Amenorrhea

Question 1

Menstrual/ proliferative phase of the menstrual cycle

• Length
• Uterus
• Hormones
• Cervix

Answer 1

Length: 7-21 days

1. Menstruation
   - Fall of oestrogen and progesterone triggers shedding of the functionalis layer.
   - Cervix dilates
2. Proliferation
   - GnRH = rise in FSH= rise in oestrogen
   - Follicular development, endometrial proliferation
   - Peak in LH= ovulation
   - Cervical mucus is watery and profuse during ovulation

Question 2

Secretory and pre-menstrual phase

• Length
• Uterus
• Hormones
• Cervix

Answer 2

Length: always 14 days
- Menstruation will always happen 14 days after ovulation

Release of ovum from follicle leaves corpus luteum= secretion of progesterone

Endometrial glands proliferate under progesterone
- Becomes more tortuous with prominent spiral vessels

Question 3

Physiological causes of amenorrhoea

Answer 3

Pregnancy

Menopause

Question 4

Functional causes of amenorrhoea

Answer 4

Describes “non-organic” causes:

• Rapid weight loss/ anorexia nervosa/ low body far percentage
• Excessive exercise
• Prolonged psychological stress

Question 5

Hypothalamic/pituitary causes of amenorrhoea

Answer 5

Functional: stress, low body fat percentage, excessive exercise

Tumours: pituitary macro adenoma, prolactinoma

Other intracranial lesions: pituitary haemorrhage, midline tumours (craniopharyngioma)

Question 6

Endocrinological causes of amenorrhoea

Answer 6

Prolactinoma

Ovarian

• PCOS
• POI
• Menopause
• Genetic: Turner’s syndrome, Klinefelter’s

Thyroid disease

Question 7

Anatomical causes of amenorrhea

Answer 7

Müllerian agenesis

Ashermann’ sydnrome

Outflow obstruction

• Cervical stenosis
• Imperforate hymen
• Transverse vaginal septum

Question 8

Ashermann syndrome

• definition
• presentation
• causes

Answer 8

Acquired intrauterine adhesions

Presentation

• Amenorrhoea
• Abdominal distension
• Pelvic pain
• Recurrent miscarriage/ inferitility

Causes:

• Dilatation and curettage (following ectopic/ miscarriage)
• Previous myomectomy

Question 9

Cervical stenosis

• Description
• Causes
• Presentation
• management

Answer 9

Narrowing of the cervix due to fibrosis/ mass.

Causes

• Previous cervical surgery: Cone biopsy, LLETZ procedure
• Endometrial/ cervical cancer
• Radiation
• Menopause (atrophy)

Presentation

• Asymptomatic
• Amenorrhoea
• Haematometra (uterus filled with blood)

Management
- Cervical dilation

Question 10

Imperforate hymen

• Description
• Presentation
• Management

Answer 10

Hymen that covers the vaginal opening

Presentation

• Amenorrhoea
• Cyclic pelvic pain (around menstruation)
• Dyspareunia
• Difficulty inserting penis/ tampon

Management
- Incision

Question 11

Primary ovarian insufficiency

- Definition

Answer 11

Cessation in menses >1 year before age 40.

Question 12

Causes of primary ovarian insufficiency

Answer 12

Most common= Idiopathic

Autoimmune conditions

Toxins: chemotherapy, radiation

Question 13

Risk factors for POI

Answer 13

• Family history
• Chemo/ radiation
• Fragile X syndrome FHx
• Galactoseamia

Question 14

Complications of POI

Answer 14

Bones
- Osteoporosis/ Osteopenia= increased fracture risk

Skin and mucous membranes

• Dry skin
• Atrophic vaginitis, painful sex

Subfertility

Increased CVD morbidity and mortality

Question 15

Presentation of POI

Answer 15

Amenorrhoea/ Oligmenorrhea

Menopausal symptoms

• Hot flushes
• Cognitive difficulties
• Insomnia
• Dry skin/ brittle hair
• Irritability

Vaginal dryness

Question 16

Investigation for POI

Answer 16

FSH and LH
- Markedly elevated

Estradiol
- Low

Testosterone and SHBG
- Normal

Pregnancy test

Normal pralactin and TFTs

Question 17

Management of POI

Answer 17

Symptomatic

• Oestrogen gel/ cream
• SSRI for flushes/ irritability

Hormonal replacement
- Combined

Question 18

Diagnostic criteria for PCOS

Answer 18

At least 2:

• Amenorrhea
• Clincal +/- biochemical Hyperandrogenism
• Polycystic ovaries ( 12+ 2-9mm in size or >10cm3)

Question 19

Presentation of PCOS

Answer 19

Anovulation

• Amenorrhea
• Irregular cycles/ oligomennorrhea
• Infertility

Hyperandrogenism

• Hirsuitism
• Acne

Insulin resistance

• Central obesity
• Acanthosis nigricans

Polycystic ovaries
- Abdominal pain/ bloating

Question 20

Investigations for PCOS

Answer 20

Serum estradiol
- Low/ normal

Testosterone
- Moderate elevation

Sex hormone binding globulin (SHBG)

• Low/ normal
• Normal-low free androgen index

FSH
- High/ normal

LH
- Low/ normal

Ultrasound
- 12+ cysts 2-9mm/ 10cm3

HBA1c
- Hyperglycaemia/ DM

Prolactin
- Mild elevation/ normal

TSH
- Normal

Question 21

Non-pharmacological treatment in PCOS

Answer 21

Weight loss if overweight/ obese

Good diet and exercise
- To avoid insulin resistance

Hirsutism
- Laser, waxing

Screening for T2 diabetes/ gluocse intolerance

Question 22

Acne management in PCOS

Answer 22

1. COCP

2. Topical retinoids/ antibiotics

Question 23

First line medical management of PCOS in adolescents

Answer 23

Hyperandrogenism +/- irregular periods

- COCP

Question 24

Screening in PCOS

Answer 24

Hyperglycaemia/ DM
- 75 oral glucose tolerance test

Cardiovascular disease

• BMI
• Lipid profile
• Smoking status
• BP
• QRISK

Question 25

Management of amenorrhoea/ oligo menorrhoea in adults with PCOS

Answer 25

1. Cyclical medroxyprogestrone 10mg + ultrasound
   - Allow withdrawal bleed after 14 days
   - Assess for endometrial thickness
2. Normal endometrium
   - cyclical progesterone
   - Low dose COCP
   - IUS

Question 26

Complications of PCOS

Answer 26

• Increase risk of CVD
• Infertility
• Diabetes
• Endometrial hyperplasia/ cancer
• Sleep apnoea
• Pregnancy: gestational diabetes, pre-term birth, pre-eclampsia

Question 27

Fertility treatment for PCOS

Answer 27

Started in specialist care

Clomifene +/- metformin

Others
- Laparoscopic ovarian drilling