Amenorrhea/Oligomenorrhea

Question 1

Amenorrhea is defined as not having periods. This can be primary or secondary amenorrhea. Match primary and secondary amenorrhea to the definitions below:

• menstrual cycles stop for a period >6 months, or >12 months in a patient who has oligomenorrhoea (irregular and inconsistent menstrual cycles)
• failure of menstruation by 16 y/o in presence of secondary sexual characteristics OR 14 y/o with no secondary sexual characteristics

Answer 1

• secondary amenorrhea = menstrual cycles stop for a period >6 months, or >12 months in a patient who has oligomenorrhoea (irregular and inconsistent menstrual cycles)
• primary amenorrhea - failure of menstruation by 16 y/o in presence of secondary sexual characteristics OR 14 y/o with no secondary sexual characteristics

Question 2

What is the average age of menarche?

1 - 10 y/o
2 - 12 y/o
3 - 15 y/o
4 - 17 y/o

Answer 2

2 - 12 y/o

Question 3

How long does the average cycle last?

1 - 15-20 days
2 - 20-26 days
3 - 21-35 days
4 - 25-39 days

Answer 3

3 - 21-35 days
- bleeding typically lasts 3-7 days
- typical amounts range between 30-40ml

Question 4

At what point of the menstrual cycles does the time period of the next cycle begin?

1 - during menstruation (bleeding) starts
2 - when ovulation occurs
3 - when progesterone levels peak around day 20
4 - when the luteal phase starts

Answer 4

1 - during menstruation (bleeding) starts

Question 5

Puberty in girls typically begins around 9-11 years old. Organise the following in the order in which they occur during puberty:

1 - pubic hair development
2 - menarche
3 - formation of breast bud
4 - growth spurt
5 - axillary hair development

Answer 5

3 - formation of breast bud
1 - pubic hair development
5 - axillary hair development
4 - growth spurt
2 - menarche

• Tanner staging is used to determine stage of puberty

Question 6

Which of the following is NOT a characteristic of oligomenorrhea?

1 - irregular and inconsistent menstrual cycle
2 - last < 25 days
3 - bleeding can be light of heavy
4 - menarche has occured

Answer 6

2 - last < 25 days
- typically lasts >35 days

Question 7

Which 2 of the following are physiological causes of amenorrhea?

1 - constitutional delay
2 - iatrogenic
3 - medication
4 - pregnancy

Answer 7

1 - constitutional delay
- delay in sexual development). The causes of primary

4 - pregnancy
- can occur prior to having a period

Question 8

Which of the following is NOT a class of medication that has been linked with primary or secondary amenorrhea?

1 - Antipsychotics
2 - Anti-depressants
3 - Chemotherapy
4 - Radiotherapy
5 - Illicit drugs e.g: cocaine, opiates

Answer 8

2 - Anti-depressants

Question 9

Which of the following is NOT a hormonal causes of primary or secondary amenorrhea?

1 - Hypothalamic pituitary ovarian dysfunction
2 - Thyroid disorder
3 - Cushing syndrome
4 - Prolactinoma
5 - Addisions disease
6 - Androgen secreting tumour
7 - Premature ovarian failure

Answer 9

5 - Addisions disease
- disease where adrenal gland does secrete sufficient cortisol and aldosterone

Question 10

Which of the following is the most common genetic causes of primary amenorrhea?

1 - Androgen insensitivity syndrome
2 - Turner syndrome
3 - Rotinstansky-Kustner-Hauser syndrome
4 - Late onset adrenal hyperplasia

Answer 10

2 - Turner syndrome
- patient is missing an X chromosome, so instead of 46 they will be 45 X
- leads to amenorrhea and infertility

Question 11

Turners syndrome is the most common genetic cause of primary amenorrhea. Which of the following is NOT a typical characteristic of patients with Turner Syndrome?

1 - tall stature
2 - webbing of neck
3 - oedema of hands and feet
4 - broad shield chest
5 - left sided heart or aortic anomalies
6 - renal anomalies
7 - gonadal dysgenesis

Answer 11

1 - tall stature
- patients are typically short in stature

Question 12

When trying to diagnose turners syndrome, we can measure Follicle-Stimulating Hormone (FSH). Is this typically high or low?

Answer 12

• high
• low levels of oestrogen and progesterone to provide negative feedback loop

Question 13

What is the gold standard for diagnosing patients with Turners syndrome?

1 - FSH and LH levels
2 - pelvic ultrasound
3 - karyotyping
4 - biopsy of ovary

Answer 13

3 - karyotyping
- confirms genetic abnormality

Question 14

Once diagnosed with Turner syndrome, how are these patients treated?

1 - steroids
2 - oestrogen
3 - synthetic FSH and LH
4 - all of the above

Answer 14

2 - oestrogen
- 0.3mg conjugated estrogen or 0.5mg oestradiol/day)
- start around puberty and gradually increased over 18- 24 months to mimic normal puberty
- aim to protect bone health

Question 15

If a patient has high levels of follicular stimulating hormone (FSH) and leutenising hormone (LH), is this referred to as Hypergonadotropic hypogonadism or Hypogonadotropic hypogonadism?

Answer 15

Hypergonadotropic hypogonadism
= high FSH and LH
- Turner syndrome, absent ovaries

Hypogonadotropic hypogonadism = low FSH and LH

Question 16

Hypogonadotropic hypogonadism
is when there is low FSH and LH and can cause primary amenorrhea. All of the following can cause this except which one?

1 - hypothalamus/ pituitary damage (radiotherapy or chemotherapy)
2 - chronic illness
3 - Turners syndrome
4 - excessive exercise
5 - diet
6 - slow constitutional development 7 - endocrine disorder
7 - Kallman’s syndrome

Answer 16

3 - Turners syndrome
- this is a genetic condition where there is a missing X chromosome and causes high LH and FSH

Question 17

Kallmans syndrome is an endocrine disorder causing hypogonadotropic hypogonadism that can cause primary amenorrhea. Which of the following is NOT an associated factor of Kallmans syndrome?

1 - loss of, or no smell
2 - high levels of gonadotropin releasing hormone
3 - low estrogen and progesterone
4 - lack of or no puberty

Answer 17

2 - high levels of gonadotropin releasing hormone
- this will be low, and explains the low LH and FSH

Question 18

An imperforate hymen can cause primary amenorrhea. What is an imperforate hymen?

1 - hymen has become fibrotic from scarring
2 - hymen has not developed
3 - hymen covers the opening to the vagina
4 - can be any of the above

Answer 18

3 - hymen covers the opening to the vagina
- blood can collect behind the hymen, appearing blue due to blood pooling
- the hymen is opened using cruciate incision then excised and the mucosal margins are approximated with fine delayed absorbable suture

Question 19

Androgen insensitivity syndrome is a genetic condition where a male with XY chromosomes does not respond to testosterone. Which of the following is NOT a typical phenotypes of these patients?

1 - absent uterus
2 - absent fallopian tubes
3 - absent ovaries
4 - testicles present in scrotum
5 - breast development at puberty
6 - pubic and axillary hair develop at puberty

Answer 19

4 - testicles present in scrotum
- testicles are present but undescended in pelvis / abdomen

• the genetics are male, but patients develop as female without reproductive organs

Question 20

When trying to identify secondary amenorrhea, which is a lack of period >6months or 12 months in patient with oligomenorrhoea, we must exclude which of the following physiological causes?

1 - pregnancy
2 - lactation
3 - menopause
4 - all of the above

Answer 20

4 - all of the above

Question 21

Secondary amenorrhea can occur anywhere from the brain to the reproductive organs. Which of the following is NOT likley to affect the hypothalamus?

1 - excessive exercise
2 - poly cystic ovarian syndrome
3 - psychological disturbance
4 - weight loss

Answer 21

2 - poly cystic ovarian syndrome
- can cause secondary amenorrhea, but affects the ovaries directly

Question 22

Sheehan syndrome can cause secondary amenorrhea, due to necrosis of the pituitary cells in the post-natal period. What is the main cause of this necrosis?

1 - substantial blood loss during labour (PPH)
2 - autoimmune following delivery of baby
3 - infection following delivery
4 - swelling of the brain

Answer 22

1 - substantial blood loss during labour (PPH)
- essentially Ischemia to the cells of the pituitary so hormone levels drop

Question 23

Ashermans syndrome can be a cause of secondary amenorrhea, but what is the cause of Ashermans syndrome?

1 - polyps rupturing causing adhesions
2 - iatrogenic causing adhesions in uterus
3 - endometriosis
4 - adenomyosis

Answer 23

2 - iatrogenic causing adhesions in uterus
- typically following delivery or procedure the uterus is damaged

Question 24

A common cause of secondary amenorrhea is polycystic ovarian syndrome (PCOS). Based on the new guidelines, how many of the following are needed to diagnose a patient with PCOS?

• oligomenorrhoea or amenorrhea
• ultrasound confirming a volume of >10cm3and/or multiple small follicles (12 or more <10mm)
• clinical evidence of excess androgens (acne, hirsutism) or biochemical evidence (raised serum testosterone).

1 - all 3 are needed
2 - just 1 is needed
3 - 2 or more are needed

Answer 24

3 - 2 or more are needed
- PCOS is associated with menstrual disorder and a common cause of anovulatory subfertility

• before diagnosis, must also rule out the exclusions in top right of figure, but anything that causes excess androgens

Question 25

Although the exact cause of why PCOS causes secondary amenorrhea, what is hypothesised to be the main cause?

1 - ovaries do not produce dominant follicle
2 - ovaries become blocked
3 - hyperinsulinaemia increases levels of ovarian androgen
4 - all of the above

Answer 25

3 - hyperinsulinaemia increases levels of ovarian androgen

Question 26

Hirsutism is often present in patients with PCOS. What is hirsutism?

1 - excess hair growth, typically male pattern hair growth
2 - reduction in breast size or development
3 - decrease in bone density
4 - all of the above

Answer 26

1 - excess hair growth, typically male pattern hair growth

• typically caused by excess androgen
  that becomes testosterone.