Amenorrhoea & Oligomenorrhoea Flashcards
What is the difference between primary and secondary amenorrhoea?
Primary is when menstruation has not started by the age of 16. Relatively uncommon.
Secondary is when menstruation has occurred in the past, but has then been absent for 6 months or more.
What are the causes of primary amenorrhoea?
2 Ts 2 Cs:
- Turners syndrome
- Testicular feminization
- Congenital malformations (e.g. Mayer-Kuster-Hauser-Rokitansky syndrome, imperforate hymen)
- Congenital adrenal hyperplasia
What is Turner syndrome?
A condition in which a female is partly or completely missing an X chromosome.
What are the features of Turner syndrome?
- Short stature
- Webbed neck
- Widely spaced nipples
- Bicuspid aortic valve
- Coarctation of the aorta
- Primary amenorrhoea
- Cystic hygromaHigh arched palate
- Short fourth metacarpal
- Multipigmented naevi
- Lymphoedema in neonates
What is congenital adrenal hyperplasia?
Type 1 is the most common and denotes a deficiency in 21-hydroxylase which leads to deficiency of cortisol and aldosterone.
No cortisol therefore to suppress release of ACTH.
ACTH continues to stimulate adrenal gland leading to hyperplasia and excessive release of androgens.
What is androgen insensitivity syndrome
A condition that results in the partial or complete inability of the cell to respond to androgens.
This therefore only affects those born XY.
However, often this is not discovered until puberty where the patient does not begin menstruation as they do not have ovaries.
(Caster Semenya)
At what age should you investigate primary amenorrhoea?
If they have no secondary sexual characteristics then investigate from 14
If they have otherwise normal sexual characteristics then investigate from 16
What are the causes of secondary amenorrhoea?
4P 3H
- Pregnancy
- Premature ovarian failure
- Polycystic ovary syndrome
- Pituartary necrosis (Sheehan’s syndrome after PPH)
- Hypothalamic disorder (anorexia nervosa, athletes, stress)
- Hyperprolactinaemia
- Hyper/hypo thyroidism
What are the physiological causes of secondary amenorrhoea?
- Pregnancy
- Lactation
- Menopause
What are the causes of hypothalamic amenorrhoea (relating to reduced function of the hypothalamus or pituitary gland)?
Weight loss - ED
Stress
Athlete
Systemic illness
Sheehan’s syndrome
What is Sheehan’s syndrome and how do we treat it?
This is where there is hypopituitarism caused by ischemic necrosis due to blood loss and hypovolemic shock during and after childbirth.
A major complication of PPH.
Requires oestrogen replacement therapy in the form of the COCP or HRT to prevent osteoporosis.
Addition of other pituitary hormones might also be necessary.
Where are androgen secreting tumours that cause secondary amenorrhoea usually found?
Ovaries
Adrenal glands
What are the causes of premature ovarian failure?
Idiopathic
Post-chemotherapy
Post-radiotherapy
Oophorectomy
What is the pathogenesis of polycystic ovarian syndrome?
Polycystic ovaries develop when the ovaries are stimulated to produce excessive amounts of male hormones (androgens), in particular testosterone, by either:
- Excessive luteinizing hormone (LH) by the anterior pituitary gland
- High levels of insulin in the blood in women whose ovaries are sensitive to this stimulus
What are the features of polycystic ovarian syndrome?
HAIR
- Hirsutism
- Amenorrhoea/oligomenorrhoea
- Increased weight gain (insulin)
- Reduced fertility & miscarrage
What is acanthosis nigricans?
Darkened, thickened patches of skin that develop in the armpit and around the groin and neck.
Caused by a number of conditions including sign of malignancy, PCOS, insulin resistant diabetes, hypothyroidism and Cushing’s disease.
What investigations should be done for someone with suspected PCOS and what would you expect to find?
USS - multiple cysts on ovaries
Blood tests: Raised LH and normal FSH
Raised LH:FSH ratio
Normal prolactin
Testosterone is either normal or mildly elevated.
If it is markedly elevated consider other causes.
Anti-Mullerian hormone is raised
- Raised DHEA
What are the Rotterdam diagnostic criteria for PCOS?
Two of:
Oligo/anovulation
Clinical or biochemical signs of hyperandrogenism
Polycystic ovaries (12+ peripheral follicles or increased volume)
How should you manage someone diagnosed with PCOS?
Encourage weight loss - this is first line in fertility treatment
COCP will help acne and hirsutism but may not be appropriate if infertility is the presenting complaint
To help with fertility issues, NICE recommends Clomifene citrate or Metformin or Clomifene in combination with metformin.
COCP or long term progesterone use (Levonorgestrel) can help with prevention of endometrial cancer
How would you manange someone for fertility treatment for PCOS?
- Weight loss
- Colmifene (anti-oestrogen) 6m use oral
- Metformin (insulin sensitising + oestrogen restoring)
- Gonadotrophin induction (stimulates follicular growth)
- Laparoscopic ovarian diathermy
- IVF if no success
What are the long term complications of PCOS?
- Endometrial hyperplasia and cancer
- Type II diabetes
- Cardiovascular pathology
- Hirsutism and acne
What are the causes of hyperprolactinaemia?
Pituitary tumour
Drug induced
What are the drugs that can cause hyperprolactinaemia?
Antipsychotics - phenothiazines, haloperidol
Antidepressants - tricyclic antidepressants
Antihypertensives - methyldopa, reserpine
Oestrogens - COCP
Anti-histamines (H2) - Cimetidine, Ranitidine, Metoclopramide, Domperidone
What are the non-sex hormone related causes of secondary amenorrhoea?
Asherman’s syndrome
Cervical stenosis
Thyroid disease
both hypo and hyperDiabetes
What is Asherman’s syndrome?
A condition characterized by adhesions and/or fibrosis of the endometrium particularly but can also affect the myometrium. It is often associated with dilation and curettage (ERPC) of the intrauterine cavity.
