1: Menstruation: Amenorrhoea and Oligomenorrhoea Flashcards
Define amenorrhoea
absence of menstruation
How is amenorrhoea classified
primary and secondary
Define primary amenorrhoea
- Failure of periods to onset from 14-years if no secondary sexual characteristics
- Or, 16-years if secondary sexual characteristics
Define secondary amenorrhoea
Absence of periods for 6-months after menstruation started
What are 4 causes of primary amenorrhoea
Turner’s
Congenital adrenal hyperplasia
Congenital malformations of genital tract
Testicular feminisation
What is the most common cause of secondary amenorrhoea
Pregnancy
What are the causes of secondary amenorrhoea
- Functional disorders
- Kallman’s
- Hyperprolactinaemia
- Thyrotoxicosis
- PCOS
What is the role of the hypothalamus in menstruation
Release GnRH
What 3 disorders can cause amenorrhoea due to affecting hypothalamus
Kallman
Functional
Thyroid disease
What are 2 functional disorders that can reduce GnRH at the hypothalamus
Anorexia
Excessive exercise
What is kallmann syndrome
X-linked recessive condition that causes failure of GnRH neurons to migrate to the hypothalamus
How does kallmann syndrome present
Anosmia
Why is kallmann syndrome rare cause of amenorrhoea
As it is x-linked recessive and females have two x-linkec chromosomes
What are the 3 hypothalamic causes of amenorrhoea
Functional
Kallman
Thyrotoxicosis
What are 4 pituitary causes of amenorrhoea
- Sheeman’s
- Cranial Irradiation
- Post-contraception amenorrhoea
- Prolactinoma
Explain how prolactinomas result in amenorrhoea
Prolactinomas is a pituitary tumour that results in hyper-secretion of prolactin. Prolactin inhibits GnRH leading to secondary amenorrhoea.
What are the presenting features of prolactinoma
Amenorrhoea and galactorrhea
What other pituitary tumours can cause amenorrhoea
Pituitary adenoma - due to compression
What is Sheehan’s syndrome
Massive obstetric haemorrhage leads to ischaemic necrosis of the pituitary gland resulting in hormone deficiency
How does Sheehan’s syndrome present
Deficiency in several pituitary hormones
Explain post-contraception amenorrhoea
Prolonged used of contraceptives can cause long-term down regulation of the pituitary gland
What is the main contraceptive that causes post-contraception amenorrhoea
Depo provea
How long can it take periods to return in depo proved
18-months
What are 3 ovarian causes of amenorrhoea
- PCOS
- Turner’s
- Pre-mature ovarian failure
How does PCOS classically present
Oligomenorrhoea (Opposed to amenorrhoea)
What is the genetics of turner’s syndrome
45XO
What is turner’s syndrome
Genetic condition that causes:
- Amenorrhoea
- Absence secondary sexual characteristics
- Infertility
What are common phenotypic presentations of Tuner’s Syndrome
- Short stature
- Webbed neck
- Aortic coarctation
- Bicuspid aortic valve (lead to aortic stenosis)
What is an ‘adrenal’ cause of amenorrhoea
Congenital adrenal hyperplasia
What is congenital adrenal hyperplasia
Absence of 21-OH
What are 4 anatomical causes of amenorrhoea
Imperforate hymen
Asherman syndrome
Transverse vaginal septum
Mayer-Rokitansky-Kuster-Hauser syndrome
What is ashermanns syndrome
Instrumentation to the uterus causes damage to basal layer of the uterus, meaning it can no longer respond to oestrogen
What procedure is the most common cause of ashermanns syndrome
Surgical management of miscarriage
what is an imperforate hymen
No opening in the vagina
how does imperforate hymen present clinically
- Asymptomatic before puberty
- At puberty there is primary amenorrhoea and lower abdominal pain
how does an imperforate hymen present on examination
Bulging, blue-is tinge to the hymen
what is a transverse vaginal septum
Failure re-cannalisation of mullerian duct, cause cervical hypoplasia
what is mayer-rokitansy-kust-hauser syndrome
Failure mullerian duct to develop
what does agenesis of the mullein duct cause
Absence uterus and upper two-thirds of vagina
what is first line secondary amenorrhoea
Pregnancy test
what blood tests are ordered in amenorrhoea
TFT
FSH, LH
Prolactin
17-OH Progesterone
why are TFTs ordered
Thyrotoxicosis - as hyperthyroidism can cause amenorrhoea at hypothalamus
Why is prolactin ordered
Exclude prolactinoma
Why is FSH and LH ordered
Exclude PCOS
Why is 17-OH progesterone ordered
CAH
When may karyotyping be ordered in amenorrhoea
Exclude Tuner’s syndrome as cause primary amenorrhoea
Why may an US scan be ordered in amenorrhoea
Exclude anatomical obstructive causes
Explain the progesterone challenge
Progesterone is given for 5-10d, or one-off dose.
Positive test is shown by bleeding in 2W.
Positive test indicates sufficient oestrogen, however individual is not ovulating (such as in PCOS).
Negative test indicates insufficient oestrogen to cause proliferation and hence ‘no secretion’
Explain managing amenorrhoea
Treat underlying cause. Aims include:
- Regulate periods
- Regulate/Replace hormones
- Fertility
- Symptom control
- Surgery if pituitary cause
What may be given to regulate periods
COCP or POP
What is the advantage of regulating periods in amenorrhoea
Stops hyper-proliferation of the endometrium which increases risk of endometrial cancer
Define oligomenorrhoea
- Less than 9 periods a year
- More than 35 days between periods
What is the commonest cause of oligomenorrhoea
PCOS
Give 5 causes of oligomenorrhoea
- PCOS
- Transient anvoulation (Stress-induced)
- COCP
- Perimenopause
- Hypothyroidism
- Medications
- Anorexia
Explain management of oligomenorrhoea
Treat underlying cause. May aim to induce regular periods by using COCP
What number of periods for PCOS is recommended per year and why
3 periods - to reduce risk of endometrial cancer
