medical issues, provera, progestin, anovulation, follicle stimulating hormone (FSH), Polycystic Ovary Syndrome (PCOS), testosterone, thyroid, withdrawal bleeding

Q: What could be wrong if I am bleeding after Provera?

A: You likely had what is known as 'withdrawal bleeding' after the progesterone challenge test.

Most likely you did not ovulate. The next step is usually to check your Prolactin level and do a TSH to check your thyroid function. An abnormal TSH test may indicate thyroid problems and an abnormal prolactin may indicate pituitary gland problems. If there is a history of recent stress, weight loss, medications, or street drugs, these factors could be causing the amenorrhea. 

Many doctors feel that a blood LH and FSH level may be helpful at this point. If the LH is high (above about 10 mIU/mL) and the LH/FSH ratio is above 2:1, this supports the clinical diagnosis of polycystic ovarian disease (PCOS or PCO) although many patients with PCO do not demonstrate this high LH/FSH ratio. Testosterone and DHEAS levels may be useful in women with PCO, especially in the presence of hirsutism (hairiness) or other signs of hyperandrogenism (excess male hormones).

Chronic anovulation should be managed by periodic progestin withdrawal, or oral contraceptive pills if the patient doesn't want to get pregnant. If you want to get pregnant, induction of ovulation with clomiphene citrate or injectable gonadotropins should be considered. If the anovulatory state has been longstanding, consider endometrial biopsy to rule out significant hyperplasia or carcinoma of the endometrium.