Amenorrhoea

Question 1

Normal age of Menache

Answer 1

Should have secondary sexual characteristics by 14 and menstruating by 16

Question 2

Primary amenorrhoea -

Answer 2

Never starting most likely due to imperforate hymen, hormonal or chromosomal problems

Question 3

Secondary amenorrhoea

Answer 3

Cessation of normal menstruation for six months in someone with a previously established cycle

Question 4

Menstrual cycle

Answer 4

Usually 28 days with days 1-3/5 of bleeding (menses)
1-14 days is follicular/proliferative phase
ovulation at ~14 days
14-28 is luteal/secretory phase

Question 5

Follicular phase

Answer 5

Increasing estrogens (estradiol) from the ovaries drives growth of 1 follicle
Estrogen from the ovaries drive LH and FSH from the hypothalamus and pituitary by positive feedback.

Question 6

Luteal phase

Answer 6

The ruptured follicle becomes the corpus luteum which continues to produce progesterone to suppress LH/FSH by negative feedback, convert endometrium to secretory phase and thickens cervical mucus
When the corpus regresses progesterone withdrawal bleeding occurs.

Question 7

HPO axis

Answer 7

The axis of the ovaries, the hypothalamus and the pituitary which controls the menstrual cycle.

Question 8

Puberty

Answer 8

The development of secondary sexual characteristics of which menarche is the last
Over 8yo GnRH pulses increase causing LH & FSH to stimulate oestrogen release from the ovary
Oestrogen drives secondary sexual characteristics

Question 9

Thelarche

Answer 9

9-11yrs,

breast development in girls at the beginning of puberty

Question 10

Adrenarche

Answer 10

Development of androgen production in the adrenal gland leading to pubic hair development

Question 11

Physiological Amenorrhoea

Answer 11

Occurs when normal hormonal states prevent menstruation
Pre-menarche or post-menopausal
During pregnancy or while lactating

Question 12

Drug causes of Amenorrhoea

Answer 12

Contraceptive Progestogens
GnRH analogues
Tranquilizers

Question 13

Outflow obstruction amenorrhoea (6)

Answer 13

Most often congenital - imperforate hymen, transverse vaginal septum, Mullerian agenesis (46XX) or androgen insensitivity (46XY)
Acquired can also occur - cervical stenosis or asherman’s syndrome (traumatic uterine atrophy)

Question 14

Pituitary amenorrhoea

Answer 14

Pituitary adenomas

Sheehans syndrome - hypopituitism due to hypovolemia and ischemia post partum

Question 15

Thyroid/adrenal causes of amenorrhoea

Answer 15

Both hypo and hyperthyroidism can cause amenorrhoea
Congenital adrenal hyperplasia
Virilising tumors

Question 16

Hypothalmaic amenorrhoea

Answer 16

The Majority cause of secondary amenorrhoea
hypogonadism due to weight loss or excessive exercise (AN), stress, craniophayngioma or Kallmans syndrome (failure of puberty)

Question 17

Ovulation

Answer 17

A spike in LH and FSH from the pituitary causes rupture of the follicle and release of the egg.
There is a change from positive to negative feedback from estrogen/progesterone on the hypothalamus and pituitary

Question 18

Causes of secondary amenorrhoea (4)

Answer 18

PCOS
Weight related/AN
Hyperprolactinaemia
Primary ovarian failure

Question 19

Causes of primary amenorrhoea (4)

Answer 19

Turners syndrome
Androgen insensitivity syndrome
Congential abnormality
Acquired

Question 20

Ovarian Disorders

Answer 20

Will cause secondary amenorrhoea etc turners

Include PCOS, primary ovarian failure, resistant ovary syndrome, virilising tumors

Question 21

Investigating Amenorrhoea

Answer 21

If prolactin high –> pituitary tumor
If thyroid disease –> treat accordingly
If testosterone high –> T. secreting tumor
If hormones normal give progestin –> if withdrawal bleed anovulation, if not check FSH –> if high gonadal failure, if FSH normal oestrogen challenge,
If no bleeding then outflow obstruction, if bleeding then pituitary or ovarian abnormality

Question 22

Body temperature changes during the menstral cycle

Answer 22

Low through the follicular phase, dips slightly just before ovulation and then high during the luteal phase.

Question 23

Levels of Progesterone during the menstral cycle

Answer 23

Absent during the follicular phase and rises after ovulation to peak at 21 days and drop by 28.

Question 24

Levels of Oestrogen during the menstral cycle

Answer 24

Increases from day 7 until ovulation and drops but peaks again at a lower level at day 20.

Question 25

FSH and LH levels during the menstral cycle

Answer 25

FSH slightly higher until day ten when it drops. both LH and FSH spike to cause ovulation but LH is much higher. They remain low for the rest of the cycle.

Question 26

Symptoms of hyperprolactinaemia

Answer 26

Anovulation and amenorrhoea
Sexual impairment & loss of libido. women may get hairy
Galactorrhoea (milk secretion). Children may present with growth failure and delayed puberty.