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4. Progesterone Withdrawal Test - Progesterone Challenge A Diagnostic Test for Secondary Amenorrhea

Progesterone Withdrawal Test - Progesterone Challenge A Diagnostic Test for Secondary Amenorrhea

• The progesterone challenge test is is also referred to as a progestin challenge
• It is done by givng a progestin medication and seeing if this induces a menstrual period
• This same protocol of giving a progestin is often used to induce a period in women with irregular periods:
  • if she has not had a period for a while
  • if she skipped a period

How the Test Works

The progesterone challenge test is done by giving oral medroxyprogesterone acetate (Provera) 10 mg daily for 5-10 days or one intramuscular injection of 100-200 mg of progesterone in oil.

A positive response is any bleeding more than light spotting that occurs within 2 weeks after the progestin is given. This bleeding will usually occur 2-7 days after the progestin is finished.

Withdrawal bleeding will usually be seen if the patient's estradiol level has been over about 40 pg/ml.

Possible Outcomes of the Test

• If the patient experiences bleeding after the progestin she has estrogen present but is not ovulating (anovulation).
• If no withdrawal bleeding occurs, either the patient has very low estrogen levels or there is a problem with the outflow tract such as uterine synechiae (adhesions) or cervical stenosis (scarring).

Women with Withdrawal Bleeding

• The test has demonstrated that she builds up a lining in the uterus.
• She bleeds after progesterone is withdrawn - showing that it is the lack of ovulation that is causing her not to have periods.

Possible Diagnoses for Women with Withdrawal Bleeding

• Anovulation
• Polycystic Ovarian Disease (PCOS)

Women without Withdrawal Bleeding

Possible Diagnosis

• Hypothalamic hypoestrogenism (low estrogen levels)
• Compromised outflow tract - either Asherman's syndrome (adhesions) or cervical stenosis (scarring)
• Premature ovarian failure

The Next Step: Give Estrogen and Progestin to Distinguish Between Hypoestrogenism or an Outflow Tract Obstruction (Asherman's Syndrome or Cervical Stenosis)

Give estrogen to ensure endometrial proliferation, followed by a progestin to induce withdrawal bleeding. A course of 2.5 mg of Premarin for 21 days including 10 mg of Provera on days 17-21 should be adequate.

• If bleeding occurs, amenorrhea is due to hypoestrogenism (hypothalamic amenorrhea or premature ovarian failure).
• If bleeding does not occur, then most likely it is an outflow tract obstruction - either Asherman's syndrome or cervical stenosis.

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