Amenorrhoea and oligomenorrhoea Flashcards
Describe amenorrhoea
The absence of menstrual periods
What is primary amenorrhoea?
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
What is secondary amenorrhoea?
cessation of periods for more than 6 months after the menarche - after excluding pregnancy
What is oligomenorrhoea?
Irregular periods with intervals between menstrual cycles of more than 35 days and or less than nine periods per year
Describe the hypothalamic pituitary axis?
Hypothalamus - GnRH anterior pituitary
- FSH - granulosa cells - inhibin
- LH- theca cells -androgens
- oestrogen which feeds back to stimulate hypothalamus and anterior pituitary
List some causes of hypothalamic amenorrhoea
Functional disorders
Severe chronic conditions
Kallmann syndrome
List some functional disorders causing hypothalamic amenorrhoea
Eating disorders
High levels of exercise
Describe how functional disorders result in hypothalamic amenorrhoea
Suppress GnRH production and subsequently lead to low oestradiol levels via ghrelin and leptin
Name some severe chronic conditions which could cause a hypothalamic amenorrhoea
Psychiatric disorders
Thyroid disorders
Sarcoidosis
What is Kallmann syndrome?
X-linked recessive disorder characterised by failure of migration of GnRH cells
Which hormones does the anterior pituitary release?
LH
FSH
List some causes of pituitary amenorrhoea
Pituitary tumours/prolactinomas
Sheehans syndrome
Destruciton of pituitary gland
Post contraception amenorrhoea
What percentage of all pituitary tumours are prolactinomas?
40-50%
Describe how prolactinomas result in amenorrhoea
Secrete high levels of prolactin which suppresses GnRH secretion
Other than amenorrhoea, which 2 other problems can prolactinomas cause?
Anovulation
Galactorrhoea
What is Sheehan’s syndrome?
Post-partum pituitary necrosis secondary to massive obstetric haemorrhage resulting in pituitary hormone deficiency
How can the pituitary gland become damaged?
Tumour
Post partum necrosis
Radiation
Autoimmune disease
Describe post-contraception amenorrhoea
Prolonged use of contraceptives can cause long term downregulation of the pituitary gland and irregular/absent periods or lack of ovulation which persists
Which contraceptive is most associated with post-contraception amenorrhoea?
Depo-Provera
How long after Depo-Provera can it take for menses to resume?
18 months
List some ovarian causes of amenorrhoea
Polycystic ovarian syndrome
Turner’s syndrome
Premature ovarian failure
Describe PCOS
High levels of androgens
Describe Turner’s syndrome
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
Describe premature ovarian failure
<40yrs
primary ovarian insufficiency
Hot sweats or night sweats
What blood hormone picture is seen in a case of premature ovarian failure?
Low oestrogen and high FSH
What is an adrenal condition that can affect ovulation?
Late onset/mild congenital adrenal hyperplasia
Describe late onset/mild adrenal hyperplasia
Autosomal recessive inherited condition which is caused by partial deficiency of 21 hydroxylase
What is 21-hydroxylase used for?
Synthesis of cortisol and aldosterone
Describe the clinical presentation of late onset/mild adrenal hyperplasia
Early development of pubic hair
Irregular/absent periods
Hirsutism
Acne
What is high in the blood of someone with late onset/mild adrenal hyperplasia?
17-hydroxyprogesterone
List some genital tract abnormalities which could lead to amenorrhoea
Ashermann’s syndrome
Imperforate hymen/transverse vaginal septum
Mayer-Rokitansky-Küster-hauser syndrome
Describe Ashermann’s syndrome
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
Describe how an imperforate hymen or transverse vaginal septum leads to amenorrhoea
Mechanical obstruction
Describe mayer-rokitansky-kuster-hauser syndrome
Agenesis of the Mullerian duct system in varying degrees
Congenital absence of the uterus and upper 2/3 of the vagina
List the common causes of oligomenorrhoea/secondary amenorrhoea
PCOS Contraceptive/hormonal treatment Perimenopause Thyroid disorders DM Eating disorders Excess exercise Medications - antiepileptics and antipsychotics
Describe the stepwise approach to investigating amenorrhoea/oligomenorrhoea
History
Examination
Pregnancy test
Blood tests - TFTs, prolactin, FSH/LH/progesterone/testosterone, 17-hydroxyprogesterone
Karyotyping
Ultrasound scan
Progesterone challenge test to ellicit withdrawla bleed
What does a withdrawal bleed after progesterone challenge suggest?
Adequate levels of oestrogen but lack of ovulation - PCOS
What does no withdrawal bleed after progesterone challenge suggest?
Low levels of oestrogen or an outflow obstruction
Describe the hormonal picture for hypothalamic causes
Decreased GnRH Normal FSH Normal/Low LH Decreased LH:FSH ratio Decreased oestrogen
Describe the hormonal picture for a prolactinoma
Decreased GnRH
Increased prolactin
Describe the hormonal picture for PCOS
Normal FSH
Increased LH
Increased LH:FSH ratio
Normal/increased testosterone
Describe the hormonal picture for premature ovarian failure
Increased FSH
Increased LH
Decreased osterogen
What does management depend on?
The cause
What do the general aims of treating amenorrhoea/oligomenorrhoea include?
Regulating periods Hormone replacement Symptom control Lifestyle advice Treat underlying disorder Improving fertility Surgery
How can periods be regulated?
Contraceptive pill - COP/Progesterone only
IUS - helpful in heavy periods
Describe the use of hormone replacement in premature ovarian failure/insufficiency
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
What medications can be used to manage excessive hair growth
Yasmin, cyproterone acetate, spironolactone, finasteride
Which drug can be given to stimulate ovulation?
Clomifene
