O+G Flashcards
What is the cervix like pre-puberty?
Lined with squamous epithelium
Becomes columnar during pregnancy and puberty
SCJ migrates down
Normal change - ectopy
When SCJ is in low pH vagina region, becomes squamous - transformation zone
Transformation Zone vs SCJ
TZ wide area between highest and lowest point that SCJ was in lifetime - pre- and post-puberty
SCJ is the exact position of histological change
What is ectopy also known as?
An ectropion
What is the pathology in an ectropion?
Columnar epithelium present on vaginal surface - normal physiological state
Presentation of an ectropion
Excess mucous secretion
Post-coital bleeding
O/E Red looking area on os
RFx for an ectropion?
Oestrogen-containing contraceptives
Menstruating age - Raised oestrogen
Ix For ectropion?
Colposcopy +/- biopsy for sinister causes
Mx for Ectropion
Not usually needed
Can stop pill
Ablation
What are the high risk HPVs
16 and 18
16 = 50% Ca’s
What is CIN?
Cervical intraepithelial neoplasia AKA dyskaryosis
Abnormal growth, potentially pre-malignant
Almost always caused by HPV
How Dx and staging CIN made?
Picked up on cervical screening, which shows degree of dyskaryosis
Colposcopy and histology
Dx made by cytology
How many grades of CIN?
3
Stage 1: Mild dyskaryosis - basal 1/3 epithelium of TZ
Stage 2: Moderate - Basal 2/3 epithelium
Stage 3: Severe - >2/3 epithelium AKA carcinoma in situ
Prognosis of CIN
~15 years until cervical Ca
RFx for CIN
Sexual promiscuity Birth < 16y Young age commencing sexual activity Aged 25-35 Not vaccinated Smoker
How to Ix CIN?
Colposcopy - 2 solutions: acetic acid (dysplastic cells), iodine (stains yellow/orange - should go dark in normal)
Biopsy usually done
Silver nitrite for cauterisation
Mx CIN
One stop clinic - ablation/excision
CIN 1 not treated
LLETZ (Large Loop excision of TZ) procedure - curative
Cold coagulation or laser ablation - efficacy 90-95%
What is common cell type of cervical Ca?
SCC
Epidemiology of cervical Ca?
Disease of young
Less common due to screening
Highly linked to smoking
Smear test screening
Negative - no further Mx
Inadequate - repeat - 3 inadequate - Colposcopy
Borderline - Endocervical - Colposcopy; Squamous cells - screen in 6m
Mild/Moderate/Severe - Colposcopy
3 years 25 - 49y; 5yearly after
Presentation of cervical Ca?
Often asymptomatic
Many present on smear testing
Non menstrual bleeding typical presentation
Advanced:
Post-coital
PMB
Very advanced:
Backache, leg pain, hydronephrosis
RFx cervical Ca?
High parity STI Hx Sexual promiscuity Birth < 16y Young age commencing sexual activity Aged 25-35 Not vaccinated Smoker
Mx of Cervical Ca?
Curative vs Palliative
Ia: Hysterectomy/Biopsy
Ib: Total Hysterectomy + RTx +/- CTx
II-IV: Chemo/RTx
Prognosis of Cervical Ca?
Average 5y survival 61%
What is the HPV vaccine?
Vaccination against 16 and 18
Given at 12-13y
3 doses over 6 months
What is Vulval Cancer?
Mostly SCC
Post menopausal females
Presentation of Vulval Cancer?
Elderly PM Itching Burning Patches discolouration - red, black or white Lumps or growths Vulval bleeding Dyspareunia Dysuria
RFx for Vulval Cancer?
HPV
Smoking
CIN/VIN
DDx of Vulval Cancer?
Vulval dermatoses - lichen sclerosis - steroid cream
VIN - Vulval intraepithelial neoplasia
Vaginal cancer - upper 1/3 post wall most common
Senile vaginitis - atrophic vaginitis
Mx for Vaginal Cancer?
RTx - preserve genitalia
What is the staging system for Vulval Cancer?
FIGO staging
Mx of Vulval Cancer?
Surgery and reconstruction AKA excision
RTx - shrink pre-op
Chemo
Palliative - symptom control
What is the most common genital tract Ca?
Endometrial Ca
What is the pathology of Endometrial Ca?
Adenocarcinoma
What is the presentation of Endometrial Ca?
Tumour related - abnormal vaginal bleeding (PMB - little and occasional: gets more frequent and heavy; Pre-menstrual - irregular, heavier or change)
Metastases related - Local, lymphogenic or haematogenic
RFx for Endometrial Ca?
Long-term exposure to oestrogens: Nulliparous Early menarche and late menopause PCOS Obesity - aromatase Tamoxifen DM
Ix for Endometrial Ca
Transvaginal USS - Ca > 5mm
Biosy via Hysteroscopy (done if >4mm on USS or multiple bleeds)
Pre-menopausal - Hysteroscopy regardless
DDx for PMB
Endometrial Ca Cervical Ca Atrophic vaginitis Ectropion Endometrial Polyp Vaginal Ca Endometrial Hyperplasia Tamoxifen HRT
Mx of Endometrial Ca?
Surgical: TAH +/- Bilat salpingo-oophorectomy +/- RTx +/- High dose progesterones
What is Endometrial Hyperplasia?
Extensive stimulation –> Proliferation of endometrium
AKA HRT without progestin
Pre-cancerous - risk carcinoma in complex hyperplasia with atypia (30%)
How to classify Endometrial Hyperplasia?
Based on histology
Simple or complex
Presentation of Endometrial Hyperplasia?
Constant bleeding
Intramenstrual bleeding
Post-menopausal bleeding
Ix of Endometrial Hyperplasia?
USS or hysteroscopy
> 1cm in pre-menopausal
5cm in post-menopausal
Mx of Endometrial Hyperplasia?
Depends on presence atypia and age
No atypia - progesterone (mirena coil) and surveillance
Atypia - TAH +/- BSO
What is Amenorrhoea?
Absence menstruation in women of reproductive age
What are the two main reasons for physiological Amenorrhoea?
Pregnancy
Breast feeding
What is primary Amenorrhoea?
When patient never had period
When should primary Amenorrhoea be Ix?
14y and no breast development
15y with breast development
Most common causes of Amenorrhoea?
Late puberty GU malformation e.g. imperforate hymen Turner's Hypothyroid Congenital absence of organs e.g. uterus/ovaries
When to consider further Ix in primary Amenorrhoea?
Abnormal genitalia
Common causes secondary Amenorrhoea?
Emotional distress Weight loss Excessive exercise Drug induced PCOS PRegnancy Contraception Anorexia
Ix in secondary Amenorrhoea?
Urinary BHCG
Serum free androgen index - PCOS
FSH in premature menopause
T and LH in PCOS and adrenal hyperplasia
LH and FSH - High = premature ovarian failure; Low = Hypothalamic cause; Normal FSH, High LH = PCOS
Prolactin in prolactinoma/anything blocking DA e.g. antipsychotics
USS for PCOS and sexually inactive girls
Mx Amenorrhoea?
Treating cause
Determined whether want children
Dysmorphic features of Turner’s
Short stature
Wide neck
Pubertal delay
Low set ears
What is PCOS?
Excess androgens
Presence multiple immature follicles ovaries
Assoc. with excessive androgen secretion and insulin resistance
Pathology of PCOS?
High LH = High androgens
Insulin resistance = Low SHBG (sex hormone binding globulin) –> Higher androgens
Why is ovulation suppressed despite high levels LH in PCOS?
Androgens suppress surge
Presentation PCOS
Amenorrhoea Oligomenorrhoea (irregular) Acne Weight gain Dark patches skin (acanthosis nigricans) Hirsutism Infertility
Diagnostic criteria for PCOS?
Rotterdam Criteria - 2/3 of:
- Oligomenorrhoea +/- anovulation
- Clinical or biochemical signs hyperandrogenism
- Poly cystic ovaries on imaging
What would be seen on bloods in PCOS?
Raised T
Low SHBG - high circulating levels of LH
Normal FSH
Low Progesterone
What would be seen on USS of PCOS?
String of pearls
> 5 follicles/ovary
Mx of PCOS
Treat DM/HTN/Hyperlipidaemia
Weight management
Oral contraceptive pill (effect oestrogen unopposed - give POP)
Anti-androgen for hirsutism aka spironolactone
Infertility:
Clomifine in conjunction with metformin
Ovarian drilling
COCP
Complications of PCOS
T2DM
Weight gain
Increased risk endometrial Ca
What is PID?
Inflam condition affecting any part of higher female reproductive system - salpingitis or endometritis
Causative organisms in PID?
Chlamydia Trachomitis and Neisseria Gonorrhoea
Presentation of PID
Lower abdo pain N&V Fever >38 Deep dyspareunia Cervical/Vaginal discharge Irregular bleeding Dysuria Cervicitis
O/E: Cervical excitability, tenderness at fornices
RFx for PID
STD Young age Multiple partners Intercourse without protection IUD insertion
Ix for PID
Swabs - endocervical (chlamydia and gonorrhoea) and high vaginal swab Bacterial vaginosis
Urine dip +/- MSSU
Pregnancy test
Mx PID
Abx - Doxycycline and Metronidazole
Paracetamol
Contact tracing
Avoid intercourse until patient and partner treated
When to admitt someone with PID
Pregnant
Septic
Peritonitic
Complications of PID
Abscess Infertility Chronic pain Chronic salpingitis - adhesions Fitz-Hugh Curtis syndrome - Liver capsulitis secondary to PID
What is an Ovarian Cyst?
Fluid filled sack within ovary
Common - especially pre-menstrual patients
How to tell if Ovarian Cyst will be malignant?
RMI (Risk of Malignancy Index)
- USS x Menopausal Status x Ca-125
- > 250 should be referred to specialist
- 1 point if pre-menopausal; 3 if post
- USS features = 1 point; 3 points if 2 or more
Presentation of Ovarian Cyst?
Incidental and asymptomatic Chronic pain - secondary to pressure bladder/bowel Dysparenueria/cyclical pain ACute pain in rupture or haemorrhage PV bleeding
Presentation of Ovarian Cyst Rupture?
Sudden onset, unilateral, lower abdo pain
Fluid and blood loss - Shock
Acute abdo
Occurring during exercise
Dx - Pelvic USS - free fluid Pouch of Douglas
Rx Ruptured Ovarian Cyst?
Stable: Supportive - Obs and analgesia
Unstable: Laparoscopy
Presentation of Ovarian Cyst Torsion?
Sudden onset, unilateral, lower abdo pain
N&V
Pain improves over 24h as ovary dies
Venous return impaired - disruption arterial supply
Occurs during exercise or ovarian enlargement
Mx Ovarian Torsion?
USS - Enlarged, oedematous ovary
Laparoscopy and flip - should turn pink
Mx Ovarian Cyst?
Post-menopausal - Low RMI, follow up for year if <5cm with Ca-125 and USS;
Moderate RMI - Bilateral oopherectomy w/ Ca-125
Severe RMO: Laparotomy and staging
Pre-menopausal LDH, aFP, B-HCG Re-scan 6wk after finding - still there --> USS and Ca-125 3-6m then RMI >5cm --> Cystectomy
Cell Type Ovarian Cancer?
Mostly epithelial subtype
Serous > mucinous cystadenocarcinoma
What do Granulosa cell tumours produce?
Oestrogen
What do Sertoli-Leydig cell tumours produce?
Androgens
What is Meigs Syndrome?
Triad of benign ovarian tumour, ascites, and pleural effusion (transudate)
What on USS is included in RMI?
Bilateral Ascites Metastases Solid areas Multilocular cysts
Presentation of Ovarian Cancer?
Vague symptoms delay Dx
Abdo/pelvic pain
Bloating
Change bowel habit
O/E: Mass, ascites, cervical excitation
RFx for Ovarian Cancer?
More ovulation = Increased risk Nulliparity Early menarche Late menopause Oestrogen-only HRT Smoking
What are 2 genetic mutations predisposing to Ovarian Ca?
BrCa 1/2
Patients < 30y
HNPCC - Lynch syndrome
3 Tumour markers in Ovarian Ca
Ca-125
CEA (Carcinoembryonic antigen)
Ca-19.9
If < 40, what additional tests for Ovarian Ca?
LDH, AFP, B-HCG
DDx for Ovarian Ca
IBS
Diverticular disease
Ix for Ovarian Ca
USS
CT abdo/pelvis
CXR for pleural effusion/ lung mets
MRI - staging?
How is Ovarian Ca Staged?
FIGO
Mx Ovarian Ca?
Full staging laparotomy with midline incision
Hysterectomy, BSO, Omentectomy, LN sampling, Peritoneal washings
Platinum-based Chemotherapy (carboplatin)
Letrozole
Role of screening in Ovarian Ca?
If gene mutation identified - yearly USS with Ca-125
BrCa +ve - BSO offered and warned of risk finding incidental disease
What does sexual offences act of 2009 say?
Legal age consent is 16
Not intended to prosecute mutually consented sex between 13 and 16
< 13y is crime with no defence
What is Gillick Competence?
< 16y and their capacity to consent to their own sexual activity
What are the Fraser Guidelines?
Only concerned of contraception UPSSI is criteria - Must have understanding - Parental involvement unless cannot be persuaded - Sex ongoing regardless of advice - Suffering will ensue - In best interest
What is Endometriosis?
Relapse and remitting Condition where endometrial tissue located outside uterus
Ovaries, pouch of Douglas, Lung
What does adenomyosis mean?
Presence Endometrial tissue in uterine muscle
What are 3 proposed theories for Endometriosis?
- Retrograde menstruation
- Metaplasia of mesothelial cells
- Impaired immunity
What hormone Endometriosis driven by?
Oestrogen - acts like would to cyclical hormones - growing and bleeding at times
What happens when there is endometrial tissue in ovaries?
Bleeds and forms chocolate cysts
What is the presentation of Endometriosis?
Cyclical pelvic pain Occurs at time of menstruation Can be chronic due to adhesions Severe dysmenorrhoea Deep dyspareneuria Dysuria Dyschezia (pain on defecation) Cyclical rectal bleeding Subfertility
O/E:
Fixed, retroverted uterus
Palpable uterosacral ligament
Tenderness and adnexal masses
What features on examination would suggest adenomyosis?
Enlarged, tender, boggy uterus
RFx for Endometriosis?
FHx
Short menstrual cycles
Heavy menstrual bleeding
Early menarche
DDx Endometriosis?
PID
Ectopic
Fibroids
IBS
Ix for Endometriosis?
Bloods - anaemia, urine dip (haematuria), MRI if bowel, transvaginal USS (cancer), pelvic USS (Severity - pre-surgery)
Gold standard is laparoscopy - chocolate cysts, adhesions, peritoneal deposits
Mx of Endometriosis?
Asymptomatic - nothing
Non-hormonal - pain management
Hormonal/Systemic:
- Pseudo-preg: COCP or POP
- Pseudo-menopause: GnRH analogues
Hormonal/Local:
- Mirena Coil
- Surgery: Diathermy or Hysterectomy
RFx for STIs
Unprotected sex Young female Multiple sexual partners MSM Metropolitan
What is most common Bacterial STI in UK?
Chlamydia trachomitis
How should chlamydia be screened?
Opportunistic and all sexually active people <25
Repeat in 3-6m
Causative organism of chlamydia
Chlamydia trachomatis which is obligate intracellular bacteria
Symptoms of chlamydia
Women: Asymptomatic in 80% Post-coital and intramenstrual bleeding Purulent discharge Lower abdo pain PRoctitis Signs: Cervicitis, contact bleeding
Men: Urethral discharge Dysurea Testicular/epididymal pain Proctitis
How to Ix Chlamydia?
PCR testing from vulvovaginal swab
Men: first void urine of day
Rx Chlamydia
Stat azithromycin
Then doxycycline
Avoid all sexual contact until 1 wk after both partners treated
Complications of Chlamydia
PID
Epididymitis
Fitz-Hugh Curtis Syndrome
What can Chlamydia cause in neonates/preg?
Neonatal conjunctivitis
Low BW
Post-partum endometreitis in mother
What is Gonorrhoea?
Neisseiria Gonorrhoea
How is Gonorrhoea transmitted?
Always sexually in adults
Neonates - eye involvement
Older children - sexual abuse
Symptoms of Gonorrhoea?
Depends on location Often asymptomatic Women: Vaginal discharge Lower abdo pain Rectal infection in absence of anal intercourse - spread by fingering or rimming
Men:
Urethral infection with discharge and dysuria
Ix of Gonorrhoea?
PCR testing via vulvovaginal swab or first void urine in men
Mx of Gonorrhoea?
Ceftriaxone and Azithromycin
OR Azithromycin and Doxycycline
Causative organism in HSV?
HSV-1/2
Symptoms of HSV?
Variable
80% no clinical symptoms
PRimary infection - febrile illness 5-7d, dysuria and ulcers
How is HSV Dx?
PCR
Causative organism Syphilis?
Treponium pallidum
Transmission of Syphilis?
Skin to skin
Mucosa to mucosa
Rx of HSV?
Acyclovir
Symptoms of Syphilis?
Ano-genital ulcers which may occur in mouth
Classically - painless ulcers, known as chancres
How to Dx Syphilis?
Syphilis serology
Swab for PCR
Rx for Syphilis?
Ben Pen IM
Complications of Syphilis
Secondary: Gumata
Tertiary: Neurosyphilis (may happen early if immunocompromised); CV
Causative organism of Anogenital warts?
HPV 6 and 11
Transmission of anogenital warts?
Close skin to skin - 40% carry (1-2% develop warts)
Symptoms of warts?
Appear round sites max trauma (introitous or penis)
May be itchy or bleed
Mx warts
Home-based Rx with toxin cream solution
Can give cryotherapy
4 common causes vaginal discharge?
Candida - thick and white; itch - Clotrimazole
BV - watery and fishy; pH >5 - Metronidazole
Trichamonis vaginalis - frothy, yellow and fishy; itch - Metronidazole
Physiological - clear white, no smell
Ix for vaginal discharge
pH
High vaginal swab - Candida, BV, TV
Vulvovaginal swab - Chlamydia, Gonorrhoea
What is female sterilisation?
Tubular ligation
Occlusion
Salpingectomy with rings or clips (99.5%)
What is male sterilisation?
Vasectomy:
- Ligation of vas deferens
- Cauterisation of the ends
- Insertion of a fascia between the two
Complications of a vasectomy?
Bleeding Infection Epididymitis Pain Granuloma
3 Types of non-hormonal contraception?
Male condom
Intrauterine
Sterilisation
Typical Failure rate of condom?
18%
What is a non-hormonal IU contraceptive?
Copper coil - 0.8% failure
MoA of combined hormonal contraceptives?
Inhibits ovulation
Alters mucous and endometrium
Can be given as pill, patch or ring
9% failure
Risks associated with combined hormonal contraceptive?
VTE and PE
Breast Ca
Migraine with aura
What is a POP?
Progestogen only
Thickens mucous
Thins myometrium
9% failure
Benefits of POP over COCP?
Can be used by women who smoke, >35y and breastfeeders
S/E of POP
Breakthrough bleeding
What is the implant?
Small, flexible rod Under dermis of non-dominant arm Contains progestogen Inhibits ovulation Thickens mucous Failure 0.05%
How long implant in for?
3 years
S/E of implants?
1/3 no periods
1/3 irregular periods
1/3 normal periods
What is the contraceptive Depot
Injection into gluteal or abdo fat Contains progestogen Stops ovulation Mucous thickening Myometrium thinning 6% failure Repeated 13 weeks - recall at 3 months
S/E depot injection?
Weight gain
Reduced BMD
Can take one week for women to ovulate again
What is IU hormonal contraception?
Progestogen Stops ovulation Mucous thickening Myometrium thickening In for 3-5y (Mirena) T-shaped device Failure 0.2%
S/E Hormonal IUD?
Irregular bleeding up to 6m
Periods then become lighter and less painful
Emergency contraception
Best within 72h but can be up to 5d after (if ellaone)
Gold standard - copper coil
EllaOne/Levonorgestrel EHC
Reasons to avoid combined hormonal contraceptives?
VTE
PEs
Cancer - endometrial and Breast
Hepatitis or Liver tumours
What is Ovarian Hyperstimulation?
Complication of ovulation induction
Superovulation
What is the pathology of Ovarian Hyperstimulation?
Ovarian enlargement
Fluid shift from intra to extravascular space - peritoneal fluid and haemoconcentration (hypercoagulable)
Presentation of Ovarian Hyperstimulation?
Abdo discomfort
SoB
Risk factors for Ovarian Hyperstimulation?
Young age
Low BMI
PCOS
Prev OHSS
Mx of Ovarian Hyperstimulation?
Analgesia
Fluid balance
Anti-embolic measures
Prevention of Ovarian Hyperstimulation?
Low dose Gonadotrophin
What is the definition of infertility?
Inability of a couple to conceive despite 1y of unprotective sex
Primary: Those who never conceived
Secondary: Previously conceived
Definition of recurrent pregnancy loss?
Inability of a woman to carry a live birth even if conception possible AKA fibroid or antiphospholipid syndrome
What are the causes of infertility?
40% female
30% male
30% combination
What are the female causes of infertility?
PCOS
Ovarian insufficiency
Tubal adhesions
Sexual dysfunctions
How to Dx Male infertility?
Semen analysis after abstaining for 3-4d
How to Dx Male infertility?
Semen analysis after abstaining for 3-4d
More than 30% sperm morphology should be normal
Mx Male infertility
Surgical treatment anomalies
Reproductive technology AKA sperm donor
Testosterone or Clomiphine for medical therapy
Ix of Female infertility?
- Ovulatory function - mid-luteal progesterone (Raised in infertility); FSH (elevated), Prolactin may be high
- Patency fallopian tubes and uterus using hysterosalpingography (dye test)
- Examine cervix
Mx of Female infertility?
Inducing OVulation:
- Weight loss/gain
- Clomiphine (increases FSH)
- Ovarian drilling in PCOS
- Letrazole (aromatase inhibitor - lowers oestrogen, increase FSH)
- ?Metformin (PCOS)
Egg Retrieval:
- HCG analogue given priorly
IUS - Intrauterine insemination
IVF - In vitro fertilisation
ICSI - Intra-cytoplasmic sperm injection
Define Heavy menstrual bleeding
Bleeding that has any adverse impact on quality of life
Causes of Heavy menstrual bleeding
Fibroids
Adenomyosis
Malignancy
Ix for Heavy menstrual bleeding
FBC - anaemia
B-hCG - pregnancy
USS - fibroids etc.
Mx of Heavy menstrual bleeding
No treatment Methanamic or tranexamic acid Pseudopregnancy or pseudomenopause - Contraception - GnRH analogues (pseudomenopause)
Surgical:
Hysteroscopy and resection (polyps)
Uterine artery ablation
Hysterectomy
What is Oligomenorrhoea?
Cycle > 35d
How to Examine for Amenorrhoea
Tanner staging
What is Asherman Syndrome?
Most common form of anovulatory infertility
Caused by excessive curettage of endometrial cavity
What is dysmenorrhoea?
Characteristically cramping lower abdo pain, radiates to back and legs
Primary: idiopathic with high level prostaglandins
Secondary: due to pelvic pathology (usually endometreisis)
What is intermenstrual bleeding?
Bleeding incl brown discharge between periods
Definition of PMV
Bleeding 12m after last menstrual period
Causes of PMV
Vulval Ca Cervical Ca Vaginal Ca Cervical Polyps Endometrial Ca
What is the climateric?
Peri-menopause
First instance of symptoms AKA infrequent menstruation
What is the menopause
Time when woman permanently stops menstruating
12m after amenorrhoea
What is post-menopause
Time beginning 12m after last menstrual cycle
Physiology of Menopause
Reduced ovarian function
Reduced -ve feedback
Increased GnRH
Anovulatory cycles
Presentation of Menopaue
3 Categories:
- Vasomotor - sweating, hot flushes, heat intolerance
- Mental - impaired sleep, depressed mood, loss libido
- Atrophic - Vulvovaginal atrophy, general weight gain and bloating
Dx for Menopause
> 45y - clinical Dx
< 45y - ?POI (prem ovarian insufficiency) - FSH measurements
Indications for Mx of menopause
Impacts QoL Premature or surgical Bleeding - coil Atrophic vaginitis - Vaginal oestrogen creams HRT Paroxetine - hot flushes
Types of HRT
Oestrogen-only if hysterectomy
Oestrogen and Progesterone if have uterus - protects from affect unopposed oestrogen
C/I to HRT
Pregnancy
DVT/PE
Chronic liver disease
Endometrial/Breast Ca
What is premature ovarian insufficiency
Cessation periods before 40
Pathology of premature ovarian insufficiency
Decreased oestrogen
Loss feedback
FSH and LH high
Causes of premature ovarian insufficiency
Idiopathic
Smoking
Post-oopherectomy
Induction multiple ovulations and infertility
Dx of premature ovarian insufficiency
High FSH after 3m amenorrhoea
Mx of premature ovarian insufficiency
HRT
IVF if want baby
Treat underlying disorders
