Amenorrhoea - Lecture Documents

Amenorrhoea Primary Amenorrhoea Classified based on presence or absence of 2ndry sexual characteristics imperforate hymen (haematocolpos) – most common cause. cyclical lower abdo pain, distended hymenal membrane through which dark blood may be seen treatment by incision & drainage Physiological delay – 2nd most common Family history often positive. Usually developmentally normal & no treatment required Progesterone challenge test (5 days oral progesterone will lead to withdrawl bleed) Other causes include low body weight, exercise etc. Secondary Amenorrhoea Cessation of established menstruation – no cycle in 6 months (or 3 times the previous cycle length) in the absence of pregnancy. NB: Pregnancy and lactation – should be excluded in all sexually active women Commonest causes are weight loss, PCOS and hyperprolactinaemia. Can be broken down by which section of the endocrine axis is involved Hypothalamic Hypogonadotrophic Hypogonadism – frequently assoc with stress, physical stress (exercise) etc. If normal weight treatment depends on fertility wishes. COCP as oestrogen replacement if fertility not required. Pulsatile GnRH release to induce ovulation if trying for child, If underweight – restoring body weight will restore ovulation Pituitary Pituitary Adenoma – presents with headaches & visual disturbance, galactorrhoea & amenorrhoea Treatment uses a dopamine agonist to suppress prolactin production Ovarian Premature ovarian failure Cessation of ovarian function before the age of 40. failure is due to inadequate numbers of follicles available. Occurs in 1% of women, can be linked to surgery, viral infection (mumps), cytotoxic drugs or chromosomal abnormality. Low oestrogen & high FSH are poor prognostic signs Hormone replacement can relieve menopausal symptoms and reduce osteoporosis risk Polycystic Ovary Syndrome (PCOS) Most common form of anovulatory infertility. Decreased insulin sensitivity (exacerbated by obesity)à hyperinsulinaemia à stimulates theca cell androgen production in ovary Diagnostic features: oligomenorrhoea/amenorrhoea (80%), anovulatory infertility (74%), hirsutism (69%), central obesity (49%). Bilaterally enlarged ovaries with multiple peripheral cysts (<10mm) “ring of pearls”. Testosterone elevated. LH>FSH Treatment with COCP à regular menses & reduces androgens but worsens insulin resistance Clomiphene is usuful for anovulatory fertility. Weight reduction à reduces insulin resistance à corrects hormone imbalance à encourages ovulation Long term à increased risk CVS disease (dyslipidaemia, hypertension), DIDDM, endometrial hyperplasia, endometrial & breast carcinoma Virilising tumour of the ovary Small and rare. Suspect if amenorrhoea with virilisation. Elevated plasma testosterone. Rx: excision Other endocrine causes Hypothyroidism can à amenorrhoea. Thyrotrophin releasing hormone stimulates prolactin secretion Congenital Adrenal Hyperplasia – treat with low dose corticosteroids Uterine Causes Excessive uterine curettage – at time of miscarriage, TOP or 2o PPH à removal of basal layer & à uterine adhesions (Asherman’s syndrome) Management Exclude pregnancy Ask about perimenopausal symptoms (hot flush, night sweats, vaginal dryness) History of weight changes, drugs, medical disorders and throid symptoms Examination – height, weight, visual fields, hirsutism, virilisation, pelvic examination Bloods – serum LH, FSH, Prolactin, testosterone, TSH Transvaginal US (to look for PCOS)