Amenorrhoea

Question 1

Definition

Answer 1

The absence of a menstrual period

Question 2

Types of amenorrhoea

Answer 2

• Primary: Failure to start menstruation by the age of 15 with secondary characteristics OR by 13 with primary characteristics
• Secondary: Absence of 3 consecutive cycles in those with a normal menstrual cycle

Question 3

Primary Causes

Answer 3

• Constitutional delay (familial)
• Imperforate hymen
• Endocrine disorders: Hypo/er-thyroidism, hyperprolactinaemia, Cushing’s syndrome
• Androgen insensitivity syndrome
• Turner’s syndrome

Question 4

Secondary

Answer 4

• Functional Hypothalamic Amenorrhoea - excessive exercise, weight loss, stress, eating disorders
• Premature ovarian insufficiency
• Sheehan’s syndrome, prolactinoma, hypopituitarism,
• Hypo/er-thyroidism

Question 5

Secondary puberty changes

Answer 5

Breast buds,
Pubic hair,
Menstrual periods about two years from start of puberty

Question 6

Diagnosis

Answer 6

• History and examination
• FBC + ferritin = anaemia
• U+E
• Anti-TTG or Anti-EMA = coeliac disease
• Hormonal blood tests:
  = FSH + LH: low in hypogonadotropic hypogonadism and high in hypergonadotropic hypogonadism
  = TFT’s
  = Insulin-like growth factor
  = Prolactin
  = Testosterone
• Genetic testing for Turner’s syndrome
• X-ray of wrist to assess bone age for constitutional delay
• Pelvic USS for reproductive organs AIS
• MRI - pituitary pathology

Question 7

Primary Treatment

Answer 7

Treat underlying cause
- Lifestyle changes: reduce stress, healthy weight gain
- hypogonadotrophic hypogonadism: pulsatile GnRH
* has risk of inducing infertility *
- PCOS, or absence of ovaries: COCP

Question 8

Secondary Diagnosis

Answer 8

Hormonal blood tests
- bHCG = pregnant
- LH + FSH
= High FSH suggests primary ovarian failure
= High LH or LH:FSH suggests PCOS
- Prolactin
- TFTs
USS of pelvis

Question 9

Treatment

Answer 9

Treat underlying cause

Question 10

Importance of withdrawal bleed for women with PCOS

Answer 10

TOM TIP: Women with PCOS require a withdrawal bleed every 3 – 4 months to reduce the risk of endometrial hyperplasia and endometrial cancer. Medroxyprogesterone for 14 days, or regular use of the combined oral contraceptive pill, can be used to stimulate a withdrawal bleed.