Amenorrhoea Flashcards
Define primary amenorrhoea
Failure to establish menstruation by the time of the expected menarche (0.3% prevalence)
By 15yo in those with normal secondary sexual characteristics
By 13yo with no secondary sexual characteristics
Define secondary amenorrhoea
Cessation of menstruation in women with previous menses (3-4% prevalence in reproductive age)
3 months in women with previously normal menstruation
6 months in women with previous oligomenorrhoea
Give examples of secondary sexual characteristics
Breast growth
Pubic hair
Armpit hair
Widening of hips
Define oligomenorrhoea
menses occurring less frequently than every 35 days
What are the causes of primary amenorrhoea with secondary sexual characteristic development
Physiological: constitutional delay, pregnancy
Genito-urinary malformation: imperforate hymen, transverse septum, absent vagina/uterus
Endocrine disorders: hypothyroidism/hyperthyroidism, Hyperprolactinaemia, Cushing’s syndrome, PCOS
Androgen insensitivity syndrome
What are the causes of primary amenorrhoea without secondary sexual characteristic development
Primary ovarian insufficiency
Hypothalamic dysfunction: stress, excessive exercise, weight loss, tumours
Chronic systemic illness: diabetes, coeliac, cancer
Pituitary dysfunction: tumour, Kallman’s syndrome, empty sella syndrome
Prader-Willi syndrome
Ambiguous genitalia: 5-alpha-reductase deficiency, androgen-secreting tumours, congenital adrenal hyperplasia
What are the causes of secondary amenorrhoea
Physiological: pregnancy, lactation, menopause
Premature ovarian insufficiency
Hypothalamic dysfunction: stress, excessive exercise, weight loss, tumours, CNS tumours, head injury, cranial irradiation
Pituitary causes: prolactinoma, hypopituitarism, Sheehan’s syndrome, Sarcoidosis, TB
Uterine causes: Cervical stenosis, Asherman’s syndrome
Endocrine: Hyperthyroidism/hyperthyroidism, PCOS, Cushing’s syndrome, late-onset congenital adrenal hyperplasia, androgen-secreting tumours
Iatrogenic: Hormonal contraception, antipsychotics, cocaine, opiates, hysterectomy
What investigations should be done for amenorrhoea
Bedside: height & weight, urine pregnancy test
Bloods: prolactin, TFTs, FSH and LH, testosterone, AMH, karyotype
other: pelvic USS, MRI
What are you looking for on pelvic US for amenorrhoea
Presenc of a vagina and uterus
Imperforate hymen or transverse vaginal septum
Evidence of PCOS
‘Streak’ ovaries - Turner’s
Abnormal uterus
What level of prolactin warrants further investigation and how
> 1000 mIU/L → warrants further investigation via MRI for pituitary adenoma, empty sella syndrome, hypothyroidism, antipsychotics
What does a high FSH/LH result suggest for in amenorrhoea
Premature ovarian insufficiency
PCOS (LH>FSH ratio >3)
What does a low FSH/LH result suggest for in amenorrhoea
Hypothalamic causes: stress, excessive exercise, weight loss, tumours, CNS tumours, head injury, cranial irradiation
What will the results (FSH, LH, prolactin, testosterone) be for hyperprolactinaemia
FSH: Normal/low
LH: Normal/low
Prolactin: High
Testosterone: Normal
What will the results (FSH, LH, prolactin, testosterone) be for PCOS
FSH: Normal
LH: Normal/increased
Prolactin: Normal/increased
Testosterone: Normal/increased
What will the results (FSH, LH, prolactin, testosterone) be for ovarian failure
FSH: High
LH: High
Prolactin: Normal
Testosterone: Normal
What will the results (FSH, LH, prolactin, testosterone) be for hypothalamic causes of amenorrhoea
FSH: Low/normal
LH: Low/normal
Prolactin: Normal
Testosterone: Normal
What is the management for primary amenorrhoea
Refer to gynaecology or endocrinology
Consider osteoporosis prophylaxis
- Assess fragility fracture risk using Qfracture or FRAX
- Advice on lifestyle: weight-bearing exercise, avoid smoking, balanced diet
- Vitamin D and calcium
- Consider HRT (cyclical combined)
What is the management for secondary amenorrhoea
Consider referral
Contraceptive advice
Consider osteoporosis prophylaxis
- Assess fragility fracture risk using Qfracture or FRAX
- Advice on lifestyle: weight-bearing exercise, avoid smoking, balanced diet
- Vitamin D and calcium
- Consider HRT (cyclical combined)
What are the complications of amenorrhoea
Osteoporosis related to oestrogen deficiency (particularly ovarian failure, weight loss, anorexia nervosa, excessive exercise)*
Cardiovascular disease related to oestrogen deficiency
Infertility
Psychological deficiency e.g. anxiety, altered self-image, loss of self-esteem, worries related to infertility
*The increased risk persists even if normal menses are resumed, especially in adolescents
