Amenorrhea Flashcards
Menstrual/ proliferative phase of the menstrual cycle
- Length
- Uterus
- Hormones
- Cervix
Length: 7-21 days
- Menstruation
- Fall of oestrogen and progesterone triggers shedding of the functionalis layer.
- Cervix dilates - Proliferation
- GnRH = rise in FSH= rise in oestrogen
- Follicular development, endometrial proliferation
- Peak in LH= ovulation
- Cervical mucus is watery and profuse during ovulation
Secretory and pre-menstrual phase
- Length
- Uterus
- Hormones
- Cervix
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
Physiological causes of amenorrhoea
Pregnancy
Menopause
Functional causes of amenorrhoea
Describes “non-organic” causes:
- Rapid weight loss/ anorexia nervosa/ low body far percentage
- Excessive exercise
- Prolonged psychological stress
Hypothalamic/pituitary causes of amenorrhoea
Functional: stress, low body fat percentage, excessive exercise
Tumours: pituitary macro adenoma, prolactinoma
Other intracranial lesions: pituitary haemorrhage, midline tumours (craniopharyngioma)
Endocrinological causes of amenorrhoea
Prolactinoma
Ovarian
- PCOS
- POI
- Menopause
- Genetic: Turner’s syndrome, Klinefelter’s
Thyroid disease
Anatomical causes of amenorrhea
Müllerian agenesis
Ashermann’ sydnrome
Outflow obstruction
- Cervical stenosis
- Imperforate hymen
- Transverse vaginal septum
Ashermann syndrome
- definition
- presentation
- causes
Acquired intrauterine adhesions
Presentation
- Amenorrhoea
- Abdominal distension
- Pelvic pain
- Recurrent miscarriage/ inferitility
Causes:
- Dilatation and curettage (following ectopic/ miscarriage)
- Previous myomectomy
Cervical stenosis
- Description
- Causes
- Presentation
- management
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
Imperforate hymen
- Description
- Presentation
- Management
Hymen that covers the vaginal opening
Presentation
- Amenorrhoea
- Cyclic pelvic pain (around menstruation)
- Dyspareunia
- Difficulty inserting penis/ tampon
Management
- Incision
Primary ovarian insufficiency
- Definition
Cessation in menses >1 year before age 40.
Causes of primary ovarian insufficiency
Most common= Idiopathic
Autoimmune conditions
Toxins: chemotherapy, radiation
Risk factors for POI
- Family history
- Chemo/ radiation
- Fragile X syndrome FHx
- Galactoseamia
Complications of POI
Bones
- Osteoporosis/ Osteopenia= increased fracture risk
Skin and mucous membranes
- Dry skin
- Atrophic vaginitis, painful sex
Subfertility
Increased CVD morbidity and mortality
Presentation of POI
Amenorrhoea/ Oligmenorrhea
Menopausal symptoms
- Hot flushes
- Cognitive difficulties
- Insomnia
- Dry skin/ brittle hair
- Irritability
Vaginal dryness
Investigation for POI
FSH and LH
- Markedly elevated
Estradiol
- Low
Testosterone and SHBG
- Normal
Pregnancy test
Normal pralactin and TFTs
Management of POI
Symptomatic
- Oestrogen gel/ cream
- SSRI for flushes/ irritability
Hormonal replacement
- Combined
Diagnostic criteria for PCOS
At least 2:
- Amenorrhea
- Clincal +/- biochemical Hyperandrogenism
- Polycystic ovaries ( 12+ 2-9mm in size or >10cm3)
Presentation of PCOS
Anovulation
- Amenorrhea
- Irregular cycles/ oligomennorrhea
- Infertility
Hyperandrogenism
- Hirsuitism
- Acne
Insulin resistance
- Central obesity
- Acanthosis nigricans
Polycystic ovaries
- Abdominal pain/ bloating
Investigations for PCOS
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
Non-pharmacological treatment in PCOS
Weight loss if overweight/ obese
Good diet and exercise
- To avoid insulin resistance
Hirsutism
- Laser, waxing
Screening for T2 diabetes/ gluocse intolerance
Acne management in PCOS
- COCP
2. Topical retinoids/ antibiotics
First line medical management of PCOS in adolescents
Hyperandrogenism +/- irregular periods
- COCP
Screening in PCOS
Hyperglycaemia/ DM
- 75 oral glucose tolerance test
Cardiovascular disease
- BMI
- Lipid profile
- Smoking status
- BP
- QRISK
Management of amenorrhoea/ oligo menorrhoea in adults with PCOS
- Cyclical medroxyprogestrone 10mg + ultrasound
- Allow withdrawal bleed after 14 days
- Assess for endometrial thickness - Normal endometrium
- cyclical progesterone
- Low dose COCP
- IUS
Complications of PCOS
- Increase risk of CVD
- Infertility
- Diabetes
- Endometrial hyperplasia/ cancer
- Sleep apnoea
- Pregnancy: gestational diabetes, pre-term birth, pre-eclampsia
Fertility treatment for PCOS
Started in specialist care
Clomifene +/- metformin
Others
- Laparoscopic ovarian drilling
