AMENORRHOEA, OLIGOMENORRHOEA AND PCOS 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?
Delayed puberty
Genital tract anomaly
Turner syndrome or other gonadal dysgenesis
Androgen insensitivity syndrome
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 hygroma
High 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 are the features of congenital adrenal hyperplasia?
Excess androgen release
Increased plasma 17-hydroxyprogesterone levels
Increased plasma 21-deoxycortisol levels
Increased urinary adrenocorticosteroid metabolites
Precocious puberty in males (sometimes as early as 6 months) and some females - this can cause early bone epiphyseal fusion and therefore short adult height.
Virilism - masculinisation in females (similar to polycystic ovarian syndrome) - masculine body shape, balding of temporal skull, increased bulk, deepening of voice, enlargement of clitoris.
Obesity
Oligomenorrhea/amenorrhoea
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.
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?
Physiological
Hypothalamic
Androgen secreting tumours
Hyperprolactinaemia
Premature ovarian failure
Polycystic ovary syndrome
Congenital adrenal hyperplasia (often primary but can also cause precocious puberty followed by amenorrhea)
Not related to changes in sex hormones
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?
Subfertility / infertility
Delayed puberty
Menstrual disturbances: oligomenorrhea and amenorrhoea
Hirsutism, acne (due to hyperandrogenism)
Obesity
Acanthosis nigricans (due to insulin resistance)
Some overlap with metabolic syndrome
Symptoms include mild headache since menarche
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 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
Reduced sex hormone binding globulin
OGTT - must be offered to all women with PCOS
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
What are the long term complications of PCOS?
Endometrial hyperplasia and cancer
Type II diabetes
Cardiovascular pathology
Hirsutism and acne
A woman with a BMI of 41 has recently been diagnosed with PCOS. She tells you that she has read online that as she has PCOS, she will not be able to become pregnant. What is the best advice to give her?
The combined oral contraceptive pill will help to regulate her cycle and therefore her fertility
Women with PCOS have no more problems with subfertility than any other group
Her concerns are correct and you will refer her immediately to a fertility specialist
Almost all women with PCOS need clomiphene to encourage ovulation
The majority of patients with PCOS do get pregnant. The best thing she could do is to lose weight before conception.
The majority of patients with PCOS do get pregnant. The best thing she could do is to lose weight before conception.
Lifestyle modification is the cornerstone to managing PCOS, especially in overweight women. PCOS can be greatly improved by losing excess weight. Weight loss of just 5% of total body weight can lead to a significant improvement in the symptoms of PCOS.
Clomifene and metformin are second line
A woman with a diagnosis of PCOS is started on clomifene as despite weight loss she is still struggling to get pregnant. What should she be warned about with regard to pregnancy and clomifene use?
Can increased likelihood of multiple pregnancy
A woman with a BMI of 41 and a diagnosis of PCOS is trying to become pregnant. Which medication is the most relevant and important at this stage?
Folic acid 5mg once daily
Folic acid 400 micrograms once daily Incorrect
Metformin 500mg once daily
Vitamin A supplementation
Metformin 500mg three times daily with meals
Folic acid 5mg once daily
Some groups of women are at higher risk than others - the recommended dose of folic acid for these women is 5mg daily:
Women who are obese
Women with diabetes
Women with epilepsy
Women with a previous child who has been affected by a neural tube defect
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 hyper
Diabetes
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.
