Primary and secondary amenorrhoea Flashcards
What is primary amenorrhoea?
Absence of menstruation by 13 with no other evidence of pubertal development
Absence of menstruation by 15 with other signs of puberty
What is the average age range for puberty starting in males?
9-15
What is the average age range for puberty starting in females?
8-14
What is menarche?
First period
What is thelarche
Breast bud development
What is pubarche
Pubic hair development
When does menarche usually occur in relation to pubarche and thelarche
Around 2 years after
What is hypogonadism?
The lack of sex hormones, oestrogen and testosterone
What is hypogonadotrophic hypogonadism?
Deficiency of LH and FSH
What is hypergonadotropic hypogonadism?
A lack of response to LH and FSH by the gonads (Testes and ovaries)
What gland produces LH and FSH?
Anterior pituitary gland
What hormone stimulates FSH and LH release?
GnRH
What are some possible causes of hypogonadotropic hypogonadism?
Hypopituitarism
Hypothalamus or pituitary damage
Chronic conditions
Excessive exercise
Constitutional delay in growth and development
Endocrine disorders (GH deficiency, hypothyroidism, Cushing’s)
Kallman syndrome
What are some possible causes of hypergonadotropic hypogonadism
Previous damage to the gonads
Congenital absence of the ovaries
Turner’s syndrome (XO)
What is Kallman syndrome?
A genetic condition resulting in hypogonadotropic hypogonadism and anosmia
What is congenital adrenal hyperplasia?
A condition caused by a congenital deficiency of 21-hydroxylase enzyme causing underproduction of cortisol and aldosterone and overproduction of androgens
Describe the inheritance of congenital adrenal hyperplasia
Autosomal recessive
What are some common features of CAH?
- Tall for their age
- Facial hair
- Absent periods (primary amenorrhoea)
- Deep voice
- Early puberty
What is androgen insensitivity syndrome?
A condition in which tissues cannot respond to androgen hormones, so typical male characteristics do not develop
How does androgen insensitivity syndrome present?
Males with normal external female genitalia, breast tissue, internal testes and absent uterus, vagina, fallopian tubes and ovaries
What are some structural pathologies that can cause primary amenorrhoea?
- Imperforate hymen
- Transverse vaginal septae
- Vaginal agenesis
- Absent uterus
- Female genital mutilation
What is imperforate hymen
Normally, the hymen is a crescent shape structure covering the entrance to the vagina
In imperforate hymen, the hymen extends fully across the vagina, preventing the release of blood
What are some initial tests required in primary amenorrhoea?
- FBC
- Ferritin
- U+E (For CKD)
- Anti-TTG and anti-EMA for coeliac
What are some hormonal blood tests required in primary amenorrhoea?
- FSH and LH (Differentiate between hyper and hypogonadotropic)
- TFTs
- IGF1 (Assess for GH deficiency)
- Prolactin
- Testosterone
What are some other tests required in primary amenorrhoea
- Genetic testing for Turner’s syndrome
- X-ray wrist for bone age to diagnose constitutional delay
- Pelvic US
- MRI brain
What are some management options for primary amenorrhoea?
Treat cause
Replacement hormones
Pulsatile GnRH if required
What is meant by secondary amenorrhoea?
No menstruation for more than 3 months after previous regular periods
What are some possible causes of secondary amenorrhoea?
Pregnancy
Menopause or Primary ovarian insufficiency
Hormonal contraception
Hypothalamic or pituitary pathology
PCOS
Asherman’s syndrome
Thyroid pathology
Hyperprolactinaemia
What causes decreased GnRH production by the hypothalamus?
Physiological and psychological stress to prevent pregnancy during unfavourable situations
(E.g. Excessive exercise, low BMI, chronic disease, stress)
What are some pituitary causes of secondary amenorrhoea?
Pituitary tumours (E.g. prolactinoma)
Pituitary failure (E.g. trauma, radiotherapy, surgery, Sheehan syndrome)
How does hyperprolactinaemia cause secondary amenorrhoea?
Hugh prolactin acts on the hypothalamus to cause release of GnRH, preventing LH and FSH release, causing hypogonadotropic hypogonadism
What is the most common cause of hyperprolactinaemia?
Pituitary adenoma secreting prolactin (Prolactinoma)
What are some management options for hyperprolactinaemia?
Dopamine agonists (E.g. bromocriptine, cabergoline)
What hormonal tests are required in secondary amenorrhoea?
HCG (Pregnancy)
LH and FSH
prolactin
TSH
T3 and T4
Testosterone
How is secondary amenorrhoea managed?
Treat underlying cause
