Amenorrhoea

Question 1

What is this a presentation of?

Absence of menstruation.

Answer 1

Amenorrhoea

Question 2

What is this a presentation of?

Menstruation not started by 16 years of age, or a 14 year old with no breast delevlopment.

Answer 2

Primary amenorrhoea

Question 3

What is the cause of primary amenorrhoea?

Answer 3

In most it is late puberty (often familial) so reassure

Question 4

How is primary amenorrhoea investigated?

Answer 4

1. Normal external secondary sexual characteristics? Normal external genitalia (if normal consider outflow issue)?
2. Test for causes of secondary amenorrhoea
3. If not developing normally: karyotyping may reveal Turner’s, AIS, or 5-alpha-reductase deficiency.

Question 5

What is this a presentation of?

Previously normal menstruation ceases for >6 months not due to pregnancy.

Answer 5

Secondary amenorrhoea

Question 6

What are the causes of secondary amenorrhoea?

Gonad, pituitary, ovarian, uterine, other, congenital, outflow

Answer 6

1. Hypothalamic hypogonadism - stress, exercise, weight loss
2. Pituitary - hyperprolactinaemia, rare tumours, Sheehan’s syndrome
3. Ovarian - PCOS, POI
4. Uterine - pregnancy, Asherman’s syndrome
   Other - thyroid issues, CAH, IUS, chemo/radiotherapy
5. Congenital - Turner’s, rarely gonadal dysgenesis/AIS
6. Outflow - imperforate hymen, transverse vaginal septum, cervical stenosis

Question 7

How is secondary amenorrhoea investigated?

Answer 7

1. bHCG - exclude pregnancy
2. Testosterone - raised in androgen secreting tumours
3. FSH/LH - raised FSH in premature menopause
4. AMH
5. Mid luteal progesterone - PCOS
6. PRL
7. TFTs
8. 17-OHP - CAH
9. TV USS - structural causes

Question 8

What is the management for secondary amenorrhoea?

Answer 8

1. Treat the cause

2. Consider bone density