection	In PCOS (unopposed oestrogen) ensure regular withdrawal bleeds/progestogen.
Fertility & contraception	Honest counselling; note return of fertility may precede periods (contraception still needed).
Psychological support	Eating disorder, POI (loss/identity), fertility distress.
Review	Recheck once cause treated; monitor recovery of menses and bone.

🎓 SCA Checkpoint — Step 7TasksRelating to OthersGlobal Skills

A plan that scores

"Here's the plan: a pregnancy test and a hormone panel today; the likely fix is improving your fuelling and easing the training a little — I'll get you dietetic and, if helpful, sports-medicine support, plus a bone scan. We'll review the results and how your periods respond. Importantly, getting this right will help your running, not harm it."

Deductions

Prescribing the pill as the sole "treatment" for hypothalamic amenorrhoea
Ignoring bone protection / eating-disorder screening
Not counselling on fertility/contraception (fertility can return before periods)

"Honestly I think this is a waste of your time — my periods just stopped a while ago and I feel fine. My mum made me come. I just want to be told it's nothing to worry about."

Who you are

Sophie Carter, 26, training hard for a marathon. Your periods stopped about 8 months ago. You've cut your food intake to "stay lean" and lost weight (BMI now 18). Work is stressful. You're sexually active but use condoms and are sure you're not pregnant. No breast discharge, no excess hair/acne, no headaches/visual changes, no hot flushes. You're not trying for a baby and aren't bothered — you came because your mum nagged you. You had a stress fracture in your foot last year. You're slightly defensive if you think someone's going to tell you to stop running.

Hidden concerns (reveal if explored)

Fertility (deep down): if asked gently, you do wonder whether this could affect having children one day.

Fear of being told to stop training: running is central to your identity; you'll resist advice framed as "do less".

Eating: you're quite controlled around food; you may downplay it but will open up a little if asked kindly and without judgement.

Clinical details if asked

Secondary amenorrhoea ~8 months; previously regular
High training volume + restricted intake; weight loss; BMI 18; work stress
No galactorrhoea, hirsutism/acne, headaches/visual symptoms, hot flushes/night sweats
Sexually active, condoms; not trying to conceive; no relevant medications
Previous foot stress fracture; no thyroid problems; no prior pregnancies/surgery

Reactions at key moments

On the pregnancy test: "I told you I'm not pregnant" → accepts when told it's routine.
On the bone/performance link: this lands — you didn't connect the stress fracture to your periods; becomes more engaged.
On "not just the pill": relieved it's not just being handed medication.
On eating questions: a little guarded; opens up if approached without judgement.
Challenge line: "So are you telling me I have to stop running?"

"So basically you're telling me to stop running and eat more? Running is my thing — I don't want to give it up just because of this."

Resolution: Sophie engages if the GP: (1) does a pregnancy test first despite her protests; (2) reasons along the HPO axis and sends the core panel, excluding PCOS/thyroid/prolactin/POI; (3) recognises functional hypothalamic amenorrhoea from low energy availability and connects the prior stress fracture to bone risk (female athlete triad); (4) screens eating sensitively and frames the plan around her performance and injury-prevention rather than "stop running"; (5) explains that restoring energy balance — not the pill — is the treatment, arranges dietetic/sports-medicine and bone (DXA) input, and counsels honestly on fertility (usually reversible; contraception still needed). She disengages if lectured, told bluntly to stop running, or simply handed the pill with no explanation.

🏥

Clinic Quick Reference

Amenorrhoea — Clinical Decision Framework

Pregnancy first · HPO axis · treat the cause

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🔍 1 — Work-up

Always pregnancy test first. Classify primary (no periods by 15/13) vs secondary (≥3–6 months). Core panel: FSH/LH, oestradiol, prolactin, TSH, testosterone (±FAI). Localise: high FSH → POI; low/normal → hypothalamic/pituitary; high prolactin → pituitary (MRI if symptoms); high androgens → PCOS. Pelvic USS/karyotype/DXA as directed.

💊 2 — Treat the cause

Hypothalamic: restore energy availability + dietetic/eating-disorder support + bone protection (not pill-only). PCOS: lifestyle, endometrial protection, metabolic/CV, fertility. POI: HRT to ~51 + fertility counselling + work-up. Hyperprolactinaemia: stop drug / dopamine agonist (specialist). Protect bone in all hypo-oestrogenic states; counsel fertility/contraception.

🎓

SCA Quick Reference

Amenorrhoea — Consultation Playbook

Pregnancy first · localise the axis · treat the cause & the bones

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🎯 The three pivots that pass this case

1 · Pregnancy first

Always a pregnancy test before any work-up — the commonest cause, whatever she says about contraception.

2 · Localise the axis

FSH/oestradiol, prolactin, TSH, androgens place the problem at ovary/pituitary/hypothalamus and name the cause.

3 · Treat cause + bones

Functional hypothalamic = restore energy balance (not the pill); protect bone; screen eating; counsel fertility.

⛔ Don't skip the pregnancy test · Don't prescribe the pill as the sole "fix" for hypothalamic amenorrhoea · Don't ignore bone health / the female athlete triad · Don't miss POI (HRT to ~51), a prolactinoma, or virilisation · Screen disordered eating sensitively; counsel that fertility can return before periods

Amenorrhoea · GP Clinical Reasoning Framework v2 · NICE CKS Amenorrhoea · RCOG / ESHRE (PCOS, POI) · female athlete triad / RED-S guidance

Always exclude pregnancy first · Classify primary vs secondary; reason along the HPO axis with FSH/LH, oestradiol, prolactin, TSH, testosterone · Functional hypothalamic amenorrhoea (low energy availability) → restore energy balance, screen eating disorder, protect bone — not the pill alone · POI (<40, raised FSH ×2) → HRT to ~51 + fertility counselling · Hyperprolactinaemia with visual/headache → MRI/endocrine · Protect bone in hypo-oestrogenic states; counsel fertility/contraception

Teaching clinicians why each step matters — not just what to do · Always consult current NICE CKS / RCOG guidance · Clinical judgement takes precedence over any framework

Amenorrhoea

Red Flags — the serious causes and consequences

🏃 Performance & bones

🍽️ Eating, sensitively

💊 Not just the pill

👶 Fertility honestly

Days

Weeks

Primary care work-up

🚩 The discipline — localise, and don't forget the bones

🎭 Patient actor brief — click to practise

Who you are

Hidden concerns (reveal if explored)

Clinical details if asked

Reactions at key moments