[43] Amenorrhoea Flashcards
What is amenorrhoea?
The absence of menstrual periods
How can amenorrhoea be classified?
- Primary
- Secondary
What is oligomenorrhoea?
Irregular periods with intervals between menstrual cycles of more than 35 days and/or less than 9 periods per year
What is primary amenorrhoea?
Failure to commence menses
When can primary amenorrhoea be diagnosed in the absence of secondary sexual characteristics?
In girls 14+
When can primary amenorrhoea be diagnosed in the presence of secondary sexual characteristics?
In girls 16+
What are some examples of secondary sexual characteristics?
- Pubic hair
- Breast development
What is secondary amenorrhoea?
When there is cessation of periods for > 6 months after menarche
Can causes of secondary amenorrhoea cause primary amenorrhoea?
Almost always, if they are established before menarche
What are some specific causes of primary amenorrhoea in the presence of secondary sexual characteristics?
- Constitutional delay
- Genitourinary malformations
- Testicular feminisation (androgen resistance syndrome)
- Hyperprolactinaemia
What is constitutional delay of menarche?
Where there is no abnormality but the girl is a little later than her peers in reaching menarche
What is a useful part of the history in identifying constitutional delay of menarche?
History of menarche in mother and sisters
What genitourinary malformations can lead to primary amenorrhoea in presence of secondary sexual characteristics?
- Imperforate hymen
- Transverse vaginal septum
- Absence of uterus or vagina
What karyotype does androgen resistance syndrome occur in?
XY
What is the external appearance in androgen resistance syndrome?
Normal adolescent girl
What is the internal appearance in androgen resistance syndrome?
No female internal organs and gonads are testosterone producing testes
How can the presentation of androgen resistance syndrome vary?
On the degree of androgen sensitivity
What can cause hyperprolactinaemia leading to primary amenorrhoea?
- Hypothyroidism
- Medication
- Pituitary tumours
What medications can lead to hyperprolactinaemia leading to primary amenorrhoea?
Phenothiazines
What can cause primary amenorrhoea in the absence of secondary sexual characteristics?
- Ovarian failure
- Other causes of failure of the HPA
- Causes of ambiguous genitalia
What can cause ovarian failure leading to primary amenorrhoea?
- Chemotherapy
- Irradiation
- Chromosomal gonadal abnormality
- Developmental abnormality
What chromosomal abnormality can lead to primary amenorrhoea?
Turner’s syndrome
What developmental abnormality can lead to primary amenorrhoea?
Mullerian agenesis
What can cause failure of the HPA leading to primary amenorrhoea?
- Tumours
- Irradiation
- Infection
- Head injury
What can cause ambiguous genitalia leading to primary amenorrhoea?
- Androgen secreting tumours
- Congenital adrenal hyperplasia
What is the most common cause of secondary amenorrhoea in women of childbearing age?
Pregnancy
What are the causes of secondary amenorrhoea with no signs of androgen excess?
- Physiological causes
- Premature ovarian failure
- Depot and implant contraception
- Cervical stenosis and intrauterine adhesions (Asherman’s syndrome)
- Hypothalamic dysfunction
- Loss of weight
- Pituitary disease and hyperprolactinaemia
- Thyroid disease
- Iatrogenic
What are the physiological causes of secondary amenorrhoea?
- Pregnancy
- Lactation
- Menopause
What can be the causes of premature ovarian failure leading to secondary amenorrhoea?
- Autoimmune
- Radiotherapy
- Chemotherapy
What can cause hypothalamic dysfunction leading to secondary amenorrhoea?
- Stress
- Excessive exercise
- Eating disorders
- Depression
- Chronic systemic illness
- Tumours
What can cause pituitary disease and hyperprolactinaemia leading to secondary amenorrhoea?
- Medication
- Recreational drugs
What are the iatrogenic causes of secondary amenorrhoea?
- Medication
- Surgery
- Irradiation
- Chemotherapy
What surgeries can lead to secondary amenorrhoea?
- Hysterectomy
- Endometrial ablation
- Ovarian surgery
What are some signs of androgen excess in women?
- Hirsutism
- Acne
- Virilisation
What are some causes of secondary amenorrhoea in the presence of signs of androgen excess?
- PCOS
- Cushing’s syndrome
- Late-onset congenital adrenal hyperplasia
- Adrenal or ovarian carcinoma
What % of amenorrhoea cases can be caused by PCOS?
30%
What should be asked about in the history when assessing amenorrhoea?
- Duration
- Contraception - recent and current
- Vasomotor symptoms
- Galactorrhoea
- Exercise habits
- Stresses
- Medication history
- PMH
What features should be looked for on examination in amenorrhoea?
- BMI
- Signs of excessive androgens
- Signs of thyroid disease or Cushing’s syndrome
What investigations should be made into amenorrhoea?
- Pregnancy test
- FSH and LH
- Prolactin
- Total testosterone and sex hormone-binding globulin
- TFTs
- Pelvic USS
What types of pregnancy test are available?
Urine or serum hCG
When are FSH and LH raised in amenorrhoea?
Ovarian failure
What can low FSH or LH suggest as the cause of amenorrhoea?
Constitutional delay or hypothalamic cause
What might raised testosterone indicate as the cause of amenorrhoea?
- Androgen secreting tumour
- Late-onset CAH
When might slightly elevated testosterone levels be seen?
PCOS
In what condition might pelvic ultrasound be helpful?
PCOS
When should a pelvic ultrasound be performed to check for normal anatomy?
In young girls who are not sexually active
What may be appropriate for some women in terms of investigation for amenorrhoea?
Referral and additional investigation
What additional investigations may be appropriate for some women with amenorrhoea?
- Karyotyping
- MRI or CT
- Hysteroscopy
When might karyotyping be appropriate in amenorrhoea?
To exclude Turner’s syndrome, testicular feminisation, and rare conditions
When might MRI or CT be appropriate in amenorrhoea?
Where pituitary tumour is suspected
When might hysteroscopy be appropriate in amenorrhoea?
In suspected Asherman’s syndrome
What does the management of amenorrhoea depend on?
Underlying cause and priorities of the woman
What should be done in women with amenorrhoea and low oestrogen levels/
Assess for the risk of osteoporosis
What conditions cause amenorrhoea and low oestrogen levels?
- Premature ovarian failure
- Hypothalamic causes
- Hypopituitarism
- Hyperprolactinaemia
What should be done in women with amenorrhoea at risk of osteoporosis?
Ensure they have adequate calcium and vitamin D intake
