Amenorrhoea

Question 1

Definition of amenorrhoea

• Primary
• Secondary

Answer 1

• Primary amenorrhoea
  
  • Failure to start menstruating by 15 years of age
  • Absence of menstruation and secondary sexual characteristics by 14 years of age
• Secondary amenorrhoea
  
  • Menstruation stops for > 6 months
    
    • Physiological reasons include:
      
      • Pregnancy
      • Breastfeeding
      • Contraception
      • Postmenopause

Question 2

Aetiology of primary amenorrhoea

Answer 2

*RULE OUT PREGNANCY*

• Constitutional delay (familial - enquire!)
• Imperforate hymen (obstructive outflow tract)
• Hypothalamic-pituitary dysfunction
  
  • Stress
  • Exercise
  • Underweight
• Turner syndrome (45 XO)
  
  • Ovarian dysgenesis/failure
  • Short stature (compare with other family members), webbed neck
• Testicular feminisation (androgen resistance syndrome)
  
  • XY karyotype
  • External appearance of normal adolescent girl, but no internal female organs (gonads are testes)
• Extreme athleticism/low body fat
  
  • Poor nutritional status (systemic illness/eating disorder?)
• Reproductive tract malformation (Mullerian anomalies)
• Absence of the uterus or vagina

Most causes of secondary amenorrhoea can also cause primary amenorrhoea, if established before the menarche.

Question 3

Aetiology of secondary amenorrhoea

Answer 3

*PREGNANCY UNTIL PROVEN OTHERWISE*

• Physiological
  
  • Pregnancy
  • Lactation
  • Menopause
  • Contraception
• Behavioural (Hypothalamic-pituitary-ovarian axis dysfunction)
  
  • Stress
  • Extreme athleticism
  • Low body fat
• Endocrine
  
  • Polycystic ovary syndrome
    
    • Hirsutism
    • Acne
    • Obesity
  • Hyperprolactinaemia
    
    • Galactorrhoea (milk secretion)
      
      • Prolactinoma (headache, visual field changes?)
      • Hyper/hypothyroidism
      • Drug-induced
  • Traumatic head injury

Question 4

Amenorrhoea history

Answer 4

• Age
• Duration of amenorrhoea
• Pregnant?
• Menstrual Hx
• Contraceptive Hx
• Differentials
  
  • Hypothalamic
    
    • Recent stressful events
    • Exercise
    • Diet/appetite/weight (anorexia nervosa)
  • Hyperprolactinaemia
    
    • Galactorrhoea
    • Headaches
    • Visual disturbances
  • PCOS (hirsutism)
  • Premature ovarian failure
    
    • Vasomotor symptoms
• PMH
  
  • Thyroid
• Drug Hx

Question 5

Main causes of amenorrhoea

Answer 5

• Hypothalamic
• PCOS
• Hyperprolactinaemia
• Premature ovarian failure