Negative Progestin Challenge

• Indicates low estrogen state
• IF
  • not pregnant OR
  • unsure of exam for: outflow patency and presence of normal uterus OR
  • risk factors for Asherman syndrome
• THEN
  • repeat progestin withdrawal after priming endometrium with estrogen
  • 2.5 mg Premarin x 21 days
  • add Provera 10 mg, last 5 days
• IF no bleed after repeat progestin w/drawal test
  • endometrial or outflow tract abnormality
  • OR noncompliance
• IF (+) bleed on repeat test
  • dx is hypoestrogenism
  • THEN test serum LH, FSH (may be falsely suppressed by recent estrogen therapy. Wait 2 weeks before checking)
  • IF elevated, dx is gonadal failure
  • IF low or normal, r/o tumor/Kallman. Do pituitary imaging.
  • IF imaging is normal, dx is hypothalamic dysfunction

return to Amenorrhea