Amenorrhoea

Question 1

Amenorrhoea - def

Answer 1

Primary = lack of menstruation by 16y in presence of secondary sexual characteristics, or 14y in their absence
Secondary = absence of menstruation for 6mo

Question 2

Amenorrhoea - common causes

Answer 2

Physiological

1. Pregnancy (must always be excluded)
2. Lactation
3. Menopause

Iatrogenic

4. Progestagenic contraceptives or therapeutic progestagens - Depo-Provera, Mirena, Implanon, POP
5. Continuous COCP use, GnRH analogues

Question 3

Amenorrhea - pathological causes (3 each, except for agenesis)

Answer 3

1. Hypothalamic/anterior pituitary
   - Stress
   - Anorexia
   - Prolactinoma (hyperprolactinaemia) or other SOL
2. Ovarian
   - PCOS
   - POF
   - Ovarian dysgenesis (esp. due to Turner’s syndrome)
3. Genital tract outflow obstruction
   - Imperforate hymen
   - Transverse vaginal septum
   - Cervical stenosis
4. Agenesis of uterus/mullerian duct structures
5. Endocrinopathies
   - Cushing’s syndrome
   - Severe hypo/hyperthyroidism
   - CAH

Question 4

Amenorrhoea - hx

Answer 4

Emphasis on

1. Sexual activity, risk of pregnancy and type of contraceptive used
2. Galactorrhoa or androgenic symptoms (weight gain, acne or hirsutism)
3. Menopausal symptoms (night sweats, hot flushes)
4. Previous genital trct surgery (intrauterine instrumentation or LLETZ)
5. Issues with eating, excessive exercise or drug use (?)

Question 5

Amenorrhoea - ex

Answer 5

1. BMI 30, hirsutism, secondary sexual characteristics (Tanner staging)
2. Stigmata of endocrinopathies (including thyroid) or Turner’s syndrome
3. Evidence of virilisation (deep voice, male pattern balding, cliteromegaly)
4. Abdominal - may show masses due to tumours or genital tract obstruction
5. Pelvic - imperforate hymen, blind-ending vaginal septum, absence of cervix and uterus

Question 6

Amenorrhoea - ix

Answer 6

1. Pregnancy test
2. FSH, LH (increased in premature ovarian failure, decreased in hypothalamic causes), testosterone and sex hormone-binding globulin (SHBG) for PCOS
3. Prolactin, TFTs. Test for other endocrinopathies if there is clinical suspicion
4. Pelvic ultrasound (anatomical structures, congenital abnormalities)
5. Karyotype if uterus absent or suspicious of Turner’s syndrome

Question 7

Amenorrhoea - mx

Answer 7

Must be guided by dx and fertility wishes.

1. Tx underlying causes, including attaining normal BMI
2. Cabergoline or surgery for hyperprolactinaemia)
3. HRT for POF (will the period come back?)
4. Relief of genital tract obstruction - cervical dilation, hysteroscopic resection, incision of hymen
5. Specific tx for endocrinopathies an tumours