Amenorrhea

Question 1

Differentiate between primary and secondary amenorrhea

Answer 1

Primary is when one has never had their period and can have or not have secondary sex characteristics

Secondary is when one has had a period but now has had a 3-6 months of no periods

Question 2

Outline the main causes of primary amenorrhea (5)

Answer 2

Errors in genital differentiation
Errors in gonaductal development
Errors in gonadal development
Disturbance in hypothalamic-pirtuitary axis
Follicles unresponsive to gonadotropins

Question 3

Outline the causes of secondary amenorrhea

Answer 3

(Think of glands and hormones contributing to periods)

Hypothalamus- Stress, Anorexia, Athlete
Pituitary- Prolactinoma, Tumour, Sheehan syndrome (infarct in brain/pirtuitaary)
Thyroid- Hypothyroidism (=hyperprolectemia)
Adrenals- Addisons, Cushing’s syndrome
Ovaries- Gonodal dysgenesis eg Turner syndrome, POF(premature ovarian failure), luteal cysts, PCOS
Uterus- Asherman syndrome
Cervix- stenosis of cervix

Question 4

List some of the long term issues of PCOS

Answer 4

Infertility
Endometrial cancer
Metabolic syndrome

Question 5

Outline the Rotterdam criteria for diagnosing PCOS

Answer 5

1. Oligo/Amenorrhea
2. Virilising features -Clinically of Biochemically
3. PCO on Scan

Question 6

What investigations do you do for someone presenting with Amenorrhea

Answer 6

Prognostics
Glucose & insulin
Lipids
Testosterone/Androgens
LH>FSH
US

Question 7

What is the criteria from investigation in a woman presenting with amenorrhea(6)

Answer 7

Delayed puberty (14 with no secondary sex characteristics)
Delayed monarch (16 with secondary sex characteristics but no period)
Signs of hyperandrogenisms
Ambiguous genitalia
Dysmorphic features
Amenorrhea for a time equivalent to at least 3 prev cycles

Question 8

What should be the average thickness of endometrium

Answer 8

4mm

Question 9

List some of the features of Turner’s syndrome (5)

Answer 9

Webbed neck
High arched palate
Low set ears
Low posterior hairline
Epicanthal folds
Micrognanthia
Increased carrying angle of arms
Shield like chest
Wide spaced nipples
CVS: coarctation of aorta
Renal abnormalities
Shortened fourth and fifth digit
Lymphoedema at birth
IUGR

Question 10

List 5 clinical features of PCOS on presentation

Answer 10

Amenorrhea /oligo
Acne
Hirsutism
Male pattern balding
Obesity
Acanthosis nigricans

Question 11

List the features of US in a pt with PCOS (4)

Answer 11

Large volume ovaries (>10m2)
Peripheral distribution of follicles
12 or more follicle of 2-9mm
Dense stroma

Question 12

Describe PCOS pathophysiology

Answer 12

(To watch YT video on it)

Question 13

Discuss the management of PCOS

Answer 13

Obese -weight loss, diet
Imsulin resistance : metformin
Hyperandrogens: therapy antiandrogens
Oligo/ amenorrhea: Contraceptives(COC, mirena or depot)
Fertility: IVF, clomifene?

Question 14

How do you diagnose PCOS (3) (Rotterdam criteria)

Answer 14

Oligo/amenorrhea
Hyperandregens (hirsuitims, acne, male pattern balding)
US

Question 15

What investigations would you do for someone presenting with features of PCOS (hirsutism and infertility for eg)

Answer 15

Oligo/amenorrhea: FSH, LH
Hyperandrogens : serum testosterone
Insulin resistance: Insulin, Glucose, Lipids
Adrenal pathology: 17 alpha hydro-progesterol for CAH, DHEAS (acanthosis nigricans may be present on exam)
US

Question 16

List the causes of hyperandrogens (3)

Answer 16

Adrenal : CAH, Cushings
Ovary: Tumours
Drugs

Question 17

List some of the end organ causes of amenorrhea (5)

Answer 17

• Congenital
  - Imperforate hymen

       - Transverse vaginal septum
  
       - Vaginal agenesis
  
       - Mayer – Rokitansky – Küster – Hauser                 Syndrome
                       
                 - Disorders of sexual differentiation

Acquired
-Asherman syndrome
-TB endometrium