Amenorrhoea Flashcards
Primary amenorrhea
Failure of menstruation by the age of 16 years in the presence of normal secondary sex characteristics
OR
14 yrs in the absence of other evidence of puberty
Secondary amenorrhea
Absent periods for at least 6 months in a woman who has previously had regular periods, or 12 months if she has previously had oligomenorrhoea
Group 1 Amenorrhoea
Low oestrogen, low FSH, no hypothalamic-pituitary pathology
Hypogonadotrophic hypogonadism
Group 2 Amenorrhoea
Normal oestrogen, normal FSH, normal prolactin
PCOS
Group 3 Amenorrhoea
Low oestrogen, high FSH
Gonadal failure
Tanner stage 1
Breast and pubic hair prepubertal
Tanner stage 2
Breast buds seen
Few hairs at labia majora
Tanner stage 3
Larger breast buds
Mainly central growth of pubic hair
Tanner stage 4
Mound formed
Triangular shaped area of pubic hair
Tanner stage 5
Fullly formed breasts
Adult shape pubic hair, spread to thighs
Causes of Amenorrhoea (subdivisions)
Pregnancy Haematocolpos Hypothalamic dysfunction (chronic illness, weight loss) Hydrocephalus, empty sella syndrome, craniophayngioma Prolactinoma Thyroid disorders Cushing syndrome Consitutional delay Genetic disorders (Turners) Androgen secreting tumors Premature ovarian failure PCOS Ashermans Head injury Sheehan’s syndrome Chromosomal abnormalities (fragile x)
Most common causes of primary amenorrhoea
Gonadal dysgensis (43%)
Mullerian agenesis (15%)
Constitutional (14%)
PCOS (7%)
Hirsuitism virilisation
May be due to an androgen-secreting ovarian or adrenal tumor, or 5 alpha-reductase deficiency
History points for primary amenorrhoea
Psychological dysfunction or emotional stress Mother and sister gynae hx Mother obs history with child Fam hx (genetic disorders, diabetes, delayed puberty) Pubertal development Galactorrhoea Hypothyroid symptoms Weight loss or gain Hirsuitism virilisation Menopausal symptoms Sexual activity Headache or visual disturbance, Polaris, poldipsia Anosmia Chronic illness RT or CT
Secondary amenorrhoea hx
Irregular menstraul cycles Hirsuitism Acne Malaise, fatigue, weight loss Heterotopic ossification (following head injury) Headaches Galactorrhoea PPH - ?sheehan’s D&C ?asherman Medications Rapid virilisation Hyperprolactinemia
Conditions with a blind vaginal pouch
Mullerian agenesis
Transverse vaginal septum
Androgen insensitivity syndrome
Testosterone >5
Androgen insensitivity
Androgen secreting tumors
Cushing syndrome
Late onset CAH
Test in both primary and secondary amenorrhoea
Raised FSH/LH and secondary sexual characteristics
PCOS
Primary amenorrhoea with normal FSH and secondary sexual characteristics
?obstructed outflow tract
Haematometra and haematocolpos
High FSH and no secondary sex characteristics
17-alpha hydroxylase deficiency (with HTN)
If high LH, turner’s sndrome or male karyotype
Low FSH and LH
Intracranial lesions and Craniopharyngioma if short stature
Normal height or normal FSH, weight loss, celiac diseae, type 1 DM, anorexia nervosa or exercise
High FSH and secondary amenorrhoea
Premature ovarian failure if on 2 occasions >20
Space occupying lesion of the hypothalamus pathophysiology
Tend to occur around the time of puberty
Cause amenorrhoea by disrupting the tonic inhibition of dopamine on prolactin release and/or compress and destroy hypothalamic and pituitary tissue
Kallman’s syndrome
1:50000
Congenital absence of GnRH neurons whose cell bodies from the olfactory area to the arcuate nucleus of the hypothalamus
May be sporadic or inherited
AD or X-linked recessive
Associated with anosmia and colour-blindness
Prolactin level 700-2500
Hypothyroidism/PCOS
Check TSH, T4, FSH/LH, testosterone, SHBG
Prolactin <3000
Non-functioning macroadenoma
MRI or CT head (if >1500 x 2 occasions)
Prolactin 1500-4000
Functioning microadenoma
Image
Symptoms of hyperprolacinaemia
Oestrogen deficiency
Galactorrhoea (30%)
Visual field defects (5%)
Bromocriptine treatment for hyperprolactinaemia
1.25mg nocte for 5 nights
Gradually uptitrate to 7.5mg daily in 2 or 3 divided doses over three weeks
SE: nausea, vomiting, headache, postural hypotension, Raynauds, constipation, psychiatric hanged (aggression)
Cabergoline for treatment of hyperprolactinameia
0.25-1mg twice weekly
Up to 1mg daily
Longer acting and better tolerated but still second line due to adverse psychiatric effects and not Licensed for pregnancy
Quinagolide for treatment of hyperprolactinaemia
25-150mcg daily in divided doses
Longer acting and better tolerated but still second line due to adverse psychiatric effects and not Licensed for pregnancy
Prolactinomas and pregnancy
80% achieve pregnancy on dopamine agonist treatment
No increase in miscarriage, ectopic or other complications of pregnancy
Can BF
Some develop signs of tumor growth in pregnancy, <2% for micro, 15% macro
Bromocriptine ok in pregnancy
Empty sella syndrome (cause, consequence and treatment)
Benign congenital absence or following surger or RT
Extension of the subarachnoid space into the pituitary fossa flattens the pituitary separating it from the hypothalamus; usually get hyperprolactinaemia
Bromocriptine
Sheehan’s syndrome (cause consequence and treatment)
Acute infarction and necrosis of pituitary due to PPH and shock
Hypopituitarism; failure of lactation and loss of pubic hair; deficiencies in GH, gonadotrophins, adrenocorticotrophin, Thyroid hormone
To: pituitary hormone replacement and oestrogen and progesterone
uterine causes of secondary amenorrhoea
Asherman syndrome
Cervical stenosis
Ovarian causes of secondary amenorrhoea
PCOS POF (genetic, autoimmune, infective, RT/CT)
Hypothalamic causes of secondary amenorrhoea (hypogonadotrophic hypogonadism)
Weight loss Exercise Chronic illness Psychological distress Idiopathic
Pituitary causes of secondary amenorrhoea
Hyperprolactinaemia
Hypopituitarism
Sheehan syndrome
Hypothalamic/pituitary damage (hypogonadism)
Tumour Cranial irradiation Head injury Sarcoidosis TB
Systemic causes of secondary amenorrhoea
Chronic illness
Weight loss
Endocrine disorders (Thyroid disease, Cushing)
