Primary and Secondary Amenorrhoea

Question 1

What is primary amenorrhoea?

Answer 1

Absence of menses by 16 with normal secondary sexual characteristics

Absence of menses by 14 without normal secondary sexual characteristics

Question 2

What is secondary amenorrhoea?

Answer 2

Absence of menses for 6 months in a previously menstruating female

Question 3

What are the 5 sexual secondary characteristics?

Answer 3

Breast development
Pubic hair development
Axillary hair development
Growth spurt
Menarche

Question 4

What is Tanner staging?

Answer 4

Scale of physical development as children develop into adolescence

Question 5

What are the causes of primary amenorrhoea with normal secondary sexual characteristics?

Answer 5

1. Imperforated hymen
2. Transverse vaginal septum
3. Absent vagina
4. XY female (androgen insensitivity)
5. Constitutional delay

Question 6

What are the causes of primary amenorrhoea with absent secondary sexual characteristics - gonadal causes (high FSH)?

Answer 6

1. Gonadal agenesis
2. Gonadal dysgenesis
3. Galactosemia
4. Premature menopause

Question 7

What are the features of androgen insensitivity (46 XY female)?

Answer 7

Normal breasts and external genitalia but absent pubic hair, uterus and upper vagina (46 XY)

Question 8

What is the likely cause of constitutional delay?

Answer 8

Immature pulsatile release of GnRH (no anatomical anomaly)

Question 9

What are the causes of primary amenorrhoea with absent secondary sexual characteristics - central causes (low FSH)?

Answer 9

1. GnRH deficiency
2. CNS mass
3. Stress
4. Weight loss
5. Hyperprolactinaemia

Question 10

What is an example of gonadal dysgenesis?

Answer 10

Turner’s syndrome (45 XO)

Question 11

What are the clinical features of Turner’s syndrome?

Answer 11

Short stature
Webbed neck
Broad chest with widely spaced nipples
Coarctation of the aorta
Streak ovaries (infertility)

Question 12

What are the causes of premature ovarian failure?

Answer 12

Radiotherapy
Chemotherapy
Mumps oophoritis

Question 13

How is primary amenorrhoea investigated?

Answer 13

History
(exercise, weight loss, chronic illness, meds, radiotherapy, stress, family Hx)
Exam
(growth chart, secondary characteristics, external genitialia, inguinal canal, bimanual exam)
Lab tests

Question 14

Can patients with androgen insensitivity (Mullerian agenesis) carry children?

Answer 14

No - they are genetically male

Question 15

What are the causes of secondary amenorrhoea (central vs gonadal vs systemic)?

Answer 15

1. Central
   Hyperprolactinaemia, hypopituitarism, hypothalamic (stress, exercise, weight loss)
2. Gonadal
   PCOS, premature ovarian failure, cervical stenosis
3. Systemic
   Chronic illness, weight loss, endocrine disorders (Cushing’s, thyroid)

Question 16

What is Ashermann syndrome?

Answer 16

Intra-uterine adhesions following uterine surgery

Question 17

How does cervical stenosis occur?

Answer 17

Following cone biopsy for CIN treatment

Question 18

What are the three criteria for a diagnosis of PCOS?

Answer 18

1. Oligo- or anovulation
2. Polycystic ovaries
3. Hyperandrogenaemia (clinical/biochemical)

Question 19

What is the most common pituitary cause of secondary amenorrhoea?

Answer 19

Hyperprolactinaemia

Question 20

Name 3 drugs that increase prolactin levels.

Answer 20

1. Metoclopramide
2. Haloperidol
3. Oestrogen

Question 21

How is secondary amenorrhoea investigated?

Answer 21

1. History
2. Exam
   (BMI, external genitalia, breast, visual fields)
3. Pregnancy test
4. Labs
   (prolactin, FSH, LH, TSH, testosterone)

Question 22

How is PCOS managed?

Answer 22

Symptomatic treatment (COCP)
Fertility (Clomifene)
Metabolic (metformin)