Amenorrhoea Flashcards
Causes of primary amenorrhoea
Turners syndrome Imperforate hymen Hyperandrogenism - congenital adrenal hyperplasia delayed puberty Mullerian agenesis Low BMI
Causes of secondary amenorrhoea
Pregnancy Contraception Sheehan's syndrome Stress - BMI/ exercise Hyperthyroidism PCOS Prolactinoma
Investigations of amenorrhoea
Bloods - TFTs, FSH, LH, androgens, oestrogen, prolactin
USS
Karyotyping
Oligomenorrhoea definition
The duration between cycles is more than 35 days but less than 6 months
Secondary amenorrhoea
Not had a period after 3 months if cycles were normally regular or 6 months if irregular with oligomenorrhoea
Investigations for secondary amenorrhoea
Pregnancy test
Bloods - FSH, TSH, Prolactin
FSH normal:
- USS
Definition of primary amenorrhoea
Not starting menstruation by:
- 13 years with no evidence of pubertal development
OR
By 15 yo where there are other signs of puberty
When should normal puberty occur
Age 8 – 14 in girls
Age 9 – 15 in boys
Female puberty
- Breast buds - thelarche
- Pubic hair
- Menarche
Types of hypogonadism
- Hypogonadotropic hypogonadism
- Hypergonadotropic hypogonadism
Hypogonadotropic hypogonadism
Deficiency of LH and FSH released from the pituitary gland
Hypergonadotropic hypogonadism
Lack of response to LH and FSH by the gonads (the testes and ovaries)
Causes of hypogonadotropic hypogonadism
Hypopituitarism
Damage to the hypothalamus/ pituitary - radiotherapy/ surgery
Chronic conditions can temporarily delay puberty (e.g. cystic fibrosis or inflammatory bowel disease)
Excessive exercise or dieting
Constitutional delay in growth and development
Growth hormone deficiency, hypothyroidism, Cushing’s or hyperprolactinaemia
Kallman syndrome
Causes of hypergonadotropic hypogonadism
Previous damage to the gonads (e.g. torsion, cancer or infections such as mumps)
Congenital absence of the ovaries
Turner’s syndrome (XO)
Kallman syndrome
Pubertal delay and anosmia
Congenital adrenal hyperplasia pathophysiology
Congenital deficiency of the 21-hydroxylase enzyme.
Causing an underproduction of cortisol and aldosterone, and overproduction of androgens from birth
Inheritance pattern of congenital adrenal hyperplasia
Autosomal recessive
Presentation of congenital adrenal hyperplasia
Tall for their age
Facial hair
Absent periods (primary amenorrhoea)
Deep voice
Early puberty
Androgen Insensitivity Syndrome pathophysiology
Tissues are unable to respond to androgen hormones (testosterone)
Presentation of androgen insensitivity syndrome
Female phenotype - female external genitalia and breast tissue with male internal sexual organs (testes)
Types of structural pathology
Imperforate hymen
Transverse vaginal septae
Vaginal agenesis
Absent uterus
Female genital mutilation
Investigations for primary amenorrhoea
Bloods:
- FBC, ferritin -anaemia
- U&E - CKD
- Anti-TTG or anti-EMA antibodies -coeliac disease
- TFTs
- Insulin-like growth factor I - screening test for GH deficiency
Hormonal blood tests assess
Genetic testing with a microarray test
Imaging
Hormonal blood tests for primary amenorrhoea
FSH and LH will be low in hypogonadotropic hypogonadism
High in hypergonadotropic hypogonadism
Prolactin -hyperprolactinaemia
Testosterone - PCOS, androgen insensitivity syndrome and congenital adrenal hyperplasia
Genetic testing with a microarray test
Turner’s syndrome (XO)
Imaging for primary amenorrhoea
Xray of the wrist -bone age for constitutional delay
Pelvic USS - assess the ovaries and other pelvic organs
MRI - pituitary pathology and assess the olfactory bulbs in Kallman syndrome
How to treat hypogonadotrophic hypogonadism
Pulsatile GnRH
How to treat primary amenorrhoea due to stress
Reduction in stress:
- CBT
- healthy weight gain
How to treat constitutional delay in growth and development
Reassurance and observation
Treatment for hyperprolactinaemia
Dopamine agonists -bromocriptine or cabergoline
Investigations for hyperprolactinaemia
Bloods - prolactin
MRI scan - pituitary adenoma
Why do women with PCOS have a withdrawal bleed every 3 - 4 months
Reduce the risk of endometrial hyperplasia and endometrial cancer
Complications of amenorrhoea
Amenorrhoea associated with low oestrogen -increased risk of osteoporosis.
Where the amenorrhoea lasts more than 12 months, treatment is indicated to reduce the risk of osteoporosis:
Ensure adequate vitamin D and calcium intake
Hormone replacement therapy or the combined oral contraceptive pill
When to reduce risk of amenorrhoea related osteoporosis
Amenorrhoea lasting 12 months + :
- Adequate vitamin D and calcium intake
- Hormone replacement therapy or the COCP
