Group sessions - Gynaecological case discussions

Question 1

Define primary and secondary amenorrhoea

Answer 1

Primary Amenorrhoea
• No menstruation by the age of 14 years accompanied by failure to develop secondary sexual characteristics
• No menstruation by the age of 16 with some or complete secondary sexual development

Secondary Amenorrhoea
• The absence of menses for 6 months or an equivalent of more than 3 times the previous cycle intervals in a woman who has menstruated before.

Question 2

Categorise causes of amenorrhea

Answer 2

Physiological
• Pre-pubertal
• Pregnancy
• Postmenopausal

HPO axis
• Disorders of hypothalamus / CNS
• Disorders of pituitary
• Disorders of ovary

Outflow tract
• Disorders of outflow tract and/or uterus

Question 3

List hypothalamic disorders that cause amenorrhoea

Answer 3

Disorders of the hypothalamus / CNS
• CNS effect: weight loss, excessive exercise, stress, anorexia nervosa
• Kallmann’s syndrome (isolatede GnRH deficiency + anosmia)
• Tumours - craniopharyngioma

Question 4

List pituitary causes of amenorrhea

Answer 4

Disorders of the pituitary
• Hyperprolactinemia
• Prolactinomas
• Non-functioning adenomas
• Sheehan’s syndrome

Endocrinopathy
• Hyper-/hypothyroidism

Question 5

List ovarian disorders that cause amenorrhoea

Answer 5

Disorders of the ovary
• Chromosomal abnormalities e.g. Turner’s Syndrome → gonadal dysgenesis
• Gonadal agenesis
• Premature ovarian failure/ Primary ovarian insufficiency
• Polycystic ovarian syndrome

Question 6

List outflow tract disorders that cause amenorrhoea

Answer 6

Disorders of outflow tract and/or uterus
• Cryptomenorrhoea – failure of normal canalisation of Mullerian duct

• Imperforated hymen

• Complete transverse vaginal septum

• Absence or hypoplasia of vagina

Absent uterus
• Rokitansky syndrome
• Androgen insensitivity syndrome (46 XY female)

• Asherman’s syndrome

Question 7

Outline history taking questions for amenorrhea

Answer 7

Previous menstruation
• Pubertal development, heigh-weight
• Past medical history and surgical history
• Drug history
• Nutrition
• Stress
• Menopausal

symptoms
• Recent weight changes, thyroid symptoms
• Excessive hair growth, hirsutism, secondary sexual characteristics (Tanner stage for breast and pubic hair)
• Family history of amenorrhea

Question 8

Physical exam for amenorrhea

Answer 8

Physical examination
• Body height / weight/BMI
• Features of chromo. abn.
• Hirsuitism/virilisation
• Secondary sexual characteristics, hymen
• Galactorrhoea, visual field
• Abdominal examination
• Genital tract / PR exam

+Thyroid exam
+ Neurological exam for other Hypothalamic and Pituitary causes

Question 9

Investigations for amenorrhoea

Answer 9

Hormonal
- FSH, LH, E2, PRL, TFT
- Androgens (testosterone, SHBG)
- Progestogen challenge test / E+P withdrawal test to rule out outflow tract obstruction and P only test to rule out functioning ovaries (need Estrogen to thicken lining and Progesterone to maintain lining)

Second line Investigations
• USG pelvis
• Renal tract imaging
• Karyotype
• Autoimmune screening
• MRI pituitary / CT brain
• Visual field by perimetry
• Laparoscopy / hysteroscopy

Question 10

Complete with senior notes