Secondary amenorrhea with normal ovulatory cycles in a young virgin with normal follicle stimulating hormone levels--a case report.

Purpose: To determine if normal ovulation is possible despite amenorrhea in the absence of any obvious uterine abnormalities or adhesions.

Methods: The study was conducted on a 17-year-old virgin with normal sexual development and normal secondary sexual characteristics whose menarche was at age 12 but whose menses ceased after two menstruations. She was first treated with medroxyprogesterone acetate 10 mg x ten days and then a cycle of oral contraceptives.

Results: She failed to get menses following progesterone (P) withdrawal and following a cycle of oral contraceptives. All of her pituitary function studies were normal. Her serum follicle stimulating hormone (FSH) was 3 mIU/ml, luteinizing hormone (LH) 9 mIU/ml, estradiol (E2) was 107 pg/ml and the serum P was 3.9 ng/ml. These values were consistent with recent ovulation. However menses failed to ensue.

Conclusions: This case confirms that in humans, similar to some non-primates, ovulation is possible without shedding the endometrium. Possibly she lacked spiral arterioles similar to ovulating mammals. Her virginal introitus and lack of any serious febrile illness made Asherman's syndrome highly unlikely. Her normal menstrual cycle at age 12 not only excluded a mullerian abnormality or imperforate hymen but led to speculation as to whether anovulatory bleeding from unopposed estrogen was possible but that somehow the presence of P inhibited the endometrial shedding process. In contrast to a previously reported study, this young woman almost had primary amenorrhea whereas the former case had more menses during her life but they ceased shortly after age 30.