Amenorrhoea 1B

Question 1

What is amenorrhoea?

Answer 1

No period

Question 2

What are the types of amenorrhea?

Answer 2

primary and secondary

Question 3

What is primary amenorrhoea?

Answer 3

This is failure to start period; consider if patient is 16years old and has not experienced menarche or if 14 years old with no breast development

Question 4

What are 2 main genetic or chromosomal causes of primary amenorrhoea?

Answer 4

Turners and fragile X

Question 5

What is secondary amenorrhoea?

Answer 5

This is when period stops for more than 6 months

Question 6

What dysfunction usually causes secondary amenorrhoea?

Answer 6

HPO axis dysfunction

Question 7

What is the mnemonic used to remember the causes of secondary amenorrhoea?

Answer 7

STOP TAMPON  
S= STRESS  
T= PITUITARY TUMOUR  
O= OVER-EXERCISE AND WEIGHT LOSS  
P= PYSCHIATRIC:ANOREXIA NERVOSA  
T= THYROTOXICOSIS  
A= ASHERMANS SYNDROME; ADHESIONS  
M= EARLY MENOPAUSE  
P= PCOS  
O= OVARIAN TUMOUR  
N= NEONATAL: POST-PREGNANCY OR BREASTFEEDING

Question 8

What is important to rule out in amenorrhoea?

Answer 8

pregnancy

Question 9

What is important during examination if chromosomal sex disorder suspected?

Answer 9

examine genitalia and consider karyotype testing

Question 10

In secondary amenorrhoea due to PCOS what is typically seen during investigations?

Answer 10

↑LH and ↑testosterone

Question 11

In secondary amenorrhoea due to ovarian failure or early menopause what sit typically seen during investigation?

Answer 11

↑LH and ↑FSH

Question 12

What happens in a patient who undergoes excess exercise and what is seen during investigation?

Answer 12

Hypothalamic dysfunction occurs and ↓LH and ↓FSH

Question 13

↑ prolactin suggest what and what is the follow up?

Answer 13

prolactinoma and follow up with MRI. Milder elevations can also be seen with stress

Question 14

What other blood investigation can be carried in secondary amenorrhoea?

Answer 14

TFT

Question 15

What is considered in early menopause as a management for secondary amenorrhoea?

Answer 15

HRT

Question 16

A 37-year-old G0 presents to your office for her annual visit. For the past 5 years she has noted irregular menses, but now she has not had a period in 7 months and wonders if this is abnormal.

Answer 16

Primary amenorrhea is the absence of menstruation by age 16. This patient is considered to have secondary amenorrhea – defined as cessation of an established menstruation for 3 months in a woman with a history of regular cycles, but now without menses.

Question 17

A 37-year-old G0 presents to your office for her annual visit. For the past 5 years she has noted irregular menses, but now she has not had a period in 7 months and wonders if this is abnormal. How should this patient be evaluated?

Answer 17

The initial priority is to make sure that she is not pregnant. Once that has been ruled out, a detailed history of reproductive events leading up to the occurrence of amenorrhea is obtained. General questions about health and lifestyle may identify a history of systemic illness or any pattern of excessive stress (physical, psychological, or nutritional) that could affect hypothalamic function. A history of past and/or present use of medication – particularly oral contraceptives or other types of hormonal contraception (Depo-Provera) – can be very illuminating.
The patient’s overall body habitus, height, and weight should be determined. This may reveal very low body weight (decreased percentage of body fat) associated with hypothalamic amenorrhea, or upper body segment obesity (truncal obesity), often associated with insulin resistance and hyperandrogenism. The presence of hirsutism would indicate the possibility of polycystic ovarian syndrome (PCOS), or less likely an adrenal or ovarian androgen-producing tumor if progression is rapid or associated with virilization. A rapid pulse may suggest hyperthyroidism, whereas a slow pulse may indicate the possibility of hypothyroidism. Signs of Graves disease, such as exophthalmos, lid retraction, or tremor would suggest thyroid dysfunction, as would a palpable goiter or other nodule.
Initially, the simplest panel would be FSH (follicle-stimulating hormone), TSH (thyroid-stimulating hormone), and prolactin.

Question 18

A 37-year-old G0 presents to your office for her annual visit. For the past 5 years she has noted irregular menses, but now she has not had a period in 7 months and wonders if this is abnormal. Her TSH and prolactin are both normal. The FSH level is not in the menopausal range. What is the next step?

Answer 18

This patient does not have evidence for thyroid dysfunction or prolactinoma. She has a normal reproductive tract and either too much unopposed estrogen or not enough. Administration of progestin for a week to induce withdrawal bleeding could be the next step. If she does not have bleeding, then an estrogen/progesterone challenge would be helpful in differentiating between a structural problem (eg, Asherman syndrome) and hypogonadotropic hypogonadism (eg, Sheehan syndrome). A “positive” withdrawal bleed after progestin therapy would suggest PCOS or some type of hypothalamic dysfunction. She appears to have eugonadotropic hypogonadism – most likely to be PCOS. However, to make a more definitive diagnosis, a panel of testosterone, DHEA (dehydroepiandrosterone), and 17-hydroxyprogesterone would be helpful.

Question 19

A 37-year-old G0 presents to your office for her annual visit. For the past 5 years she has noted irregular menses, but now she has not had a period in 7 months and wonders if this is abnormal. She has a “period” after 7 days of progestin therapy and her examination suggests PCOS. As she is not attempting to get pregnant, what is the best medical therapy to treat anovulation and amenorrhea?

Answer 19

Oral contraceptives are very effective agents in the long-term management of PCOS. They break the cycle through suppression of pituitary LH (luteinizing hormone) secretion, suppression of ovarian androgen secretion, and increased production of circulating sex hormone-binding globulin (SHBG). Oral contraceptives are also associated with a reduction in the risk of endometrial cancer. Alternatively, cyclic progestin therapy is an option. Metformin and other insulin-sensitizing agents have been explored, but are currently unproven therapeutic options.

Question 20

Does weight loss improve ovarian function in obese women with PCOS?

Answer 20

Yes – obesity contributes substantially to reproductive and metabolic abnormalities in women with PCOS. Weight loss can improve the fundamental aspects of the endocrine syndrome by decreasing circulating androgen levels and causing spontaneous resumption of menses. Other benefits include decreased circulating testosterone levels largely mediated through increases in SHBG. In addition, weight loss can result in significant improvement in the risk of diabetes and cardiovascular disease. Lifestyle modification (diet and exercise) should be promoted as the main primary treatment for all obese women with PCOS