Amenorrhoea and oligomenorrhoea

Question 1

Describe amenorrhoea

Answer 1

The absence of menstrual periods

Question 2

What is primary amenorrhoea?

Answer 2

Failure to commence menses (absence of menarche)

• girls aged >16 in presence of secondary sexual characteristics
• girls aged >14 in the absence of sexual characteristics

Question 3

What is secondary amenorrhoea?

Answer 3

cessation of periods for more than 6 months after the menarche - after excluding pregnancy

Question 4

What is oligomenorrhoea?

Answer 4

Irregular periods with intervals between menstrual cycles of more than 35 days and or less than nine periods per year

Question 5

Describe the hypothalamic pituitary axis?

Answer 5

Hypothalamus - GnRH anterior pituitary

• FSH - granulosa cells - inhibin
• LH- theca cells -androgens
• oestrogen which feeds back to stimulate hypothalamus and anterior pituitary

Question 6

List some causes of hypothalamic amenorrhoea

Answer 6

Functional disorders
Severe chronic conditions
Kallmann syndrome

Question 7

List some functional disorders causing hypothalamic amenorrhoea

Answer 7

Eating disorders

High levels of exercise

Question 8

Describe how functional disorders result in hypothalamic amenorrhoea

Answer 8

Suppress GnRH production and subsequently lead to low oestradiol levels via ghrelin and leptin

Question 9

Name some severe chronic conditions which could cause a hypothalamic amenorrhoea

Answer 9

Psychiatric disorders
Thyroid disorders
Sarcoidosis

Question 10

What is Kallmann syndrome?

Answer 10

X-linked recessive disorder characterised by failure of migration of GnRH cells

Question 11

Which hormones does the anterior pituitary release?

Answer 11

LH

FSH

Question 12

List some causes of pituitary amenorrhoea

Answer 12

Pituitary tumours/prolactinomas

Sheehans syndrome

Destruciton of pituitary gland

Post contraception amenorrhoea

Question 13

What percentage of all pituitary tumours are prolactinomas?

Answer 13

40-50%

Question 14

Describe how prolactinomas result in amenorrhoea

Answer 14

Secrete high levels of prolactin which suppresses GnRH secretion

Question 15

Other than amenorrhoea, which 2 other problems can prolactinomas cause?

Answer 15

Anovulation

Galactorrhoea

Question 16

What is Sheehan’s syndrome?

Answer 16

Post-partum pituitary necrosis secondary to massive obstetric haemorrhage resulting in pituitary hormone deficiency

Question 17

How can the pituitary gland become damaged?

Answer 17

Tumour
Post partum necrosis
Radiation
Autoimmune disease

Question 18

Describe post-contraception amenorrhoea

Answer 18

Prolonged use of contraceptives can cause long term downregulation of the pituitary gland and irregular/absent periods or lack of ovulation which persists

Question 19

Which contraceptive is most associated with post-contraception amenorrhoea?

Answer 19

Depo-Provera

Question 20

How long after Depo-Provera can it take for menses to resume?

Answer 20

18 months

Question 21

List some ovarian causes of amenorrhoea

Answer 21

Polycystic ovarian syndrome

Turner’s syndrome

Premature ovarian failure

Question 22

Describe PCOS

Answer 22

High levels of androgens

Question 23

Describe Turner’s syndrome

Answer 23

45 XO - a genetic condition that causes amenorrhoea, failure to develop secondary sexual characteristics and almost universal infertility
Other features include short statue, webbed neck and coarctation of the aorta

Question 24

Describe premature ovarian failure

Answer 24

<40yrs
primary ovarian insufficiency
Hot sweats or night sweats

Question 25

What blood hormone picture is seen in a case of premature ovarian failure?

Answer 25

Low oestrogen and high FSH

Question 26

What is an adrenal condition that can affect ovulation?

Answer 26

Late onset/mild congenital adrenal hyperplasia

Question 27

Describe late onset/mild adrenal hyperplasia

Answer 27

Autosomal recessive inherited condition which is caused by partial deficiency of 21 hydroxylase

Question 28

What is 21-hydroxylase used for?

Answer 28

Synthesis of cortisol and aldosterone

Question 29

Describe the clinical presentation of late onset/mild adrenal hyperplasia

Answer 29

Early development of pubic hair Irregular/absent periods Hirsutism Acne

Question 30

What is high in the blood of someone with late onset/mild adrenal hyperplasia?

Answer 30

17-hydroxyprogesterone

Question 31

List some genital tract abnormalities which could lead to amenorrhoea

Answer 31

Ashermann's syndrome Imperforate hymen/transverse vaginal septum Mayer-Rokitansky-Küster-hauser syndrome

Question 32

Describe Ashermann's syndrome

Answer 32

Can occur secondary to instrumentation of the uterus typically following surgical management of miscarriage Damages the basal layer of endometrium which causes intrauterine adhesions which fail to respond to oestrogen stimulus

Question 33

Describe how an imperforate hymen or transverse vaginal septum leads to amenorrhoea

Answer 33

Mechanical obstruction

Question 34

Describe mayer-rokitansky-kuster-hauser syndrome

Answer 34

Agenesis of the Mullerian duct system in varying degrees | Congenital absence of the uterus and upper 2/3 of the vagina

Question 35

List the common causes of oligomenorrhoea/secondary amenorrhoea

Answer 35

``` PCOS Contraceptive/hormonal treatment Perimenopause Thyroid disorders DM Eating disorders Excess exercise Medications - antiepileptics and antipsychotics ```

Question 36

Describe the stepwise approach to investigating amenorrhoea/oligomenorrhoea

Answer 36

History Examination Pregnancy test Blood tests - TFTs, prolactin, FSH/LH/progesterone/testosterone, 17-hydroxyprogesterone Karyotyping Ultrasound scan Progesterone challenge test to ellicit withdrawla bleed

Question 37

What does a withdrawal bleed after progesterone challenge suggest?

Answer 37

Adequate levels of oestrogen but lack of ovulation - PCOS

Question 38

What does no withdrawal bleed after progesterone challenge suggest?

Answer 38

Low levels of oestrogen or an outflow obstruction

Question 39

Describe the hormonal picture for hypothalamic causes

Answer 39

``` Decreased GnRH Normal FSH Normal/Low LH Decreased LH:FSH ratio Decreased oestrogen ```

Question 40

Describe the hormonal picture for a prolactinoma

Answer 40

Decreased GnRH | Increased prolactin

Question 41

Describe the hormonal picture for PCOS

Answer 41

Normal FSH Increased LH Increased LH:FSH ratio Normal/increased testosterone

Question 42

Describe the hormonal picture for premature ovarian failure

Answer 42

Increased FSH Increased LH Decreased osterogen

Question 43

What does management depend on?

Answer 43

The cause

Question 44

What do the general aims of treating amenorrhoea/oligomenorrhoea include?

Answer 44

``` Regulating periods Hormone replacement Symptom control Lifestyle advice Treat underlying disorder Improving fertility Surgery ```

Question 45

How can periods be regulated?

Answer 45

Contraceptive pill - COP/Progesterone only | IUS - helpful in heavy periods

Question 46

Describe the use of hormone replacement in premature ovarian failure/insufficiency

Answer 46

Cyclical HRT with oestrogen (and progesterone if the woman still has a uterus) Treats the symptoms and decreases risk of cardiovascular disease and maintains bone mineral density to prevent osteoporosis

Question 47

What medications can be used to manage excessive hair growth

Answer 47

Yasmin, cyproterone acetate, spironolactone, finasteride

Question 48

Which drug can be given to stimulate ovulation?

Answer 48

Clomifene