Amenorrhoea & PCOS Dr H McMillan MBCHb MSc MRCOG MFSRH Dip Med Ed Consultant in Obstetrics &...
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Transcript of Amenorrhoea & PCOS Dr H McMillan MBCHb MSc MRCOG MFSRH Dip Med Ed Consultant in Obstetrics &...
![Page 1: Amenorrhoea & PCOS Dr H McMillan MBCHb MSc MRCOG MFSRH Dip Med Ed Consultant in Obstetrics & Gynaecology CUMH/ Mercy University Hospital 4 th Year Medical.](https://reader036.fdocuments.net/reader036/viewer/2022062404/551920a455034626428b4b57/html5/thumbnails/1.jpg)
Amenorrhoea & PCOS
Dr H McMillan MBCHb MSc MRCOG MFSRH Dip Med Ed
Consultant in Obstetrics & GynaecologyCUMH/ Mercy University Hospital
4th Year Medical Student Lecture March 2011
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Introduction• Relevant to :• Obstetrics & Gynaecology• GP• General Medicine• Cardiology• Endocrinology• General Surgery
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Overview• Basic Science
• Puberty• Menstrual Cycle
• Amenorrhoea• Primary• Secondary
• PCOS
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Puberty• Thelarche- breast development• Adrenarche- axillary +pubic hair• Menarche- start of periods
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Anatomy-Secondary Sexual Characteristics
Tanner Stages
Pubic Hair development
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Physiology- Pituitary
• Anterior lobe• Adenohypophysis• Secretes • Follicle
Stimulating FSH• Luteinising
Hormone LH• (also TSH, GH,
Prolactin, ACTH, MSH)
Posterior lobeNeurohypohysisStores and releasesOxytocin and
vasopressin
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Menstrual cycle
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Menstrual cycle in action
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Menstrual Cycle• Day 1 is 1st day of bleeding• Days 1-4 FSH high
• Signals to develop follicle in ovary• Follicle produces OESTROGEN
• Oestrogen causes -• Cervical mucus to be receptive to sperm• Endometrium “proliferative” • Down-regulates FSH
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Menstrual Cycle• Day 14
• (if 28 day cycle)• OESTROGEN so high
• Positive feedback to pituitary leads to LH surge
• LH stimulates ovulation • egg released from matured follicle
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Menstrual Cycle• Rest of follicle = corpus luteum (cyst)
secretes PROGESTERONE• Progesterone causes -• Endometrium to thicken “secretory” ready for
implantation• Cervical mucus becomes hostile• FSH down-regulated• No more follicles recruited
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Menstrual Cycle• If ovum not fertilized + no implantation
• Corpus luteum breaks down• Oestrogen and progesterone falls
• Endometrium not being maintained so sloughs off = period
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Amenorrhoea• Primary
• Absence of Menarche• No period by age 14
• with absence of secondary sexual characteristics• No period by age 16
• with normal secondary sexual characteristics
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Primary Amenorrhoea• Differential Diagnosis- Work it out• Anatomical sieve
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Hypothalamic- Pituitary axis
Pineal glandSmellSeeStress
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Hypothalamic- Pituitary axis
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Primary Amenorrhoea• (Constitutional delay)• (Chronic systemic illness)
• Chromosomal• Hypothalamic • Hypopituitarism • Congenital Adrenal Hyperplasia• Premature Ovarian failure/ Ovarian cysts/
PCOS• Uterine anomalies- absence of uterus/
vagina• Vaginal anomalies- Imperforate hymen
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Primary AmenorrhoeaDiagnosis -Work it out• T- Trauma• I- Infection• N-Neoplasia• C- Connective Tissue• A- Autoimmune• N –Naughty Drs (Iatrogenic)• B – Blood Disorders• E- Endocrine• D –Drugs/ Diet
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Primary AmenorrhoeaTrauma (Pituitary /Ovarian Trauma)
Infection
Neoplasia Pituitary Tumour Prolactin Microadenoma
Connective Tissue Uterine
Vagina- Imperforate Hymen
Absent uterus norm ovariesRokintansky XX
Automimmune Myasthenia Gravis, Crohns , Addison’s39% co-exist
Naughty Drs ( Iatrogenic) Chemotherapy Radiotherapy
Blood -
Endocrine Congenital Adrenal Hyperplasia
Ovarian cyst/ PCOSHypothalamic hypopituitarism
21 hydroxlylase deficiency (more 17OH progesterone)
Kallman’s Syndrome(Anosmia)
Drugs/ Diet Chemotherapy RadiotherapyAnorexia / UnderweightGalactosaemia
Chromosomal Androgen InsensitivitySwyersTurner’s Syndrome
XY absent uterus xlinked recXY uterus presentX0 uterus present
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Androgen Insensitivity
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Primary Amenorhhoea - Cause Investigation Treatment
Chromosomal Karyotype HRTAdoptionSurgical removal of XY gonads
Hypothalamic FSH, LH, Prolactin,TFTs, Oestradiol, FAI
Increase weightDecrease excess exercise
Hypothalmic FSH, LH ,Prolactin, Growth HormoneTFTs, Oestradiol, FAI
HRT Growth Hormone replacementAdoptionInduce menarcheInduce puberty
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Primary AmenorrhoeaCause Investigation Treatment
Pituitary tumour MRI head (Sella Turcica)
Pituitary SurgeryRadiotherapy
Congenital Adrenal Hyperplasia
17OH Progesterone DHEA FAIACTH stimulation test
COCPSteroids
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Primary AmenorrhoeaCause Investigation Treatment
Ovarian cysts
PCOS
Prem Ovarian Failure
Ultrasound Pelvis
FAI SHBG(FSH:LH)
+ FSH LH Oestradiol
Surgery – cystectomy
Cons/ Medical/ Surgical
HRT,Egg donationInduce puberty
Uterine anomaliesAbsent uterus
Absent vagina
MRI Pelvis Laparoscopy
Surrogacy – egg collection from normal ovaries
Dilators/ Surgery
Imperforate Hymen External examination Surgery- Incision and drainage of haematometra
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Primary Amenorrhoea
1y Amen
No sexual development
Low FSH LHLow E2
Constitutional
Chronic Illness
High FSH LHLow E2
45 X0 46XY
Uterus present Swyer syndrome
gonadal dysgenesis
Gonadectomy Induce puberty
HRT
Sexual development
High FSH LHLow E2
46XX
Prem Ovarian failure
Induce puberty
HRT
46XY
Andirogen Insensitivi
ty
GonadectomyInduce puberty
Vaginal reconstructionOes only HRT
Normal FSH Lh Normal E2
Uterus present
Vaginal septum
Surgery
Uterus absent
Rokitansky Kuster hauser
Vaginal reconstruc
tion
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Secondary Amenorrhoea• Absence of menses after menarche
• NOT Oligomenorrhoea ( infrequent menses)
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Secondary Amenorrhoea• Absence of menses after a preceding
Menarche
• Exclude obvious causes:• Pregnancy• Menopause• Contraception• GnRha
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Hypothalamic- Pituitary axis
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Hypothalamic Pituitary Ovarian Axis
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Secondary Amenorrhoea• Provide a brief summary of your
presentation
Cause Investigation Treatment
HypothalamicStress/ anorexia
Alleviate stressDiet
Pituitary tumour MRI head (Sella Turcica)
Pituitary SurgeryRadiotherapy
Hypothyroidism TFTs Thyroid replacement
Congenital Adrenal Hyperplasia
17Beta Oestradiol DHEA FAIACTH
COCPCortisol/ FludrocortisoneAs for PCOS
Ovarian cysts
PCOS
Prem Ovarian Failure
Ultrasound Pelvis
+ FAI SHBG
+ FSH LH Oestradiol
Surgery – cystectomy
Cons/ Medical/ Surgical
HRT,Egg donationInduce puberty
![Page 30: Amenorrhoea & PCOS Dr H McMillan MBCHb MSc MRCOG MFSRH Dip Med Ed Consultant in Obstetrics & Gynaecology CUMH/ Mercy University Hospital 4 th Year Medical.](https://reader036.fdocuments.net/reader036/viewer/2022062404/551920a455034626428b4b57/html5/thumbnails/30.jpg)
PCOS
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PCOS• Incidence• Genetics • Definition• Investigation• Treatment
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PCOS Incidence• 7% in UK• 52% of South Asian Immigrants in UK
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PCOS• Familial Inheritance• Genetic link
• Probably Autosomal Dominant• Male line- Premature baldness• Cholesterol side chain cleavage (CYP11a)• Polymorphisms in INSR gene- insulin
receptor function• VNTR on chromosome 11p15.5 on nearby
microsattelite locus
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PCOS• Definition?
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PCOSClinical definition (Old fashioned)
• 1) Hyperandrogensim• Acne, hirsuite, alopecia – not virilisation
• 2) Menstrual irregularity• 3) Anovulatory Infertility
• Usually associated with obesity
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Hypothalamic- Pituitary –Ovarian axis
SHBG are the buses of the blood stream that carry androgens.If there are fewer buses there is more free androgen free to cause symptoms
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PCOS- Obese Women
Obese womenadipose tissue –peripheral conversion of oestrone, which increase LH secretionInsulin insensitivity- leads to hyperinsulinaemia – less SHBG, more free androgen
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PCOS & Obesity
Weight Loss
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PCOS – Lean women
Lean women with PCOS – LH hypersecretion
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PCOS• Diagnostic definition – • ESHRE / ASRM /Rotterdam Criteria
• 2 out of 3 criteria• 1) US features of PCOS • 2) Oligo or anovulation• 3) Clinical or biochemical
hyperandrogenism
• With exclusion of other aetologies
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1. Ultrasound of Polycystic Ovaries
(> 12 peripheral follicles 2-9mm, per ovary >10cm3 volume)Truly a “polyfollicular ovary”Seen in 20-33% of general population
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1. Ultrasound of Polycystic ovaries
• “Ring of pearls”
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2. Oligomenorrhoea or Anovulation
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3. Clinical Hyperandrogenism
Ferriman Gallwey Hirsuitism Score
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3. Biochemical Hyperandrogenism
Weight Loss
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PCOS - PathophysiologyGynae presentation of a metabolic disease insulin- ovarian axis
Insulin resistance (obese)LH (slim)
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PCOS
• USS Pelvis• Day 21 Progesterone (Anovulatory
subfertility)• Day 2-5 bloods
LH:FSH ≥ 3:1ratioFree Androgen Index >5Decreased SHBG <16If total testosterone > 5 check other
androgens
• Investigations
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PCOSInvestigations to exclude other causes
17OH Progesterone (CAH)DHEAAndrostenedione
ProlactinTFTs
GTT/ Lipid profile
D&C/ Pipelle for endometrial hyperplasia
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Differential Diagnosis Menstrual Disturbance
• Menstrual disturbance -• Weight gain> 10%• NIDDM/ IGT• Hypothalamic
• stress, over-exercise, eating disorder• Pituitary causes• Perimenopausal • Hypothyroidism
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Differential Diagnosis Menstrual Disturbance• Menstrual Disturbance
• Endometrial pathology (>45y D&C)• PID (Endocervical swabs)• Cervical disease (Speculum)• Ovarian disease (USS pelvis)• Endometriosis
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PCOS- Menstrual Treatment• For cycle control:• Diet and Exercise (PCOS Diet)• Dianette/ cOCP (if <70kg)• Cyclical norethisterone (non-
contraceptive)• Metformin
• For heaviness:• Tranexamic acid +Mefenamic acid • Mirena
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Differential Diagnosis of Hirsuitism• Hirsuitism
• Androgen secreting tumours- rapid• CAH • Thyroid disease• Acromegaly, Cushings Syndrome• Hyperprolactinaemia
• Drugs – phenytoin
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PCOS-Treatment for hirsuitism • Diet and Exercise (PCOS)• COCP- Dianette• +Further cyproterone acetate for 10/7
(LFTs)• Yasmin ( Drosperinone)• Spironolactone• Metformin• Flutamide• Finasteride
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PCOS Treatment for subfertility• Diet & Exercise
• PCOS diet book by Colette Harris• Clomid* – Anti-oestrogen
• days 2-6 of cycle • with follicle tracking
• Metformin• start at 250mg od increase to max 500mg
tds• GnRHa*• Laparoscopic ovarian drilling• * Risk of OHSS
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PCOS Long term management• NIDDM
• Yearly GTT• CVS disease
• Yearly BP/ Weight• Dyslipidaemia
• Yearly lipid profile• Endometrial hyperplasia
• induce a regular bleed/ Mirena/ D&C• Breast cancer
• due to elevated endogenous oestrogens• Breast examinations/ screening
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Useful websites• www. rcog.org.uk• www. library.nhs.uk
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