Menstrual cycle & amenorrhoea

Question 1

What is meant by PRIMARY Amenorrhoea

Answer 1

Failure to menstruate
- by age 15 in girls with normal secondary sexual characteristics (e.g. breast development)
- OR by 13 years of age in girls with no secondary sexual characteristics

Question 2

What is secondary amenorrhoea?

Answer 2

• Cessation of menstruation for 3-6 months in women with previously normal and regular menses
• OR cessation for 6-12 months in women with previous oligomenorrhoea

Question 3

Causes of PRIMARY amenorrhoea?

Answer 3

• Turner’s syndrome
• Testicular feminisation
• Congenital malformations of the genital tract
• Functional hypothalamic amenorrhoea (e.g. secondary to anorexia)
• Congenital adrenal hyperplasia
• Imperforate hymen

Question 4

Causes of SECONDARY amenorrhoea

Answer 4

• hypothalamic amenorrhoea (e.g. stress, excessive exercise)
• PCOS
• hyperprolactinaemia
• Premature ovarian failure
• Thyrotoxicosis
• Sheehan’s syndrome
• Asherman’s syndrome (intrauterine adhesions)

Question 5

Investigations for unexplained amenorrhoea

Answer 5

• pregnancy test
• Bloods - coeliac screen, TFTs, gonadotrophins, prolactin, androgen level, oestradiol

Question 6

If gonadotrophins are normal/high when investigating amenorrhoea, what does this suggest?

Answer 6

Ovarian problem rather than hypothalamic problem

=> Primary ovarian insufficiency or premature ovarian failure

Question 7

How should primary amenorrhoea be managed?

Answer 7

If primary ovarian insufficiency (eg Turners)

These patients will benefit from HRT
(e.g. to prevent osteoporosis)

Question 8

What should be excluded before treating the cause of secondary amenorrhoea?

Answer 8

pregnancy
Lactation/breastfeeding
Menopause (age >40)