Amenorrhoea Flashcards
Define Primary Amenorrhoea
Absence of onset of menses by age 13 in the absence of secondary sexual characteristics
or age 15 but with secondary sexual characteristics
What are the top 5 causes of primary amenorrhoea?
Constitutional delay
X- Turner’s (Hyper Hypo)
M - Mullerian Agenesis (2)
A - Androgen insensitivity (2)
S - Swyer Syndrome (Hyper Hypo)
Give your list of differential diagnoses
First we need to determine if the patient has or does not have secondary sexual characteristics:
No sexual characteristics:
1) Hypogonadotropic Hypogonadism:
a) Constitutional delay
b) Anorexia/excessive weight loss
c) Chronic illness
d) Kallman’s Syndrome
2) Hypergonadotropic Hypogonadism: Ovarian problems (Hyper means axis is fine but ovaries are not)
a) Gonadal dysgenesis (Turner’s, Swyer) - Streak ovaries
b) Premature ovarian insufficiency (chromosomal, ovulation induction, GnRH)
c) Surgically/radiation -induced menopause
Presence of secondary sexual characteristics: Anatomical
a) Mullerian Agenesis
b) Vaginal septum
c) Imperforate Hymen
d) Androgen insensitivity syndrome
What is Kallman’s Syndrome?
Abnormal GnRH neuron development during embryogenesis and olfactory nerves also effective => Anosmia + infertility + primary amenorrhea
What is Swyer’s
46XY
Phenotypically female but genotypically a male
What should you elicit in a hx for primary amenorrhoea?
What are you looking for on exam?
Anosmia, cyclical pelvic pain (obstruction)
Past med of chronic systemic illness
Caloric intake and excessive exercise
Exam:
Presence or absence of secondary sex characteristics
BMI
Stature!!
Hirsuitism/virilization
Pelvic/inguinal mass
What investigations would you perform?
First, I would take B-hcg to rule out pregnancy
In the absence of secondary sexual characteristics:
FSH/LH to determine if hyper or hypo. If Hypo => constitutional delay, anorexia, Kallman, chronic illness
If Hyper => Karyotyping to rule out chromosomal
In the presence: of sexual characteristics, I would perform US uterus to check for abnormalities.
If abnormalities => Mullerian
If no abnormalities => Anatomical => vaginal septum or imperforate hymen
In Mullerian Agenesis: Ovaries are typically normal but may lie in an ectopic position. What is Mullerian Agenesis?
How do they present?
Vaginal Aplasia + other mullerian duct abnormalities
Type 1 - + uterus underdevelopment
Type 2 - + Uterus + Extrapelvic abnormalities, most commonly vertebral => scoliosis. May also be cardiac, urological or otological
They typically present with infertility, primary amenorrhoea, inability to have sex +/- Renal malformations +/- scoliosis
Define Secondary amenorrhoea
Absence of menorrhoea for >6 months, previously having menses
What are the top 3 causes of secondary amenorrhoea
Physiological causes:
1) Pregnancy
2) Lactation
3) Menopause >40
4) Contraception
Must include! PCOS
How does a traumatic brain injury lead to amenorrhoea?
What group of causes of secondary amenorrhoea would this fall into?
What other pathologies are in that list?
TBI causing hemorrhage will decrease blood flow to the pituitary leading to reduced action of the anterior pituitary from releasing FSH and LH
This is a part of pituitary pathologies
Pituitary adenoma and Sheehan’s
What is Sheehan’s syndrome?
What group of causes of secondary amenorrhoea would this fall into?
What other pathologies are in that list?
After PPH, there is reduced blood flow to the pituitary leading to pituitary necrosis leading to reduced action of the anterior pituitary from releasing FSH and LH
This is a part of pituitary pathologies
Pituitary adenoma and TBI
What is Asherman’s syndrome?
What group of causes of secondary amenorrhoea would this fall into?
What other pathologies are in that list?
Formation of scar tissue and adhesions in the uterus and cervix due to repeat LLETZ, D&C, PPH, ERPC
Anatomical causes
Cervical stenosis
Give 12 Ddx for secondary amenorrhoea
Physiological causes:
1) Pregnancy
2) Lactation
3) Menopause >40
4) Drugs (contraception, antipsychotics)
Hypogonadotropic hypogonadism:
1) Stress
2) Exercise
3) Anorexia
Hypergonadotropic hypogonadism:
1) Premature ovarian insufficiency
2) Surgical/radiation-induced menopause
Pituitary:
1) Pituitary adenoma (=> hyperprolactinemia)
2) Sheehan’s Syndrome
Thyroid/Adrenal:
1) Hypo/hyperthyroidism
2) Adrogen-secreting tumour
3) Cushing’s syndrome
Ovarian Disorders:
1) PCOS
2) Androgen secreting germ cell tumours
Anatomical:
1) Asherman’s syndrome
2) Cervical stenosis
What would you elicit in a history of secondary amenorrhoea
Hot flushes, vaginal dryness, weight changes (for menopause, premature ovarian insufficiency, radiotherapy-induced),
Weight change (Exercise, anorexia, hyperthyroidism)
Hx of TBI, hemorrhagic stroke
Visual disturbance, headache (Pituitary adenoma)
Gynae History -> Menstrual changes, contraception
Obs hx -> PPH, Sheehan’s
Surgical hx -> LLETZ, D&C, ERPC (Asherman’s)
Fam hx -> PCOS (50% familial)
Medications (Antipsychotics, contraception)
