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OBG: Functional Gynaecology > Amenorrhoea > Flashcards

Amenorrhoea Flashcards

1
Q

What is the definition of amenorrhoea?

A

Failure of menstruation to occur at the expected time

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2
Q

What are the 2 categories of amenorrhoea?

A
  1. Primary amenorrhoea
  2. Secondary amenorrhoea
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3
Q

What is primary amenorrhoea?

A

Menstruation has never occurred - failure to menstruate by age of 16 in females

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4
Q

What is the definition of secondary amenorrhoea?

A

Established menstruation ceases for 6 months or more

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5
Q

What key feature helps determine the likely cause of primary amenorrhoea?

A

if secondary sexual characteristics are present or not

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6
Q

If secondary sexual characteristics are absent in primary amenorrhoea, what is the likely cause?

A

delayed puberty

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7
Q

What type of cause should be suspected in primary amenorrhoea when pubertal development is otherwise normal?

A

Anatomical cause

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8
Q

What are the 2 key anatomical causes of primary amenorrhoea?

A
  1. Congenital absence of uterus - failure of Müllerian ducts to develop
  2. Imperforate hymen
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9
Q

What causes congenital absence of the uterus?

A

failure of Müllerian ducts to develop

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10
Q

What is meant by imperforate hymen?

A

menstrual blood is retained within the vagina (a haematocolpos) causing cyclical lower abdominal pain each month at the time of menstruation (cryptomenorrhoea)

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11
Q

What is the term given to menstrual blood retained in the vagina in the case of imperforate hymen?

A

haematocolpos

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12
Q

What key symptom, in addition to absence of periods, will there be in primary amenorrhoea caused by imperforate hymen?

A

cyclical lower abdominal pain each month at the time of menstruation - cryptomenorrhoea

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13
Q

What will be present on inspection in primary amenorrhoea due to an imperforate hymen?

A

Distended hymenal membrane through which dark blood may be seen

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14
Q

What is the management of imperforate hymen?

A

Incision, usually under anaesthesia

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15
Q

In addition to anatomical and sexual development pathology, what else could cause failure to menstruate?

A

physiological delay - development normal, but inherent delay in onset of menstruation

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16
Q

What is common in the history of a patient with physiological delay in onset of menstruation?

A

family history of same delay in mother

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17
Q

What test is useful to identify constitutional menstrual delay?

A

Progestogen challenge test: progestogen e.g. medroxyprogesterone acetate is given orally for 5 days, and if endometrium has been stimulation from endogenous oestradiol then withdrawal of progestogen should lead to a vaginal bleed

If bleed occurs, offer reassurance that spontaneous menstruation likely to occur

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18
Q

In addition to the diagnostic test for constitutional delay in onset of menstruation what other test can be useful?

A

In addition to progestogen challenge test, abdominal ultrasound may be used to confirm uterus and ovaries normal

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19
Q

What are 6 groups of causes of primary amenorrhoea that are not structural?

A
  1. Chromosomal
  2. Hypothalamic
  3. Pituitary
  4. Ovarian
  5. Other endocrine
  6. Uterine / vaginal
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20
Q

What are 3 chromosomal causes of primary amenorrhoea?

A
  1. XO - Turner syndrome
  2. 46, XY disorders of sex development (DSD)
  3. Ovotesticular DSD
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21
Q

What are 5 hypothalamic causes of primary amenorrhoea?

A
  1. Physiological delay
  2. Weight loss/ anorexia/ heavy exercise
  3. Isolated GnRH deficiency
  4. Congenital central nervous system (CNS) defects
  5. Intracranial tumours
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22
Q

What are 5 pituitary causes of primary amenorrhoea?

A
  1. Partial/ total hypopituitarism
  2. Hyperprolactinaemia
  3. Pituitary adenoma
  4. Empty sella syndrome
  5. Trauma/ surgery
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23
Q

What are 5 ovarian causes of primary amenorrhoea?

A
  1. True agenesis
  2. Premature ovarian failure
  3. Radiation/ chemotherapy/ autoimmune
  4. Polycystic ovaries
  5. Virilising ovarian tumours
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24
Q

What are 3 other endocrine causes of primary amenorrhoea?

A
  1. Primary hypothyroidism
  2. Adrenal hyperplasia
  3. Adrenal tumour
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25
Q

What are 2 uterine/ vaginal causes of primary amenorrhoea (structural causes)?

A
  1. Imperorate hymen
  2. Uterovaginal agenesis
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26
Q

What are the 3 most common clinical causes of secondary amenorrhoea?

A
  1. Weight loss
  2. Polycystic ovary syndrome (PCOS)
  3. Hyperprolactinaemia
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27
Q

What are 6 groups of causes of secondary amenorrhoea?

A
  1. Physiological
  2. Hypothalamic
  3. Pituitary
  4. Ovarian
  5. Other endocrine
  6. Uterine/ vaginal
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28
Q

What are 3 physiological causes of secondary amenorrhoea?

A
  1. Pregnancy
  2. Lactation
  3. Menopause
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29
Q

What are 3 hypothalamic causes of secondary amenorrhoea?

A
  1. Weight loss/ anorexia
  2. Heavy exercise
  3. Stress
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30
Q

What are 3 pituitary causes of secondary amenorrhoea?

A
  1. Hyperprolactinaemia
  2. Partial/ total hypopituitarism
  3. Trauma/ surgery
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31
Q

What are 5 ovarian causes of secondary amenorrhoea?

A
  1. Polycystic ovarian syndrome
  2. Premature ovarian failure
  3. Surgery/ radiotherapy/ chemotherapy
  4. Resistant ovary syndrome
  5. Virislising ovarian tumours
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32
Q

What are 4 uterine/ vaginal causes of secondary amenorrhoea?

A
  1. Surgery - hysterectomy
  2. Endometrial ablation
  3. Progestogen intrauterine device
  4. Asherman syndrome
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33
Q

What physiological cause must be excluded in all sexually active women presenting with amenorrhoea?

A

Pregnancy (and lactation)

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34
Q

What causes secondary amenorrhoea during breastfeeding?

A

high postpartum level of prolactin associated with breastfeeding - suppresses ovulation and gives rise to lactational amenorrhoea

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35
Q

What can cause amenorrhoea to persist during breastfeeding?

A

persists throughout time infant fully breastfed, but with introduction of supplementary feeding and subsequent reduction in frequency of suckling, prolactin levels fall and ovarian activity resumed

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36
Q

What can occur as a result of high levels of prolactin during breastfeeding?

A

hypo-oestrogenic state which can lead to atrophic vaginitis and occasionally painful intercourse - prolactin exerts antagonistic action of oestrogen production

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37
Q

What is the name given to refer to hypothalamic amenorrhoea?

A

hypogonadotrophic hypogonadism

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38
Q

What is usually the cause of hypogonadotrophic hypogonadism leading to amenorrhoea?

A

stress

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39
Q

What is usually the outcome of stress-induced hypogonadotrophic hypogonadism and amenorrhoea?

A

usually resolves spontaneously

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40
Q

What can cause secondary amenorrhoea in physical stress e.g. due to athletic training?

A

suppression of hypothalamo-pituitary-ovarian axis due to physical stress - low levels of pituitary gonadotrophins in association with low levels of prolactin and oestradiol

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41
Q

What level of weight loss may result in secondary amenorrhoea?

A

change in body weight to only 10-15% below the ideal

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42
Q

What should you consider when weight loss is associated with secondary amenorrhoea?

A

anorexia nervosa

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43
Q

What can restore ovulatory function following secondary amenorrhoea due to weight loss?

A

Restoration of body weight - may be significant time interval between attainment of ideal body weight and resumption of ovarian activity

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44
Q

Why is ovulation induction therapy not recommended in cases of weight-loss induced secondary amenorrhoea until normal weight is restored?

A

not recommended until restoration of body weight as pregnancy, if it occurs, carries risk of growth restriction of fetus and increased perinatal mortality

45
Q

If hypothalamic amenorrhoea is not related to low body weight, what does treatment for it depend on?

A

whether or not woman wants to conceive

46
Q

In the case of hypothalamic secondary amenorrhoea, what is the treatment of choice for women who do not want to conceive?

A

oestrogen replacement therapy - oral contraceptive pill

47
Q

In the case of hypothalamic secondary amenorrhoea, what is the treatment of choice for women who do want to conceive? 2 options

A
  • Ovulation may be induced with pulsatile GnRH therapy OR
  • Exogenous gonadotrophins
48
Q

What is the effect of prolactin in the body?

A

stimulates breast development and subsequent lactation

49
Q

What other hormone influences the secretion of prolactin and how?

A

Inhibited by dopamine from hypothalamus

50
Q

What type of hormone is prolactin and where is it produced from?

A

Polypeptide hormone produced by lactotrophs of anterior pituitary

51
Q

What is the action of prolactin on other hormones?

A

suppresses ovarian activity by interfering with secretion of gonadotrophins

52
Q

What can cause mildly elevated prolactin levels?

A

common, can be due to stress e.g. of venepuncture

53
Q

What are 2 key effects of sustained higher levels of prolactin?

A
  1. Amenorrhoea
  2. Galactorrhoea unrelated to pregnancy
54
Q

In what proportion of patients with hyperprolactinaemia does galactorrhoea occur?

A

<50%

55
Q

What proportion of patients with galactorrhoea have an elevated prolactin level?

A

<50%

56
Q

What are 2 groups of causes of hyperprolactinaemia?

A
  1. Pituitary adenoma
  2. Secondary to other causes
57
Q

What are 2 types of pituitary adenomas which can cause hyperprolactinaemia?

A
  1. Microadenoma
  2. Macroadenoma
58
Q

What are 6 causes of hyperprolactinaemia that are secondary to causes other than pituitary adenoma?

A
  1. Primary hypothyroidism
  2. Chronic renal failure
  3. Pituitary stalk compression
  4. Polycystic ovarian syndrome
  5. Drugs (phenothiazines, haloperidol, metoclopramide, cimetidine, methyldopa, antihistamines, morphine)
  6. Idiopathic
59
Q

What are 7 drug causes of hyperprolactinaemia?

A
  1. Phenothiazines
  2. Haloperidol
  3. Metoclopramide
  4. Cimetidine (histamine H2-receptor antagonist)
  5. Methyldopa
  6. Antihistamines
  7. Morphine
60
Q

Where in the anterior pituitary do adenomas occur (that can cause hyperprolactinaemia)?

A

lateral wings

61
Q

At what level of hyperprolactinaemia is imaging performed to investigate for a potential pituitary adenoma and what imaging is performed?

A
  • prolactin >1000 mU/L
  • CT or ideally MRI
62
Q

What defines the difference between micro and macroadenoma for pituitary tumours?

A

microadenoma is <10mm and macro is >10mm

63
Q

What should you check in examination in suspected pituitary adenoma which may cause secondary amenorrhoea?

A

visual fields checked - optic chiasm compression may lead to bitemporal hemianopia

64
Q

What is the typical prognosis of pituitary adenomas?

A
  • 1/3 regress spontaneously
  • <5% of microadenomas become macroadenomas
65
Q

What do serum levels of hyperprolactinaemia correlate with in pituitary adenoma?

A

tumour size

66
Q

What should you suspect if a tumour appears relatively large and prolactin level is only modestly elevated?

A

pituitary stalk compression from nonsecreting macroadenoma or other tumour (e.g. craniopharyngioma) is possible

67
Q

What is a possible cause of apparently idiopathic hyperprolactinaemia?

A

microadenomas too small to be picked up by MRI scan

68
Q

What should be performed for all patients with pituitary adenoma before treatment?

A

pituitary imaging

69
Q

What are 2 types of management for pituitary adenoma that may be causing hyperprolactinaemia (causing secondary amenorrhoea)?

A
  1. Dopamine agonist - bromocriptine or cabergoline
  2. Transnasal transsphenoidal microsurgical excision of adenoma
70
Q

What is the most common management of pituitary adenoma?

A

Dopamine agonist (bromocriptine or cabergoline) - transnasal transphenoidal excision only rarely required

71
Q

What are the 2 types of dopamine agonist which can be used to treat pituitary adenoma causing hyperprolactinaemia?

A

Bromocriptine or cabergoline

72
Q

What is meant by the term premature ovarian failure?

A

Cessation of ovarian function before age of 40. Failure is due to depletion of primordial follicles in the ovaries

73
Q

How common is premature ovarian failure?

A

1% of women

74
Q

What are 6 causes of premature ovarian failure?

A
  1. Surgery
  2. Viral infections e.g. mumps
  3. Cytotoxic drugs
  4. Radiotherapy
  5. Idiopathic
  6. Chromosomal abnormality - XO mosaicism or XXX
75
Q

What are 3 poor prognostic signs for recovery from premature ovarian failure?

A
  1. Low oestradiol level
  2. Very high FSH
  3. Absence of any menstrual activity
76
Q

What are 2 elements of treatments for premature ovarian failure?

A
  1. Pregnancy by in vitro fertilisation with donor oocytes may be possible
  2. Hormone replacement therapy - to relieve postmenopausal symptoms, minimise osteoporosis risk
77
Q

What is premature ovarian failure sometimes associated with?

A

other autoimmune disorders

78
Q

Waht are 2 reasons why hormone replacement therapy is given in premature ovarian failure?

A
  1. Relieve postmenopausal symptoms
  2. Minimise risk of osteoporosis
79
Q

What is the most common form of anovulatory infertility?

A

Polycystic ovary syndrome

80
Q

What proportion of women are believed to be affected by PCOS?

A

20%

81
Q

What are the criteria for diagnosis of polycystic ovary syndrome?

A

at least 2 out of the following 3: (Rotterdam)

  1. oligomenorrhoea or amenorrhoea
  2. ultrasound appearane of large-volume ovaries (>10cm3) and/or multiple small follicles (12 or more <10mm)
  3. Clinical evidence of excess androgens (acne, hirsutism) or biochemical evidence (raised testosterone)
82
Q

What is thought to be the principal underlying disorder of PCOS?

A

insulin resistance, with resultant hyperinsulinaemia stimulating excess ovarian androgen production

thought to be systemic metabolic condition (rather than primary gynaecological)

83
Q

What are 3 associations of PCOS?

A
  1. Dyslipidaemia
  2. Predisposition to non-insulin-dependent diabetes
  3. Predisposition to cardiovascular disease
84
Q

What does the treatment of PCOS depend on?

A

whether presenting problem is menstrual irregularity, hirsutism or infertility

85
Q

What treatment is available for PCOS where irregular menses is the primary problem?

A

COCP to regulate menses

86
Q

How can PCOS be treated if the primary problem is hirsutism? 3 ways

A
  1. cosmetic measures such as waxing or laser treatment
  2. with COCP as suppresses ovarian androgen production
  3. with the antiandrogen cyproterone acetate
87
Q

What must be remembered in women who are taken an antiandrogen (e.g. cyproterone acetate) who have PCOS and why?

A

must use effective contraception during, and for at least 3 months after, treatment - potential risk of teratogenicity (feminisation of male fetus) with antiandrogen therapy

88
Q

What is used to treat women with PCOS where infertility is the primary problem? 3 options

A
  1. Clomifene - to induce ovulation in women with anovulatory infertility
  2. Gonadotrophin injections if clomifene doesn’t work
  3. Laproscopic laser or diathermy to the ovary
89
Q

What is clomifene?

A

oral ovulatory stimulant - acts as selective oestrogen receptor modulator (SERM)

90
Q

What is the cornerstone of management of PCOS for all presenting complaints?

A

weight reduction - reduces insulin resistance, corrects hormone imbalance, promotes ovulation

91
Q

What is the role of insulin-sensitising agents e.g. metformin to treat PCOS?

A

larger trials have failed to demonstrate benefit

92
Q

In addition to treating symptoms and weight loss in PCOS, what is another key aspect of the management of these patients?

A

Screening of cardiovasuclar risk factrs - HTN and glucose intolerance

Screening for endometrial hyperplasia and endometrial carcinoma

93
Q

Why is there increased risk of endometrial hyperplasia/ carcinoma in PCOS?

A

consequence of effects of anovulation with unopposed oestrogen stimulation of the endometrium

94
Q

What are 4 other endocrine causes of secondary amenorrhoea?

A
  1. Thyrotoxicosis
  2. Primary hypothyroidism
  3. Late-onset congenital adrenal hyperplasia
  4. Androgen-secreting adrenal tumours
95
Q

Why can primary hypothyroidism cause secondary amenorrhoea?

A

thyrotrophin-releasing hormone (TRH, secreted by hypothalamus) also stimulates prolactin secretion

96
Q

What usually causes late-onset congenital adrenal hyperplasia?

A

Deficiency of enzyme 21-hydroxylase

97
Q

What is usually the management of late-onset adrenal hyperplasia, a cause of secondary amenorrhoea?

A

low dose corticosteroids to re-etsablish ovulatory function by suppressing adrenal function

98
Q

What are 2 causes of Asherman syndrome, a uterine cause of secondary amenorrhoea?

A
  1. Excessive uterine currettage
  2. Severe postpartum infection
99
Q

What is the treatment of Asherman’s syndrome?

A

breaking down adhesions through hysteroscope with or without inserting intrauterine contraceptive device to deter reformation

100
Q

What is Asherman’s syndrome?

A

adhesions in the uterine cavity form that are so severe they obstruct menstrual flow

101
Q

How can excessive uterine curettage come about and cause Asherman’s syndrome?

A

usually at time of miscarriage, termination of pregnancy or secondary PPH - may remove basal layer of endometrium and result in uterine adhesions (synechiae)

102
Q

What are the 7 aspects of clinical management for all types of amenorrhoea?

A
  1. Exclude pregnancy
  2. Ask about perimenopausal symptoms (flushing, vaginal dryness)
  3. History - weight changes, drugs, medical disorders, thyroid symptoms
  4. Examination - height, weight, visual fields, hirsutism, virilisation, pelvic exam
  5. Serum LH, FSH, prolactin, testosterone, thyroxine, TSH
  6. Transvaginal ultrasound scan - polycystic ovaries
  7. Review with the results
103
Q

What are 4 key things to ask about in the history for amenorrhoea?

A
  1. Weight changes
  2. Drugs
  3. Medical disorders
  4. Thyroid symptoms
104
Q

What are 5 key things to do in the examination for amenorrheic patients?

A
  1. Height
  2. Weight
  3. Visual fields
  4. Hirsutism/ virilisation
  5. Pelvic examination
105
Q

What are 6 blood tests to perform in amenorrhoea?

A
  1. FSH
  2. LH
  3. Prolactin
  4. Testosterone
  5. Thyroxine
  6. TSH
106
Q

What criterion is required to make a diagnosis of hyperprolactinaemia?

A

Prolactin >1000mU/L on at least 2 occasions

107
Q

If FSH is elevated what is the management?

A

if >30U/L, repeat 6 week later. If still elevated and patient >40 years, patient is menopausal. If <40, diagnosis is premature ovarian failure

Consider HRT. Pregnancy with oocyte donation possible

108
Q

What is the usual management of patients with idiopathic amenorrhoea?

A

anti-oestrogen e.g. clomifene - usually respond well

OBG: Functional Gynaecology (7 decks)

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