Oligo/Amenorrhoea

Question 1

Define

• primary amenorrhoea
• secondary amenorrhoea
• oligoamenorrhoea

Answer 1

Primary amenorrhoea- failure of menstruation by age 16
Secondary amenorrhoea- cessation of menstruation for over 6 months
Oligoamenorrhoea- menstruation occurring every 35 days to 6 months

Question 2

How do you investigate amenorrhoea?

Answer 2

1. Serum urine hCG
2. LH and FSH
3. Serum basal prolactin
4. Testosterone- total testosterone, sex binding globulin, free testosterone
5. TFT’s (TSH, T3 and T4)
6. Transvaginal ultrasound
7. Karyotyping

Question 3

What would you see with the FSH and LH levels: 
ovarian failure 
Tuner's syndrome 
Testicular feminisation
Hypothalamic hypogonaidism 
Constitutional delay

Answer 3

• raised in ovarian failure
• raised in Turner’s: will also be shorter
• raised in TF (receptors not responding)
• decreased in Hypothalamic hypogonaidism
• normal in constitutional delay

Question 4

What causes hyperprolactinaemia?

Answer 4

Prolactinoma
Prolactin secreting tumour
Hypothyrodism
Head injury, brain surgery, irradiation
TB, Sarcoidosis, Sheehan’s syndrome (Secondary amenorrhoea)
Drugs- dopamine agonists, antidepressants, metacloparamide, opiates, cocaine, heroin

Question 5

What is a raised prolactin levels, and how many times do you do the investigation?

What is the management of hyperprolactinaemia

Answer 5

> 1000, and do the test twice

• Dopamine agonists: Bromocriptine
  Surgical removal if tumour

Question 6

What are the adrenal causes of primary and secondary amenorrhoea?

Answer 6

Primary: Congenital adrenal hyperplasia, Testicular feminsisation, adrenal tumours
Secondary: Adrenal tumours

Question 7

What is congenital adrenal hyperplasia and what are it’s features during infancy?

Answer 7

• Due to 21- hydroxylase deficiency which results in cortisol (and or aldosterone) deficiency and androgen excess

Features
- ambigious genitalia
- Enlarged clitoris
- Urogenital sinus (instead of separate vagina and uterus)
If aldosterone deficiency- then nausea, vomiting, diarrhoea, weight loss, lethargy, dehydration, hypnoatraemia, hyperkalaemia, and shock

Question 8

What is testicular feminisation and what are its clinical features?

Answer 8

X-linked disorder, genotype is male
Testosterone receptors are not sensitive to testosterone, so have peripheral conversion of testosterone to oestrogeon

• External genitalia are feminine (vagina is blind ending) but have absence of uterus or ovaries
• testes fail to descend normally in the groin
• will have breast development and female contours

Question 9

What are the ovarian causes of primary and secondary amenorrhoea?

Answer 9

Primary-Tuner’s syndrome, PCOS

Secondary- Premature ovarian failure, PCOS, virilizing ovarian tumours

Question 10

What is a polycystic ovary

What is epidemiology of PCOS?

Answer 10

Polycyctsic ovary, when >12 follicles, small 2-8 cm follicles in enlarged ovary >10cm

Epidemiology: Obese women, causes 80% of infertility, patients present in prepubertal period to mid 20’s

Question 11

What is pathophysiology of PCOS?

Answer 11

• Have disordered LH production with high LH levels, and insulin resistance so high insulin levels
• LH and insulin act on polycystic ovary which produced testosterone
• Insulin also act on adrenal gland to produce testosterone
• Insulin works on liver produces less steroid binding globulin

Question 12

How do you diagnose PCOS

What are clin features of PCOS?

Answer 12

Rotterdam criteria (2 out 3): PCO ovary on transvaginal ultrasound, oligo-ovulation or amennorrhoea (periods >35 days apart) and clinical or biochemical signs of raised testosterone

Features

• Oligoamenorrhoea (<9 periods a year), amenorrhoea
• Subfertility
• Miscarriage
• Virilization: acne, hirsutism (upper lip, chin, nipple, umbilicus), clitomegaly, deep voice, increased muscle mass
• Obesity, acanthosis nigricans
• Alopecia
• Psychological symptoms: low self esteem, mood swings, depression, anxiety, sleep aponea

Question 13

What are investigations for PCOS?

Answer 13

1. Serum bHCG
2. FSH- normal
3. Prolactin- exclude prolactinoma
4. Testosterone- total testosterone (normal), free testosterone(raised) , steroid binding globulin (normal/reduced)
5. HB1ac, lipids (increased cardiovascular risk)
6. Transvaginal ultrasound- visualize polycystic ovary

Question 14

What are complications of PCOS?

Answer 14

• Dyslipidaemia and cardiovascular risk and type 2 diabetes

- Endometrial cancer (amenorrhoea means unopposed oestrogeon causes endometrial hyperplasia- cancer)

Question 15

What is management of PCOS? (general and pharmacological)

Answer 15

• Weight loss
  Not getting pregnant:
  -Cycle control: COCP (want 3-4 bleeds a year to protect endometrium) progesterone or Mirena IUS
• Hirsutism: Topical Elfornithine, or spironolactone/cryptocerone acetate (all anti-androgens)
• Metformin

Getting pregnant:

• Clomifene (antioestrogeon)- max 6 months with TVS monitoring
• Metformin used instead of clomifene to increase fertility

Question 16

Which outflow tract problems may cause primary and secondary amenorrhoea?

Answer 16

Primary- Imperforate hymen, transverse vaginal septum

Secondary- Asherman’s syndrome and cervical stenosis

Question 17

What would be the features of an imperforate hymen and transverge vaginal septum?

Answer 17

Cyclical pain near menstrual cycle

O/E palpable haematocolpus (blood in vagina) and haematometra (blood in uterus)

Question 18

What causes cervical stenosis and Asherman’s syndrome?

Answer 18

Cervical stenosis- narrowing of cervix due to coloposcopy, trauma, repeated vaginal infections, atrophy, cervical cancer
Ashermnan’s syndrome- adhesions and fibrosis of endometrium secondary to excessive curettage at RPOC

Question 19

Which contraceptives cause amenorrhoea?

Answer 19

• Mirena IUS

- Depot

Question 20

In how many months should post-pill amenorrhoea settle by?

Answer 20

-3 months