Amenorrhoea

Question 1

What is amenorrhoea?

Answer 1

Primary
- failure to establish period by the age of 15 in girls with normal sexual development
- failure by 13 with no secondary sexual characteristics

Secondary
- cessation of period for 3-6 months with previous normal menses
- cessation 6-12 months if history of oligomenorrhoea

Question 2

What are causes of primary amenorrhoea?

Answer 2

Normal Characteristics
-Constitutional delay- esp if family history
-Endocrine- thyroid dysfunction, hyperprolactinaemia
-Androgen Insensitivity syndrome
- imperforate hymen
- congenital malformations of genital tract

No characteristics
- Gonadal dysgenesis e.g. Turners
- Functional hypothalamic amenorrhoea e.g. anorexia

Question 3

What are causes of secondary amenorrhoea?

Answer 3

Exclude pregnancy first
PCOS
Hypothalamic amenorrhoea e.g. anorexia
Cushing Syndrome
Sheehan Syndrome
Ashermann syndrome
Hyperprolactinaemia
Premature ovarian failure (FSH >20 in women <40)
Thyrotoxicosis

Question 4

What investigations are required in primary amenorrhoea?

Answer 4

Exclude pregnancy
FBC
U&Es
Coeliac Screen
TFTs
Prolactin
FSH/LH- raised = turners syndrome?
- low levels= hypothalamic cause
Testosterone
- raised= androgen insensitivity syndrome
- mildly raise= PCOS
Oestradiol
US- to rule out absent uterus/abnormal organs

Question 5

What investigations are required in secondary amenorrhoea?

Answer 5

Exclude pregnancy
FSH/LH
- elevated= premature ovarian failure
- Normal FSH and raised LH= PCOS
- Low/normal could be hypothalamic cause
Prolactin
TFTs
Testosterone
US- polycystic ovaries

Question 6

What is the management of primary amenorrhoea?

Answer 6

Investigate and treat underlying cause
If due to Turners syndrome or other genetic cause then consider hormonal replacement therapy to reduce risk of things like osteoporosis

Question 7

What is the management of secondary amenorrhoea?

Answer 7

Exclude pregnancy/lactation/menopause
Treat underlying cause