Secondary Amenorrhoea

Question 1

Define secondary amenorrhoea? [2]

Answer 1

Had periods in the past but not in the last 6 months

Question 2

What are the possible causes of secondary amenorrhoea? [5]

Answer 2

Contraception, pregnancy
PCOS, hypothalamic stress causing weight change, excessive exercise
Premature menopause
Prolactinoma, androgen secreting tumour
Sheehan’s syndrome (pit failure), Asherman’s Syndrome (intrauterine adhesions)

Question 3

What signs can we look for to explain secondary amenorrhoea? [4]

Answer 3

Take BP, BMI
Look for sings of androgen excess e.g. Hirsutism, enlarged clitoris & deep voice
Acne and Cushingoid signs
Abdo, pelvic Exam

Question 4

What blood tests can we do to explain secondary amenorrhoea? [3]

Answer 4

Urine pregnancy test & glucose dipstick

FSH, LH, oestradiol, prolactin, TFTs, testosterone

Pelvic US (for PCOS)

Question 5

How can we treat secondary amenorrhoea? [4]

Answer 5

Aim to get the BMI to 20-25
Assume they’re still fertile and require contraception
Emotional support
Check for fragile bones (low oestrogen -> Osteoporosis)

Question 6

Mx premature ovarian insufficiency [2]

Answer 6

Offer HRT till 50 yo (menopause will begin after that anyways)
Emotional support - Daisy network

Question 7

How can weight loss/exercise help in PCOS?

Answer 7

Weight loss/exercise can help all symptoms, increase SHBG (sex hormone binding globulin) so less free androgens

Question 8

Mx PCOS [6]

Answer 8

Weight loss
Anti-androgen therapy
COCP - endometrial protection
Spironolactone has a feminizing effect
Eflornithine cream - stops facial hair growth
Fertility problems: clomiphene for ovulation induction, metformin helps ovulation but no anti-androgenic effects

Question 9

PCOS - complications in management [2]

Answer 9

Increased NIDDM risk even if slim so consider GTT

Risk of endometrial hyperplasia if <4 periods a year

Question 10

Forms of endometrial protection in PCOS [3]

Answer 10

Endometrial protection: COCP, progestogens, mirena IUS

Question 11

DDX: polycystic ovaries and PCOS
Polycystic ovaries can be physiological and are found in 20% of women on scan but with no other features of PCOS. What are polycystic ovaries?
PCOS [3] defining features

Answer 11

Small peripheral ovarian cysts x 10 or ovarian volume > 12cm3

PCOS:

1. Oligomenorrhea
2. Androgen excess
3. Polycystic ovaries