amenorrhoea

Question 1

primary vs secondary

Answer 1

primary - period never occurred by 16 years of age
secondary- absence of menses for >3 months

Question 2

causes of primary amenorrhea

Answer 2

mullerian agenesis
gonadal dysgenesis eg turners syndrome
pituitary disorders eg prolactinoma
hypothalamic disorders eg kallman’s syndrome

Question 3

causes of secondary amenorrhea

Answer 3

anorexia, extreme exercise and stress
pregnancy, menopause, usage of hormonal contraception
thyroid disorders
adrenal disorders
congenital adrenal hyperplasia
PCOS
androgen insensitivity syndrome
ashermans syndrome

Question 4

investigations for primary amenorrhea

Answer 4

FSH and LH
TFTs
IGF-1 for growth hormone deficiency
raised prolactin in hyperprolactinoma
raised testosterone in PCOS and androgen insensitivity syndrome and congenital adrenal hyperplasia

genetic testing with microarray for turners syndrome

Question 5

radiological investigations of secondary amenorrhea

Answer 5

CT or MRI scan of brain for prolactinoma
ultrasound of pelvis for polycystic ovarian syndrome

Question 6

hormonal tests of secondary amenorrhea

Answer 6

beta hCG
oestradiol and high FSH- menopause
high FSH- primary ovarian failure
high LH- PCOS
prolactin
TSH
SHBG
17 hydroxy progesterone (CAH)
fragile X for premature ovarian insufficiency

Question 7

management of primary amenorrhea

Answer 7

treat underlying cause
replacement hormones eg GnRH for hypogonadotrophic hypogonadism such as hypopituitarism or kallman syndrome

Question 8

Management of Secondary Amenorrhoea

Answer 8

• treat the underlying cause
• BMI: Aim for 20-30
• Offer HRT for Premature ovarian insufficiency
• Dopamine agonists, e.g. bromocriptine or cabergoline, for Prolactinoma
• Medroxyprogesterone or Combined oral contraceptive to stimulate a withdrawal bleed for Polycystic ovarian syndrome

Question 9

premature ovarian insufficiency

Answer 9

menopause occurring before age 40

Question 10

lack of oestrogen increases risk of what

Answer 10

• Cardiovascular disease
• Osteoporosis
• Pelvic organ prolapse
• Urinary incontinence

Question 11

contraindications of HRT

Answer 11

risk of VTE
recent MI
endometrial hyperplasia
deranged LFTs
oestrogen dependent cancer
breast cancer

Question 12

what must you do in HRT prescribing if woman still has a uterus

Answer 12

A prosgestogen must be used with oestrogen in HRT to prevent increased risk of endometrial cancer.

Question 13

HRT management regimens

Answer 13

Cyclical Combined HRT(Oestrogen all the time while Progesterone added for 2 weeks every month then stopped) is given to women who still have some natural ovarian function

Continuous Single HRT(Oestrogen only) is given to women who have had a hysterectomy

Continuous Combined HRT(Oestrogen and Progesterone every single day) is given to women who do not have any ovarian function(e.g. >1 yr after LMP)

can treat with conservative approach, should improve without improvement in 2-5 years