AMENORRHOEA Primary & Secondary DR. AMRO BANNAN OBS-GYNE DEMONSTRATOR.
Approach to secondary amenorrhoea Definition •Secondary amenorrhoea refers to absence of menses...
Transcript of Approach to secondary amenorrhoea Definition •Secondary amenorrhoea refers to absence of menses...
Problem solving - Approach to
secondary amenorrhoea
Dr Marilyn Lee
KTPH
Objectives
• Causes of secondary amenorrhoea
• Evaluation
• Management
• HRT vs OCP
• Learning points
• 26/F
• Amenorrhoea 8 months
• Not sexually active
• Menarche age 13, regular until a year ago.
• History of migraines – no regular meds
• No hot flushes, vaginal dryness
• No hirsutism/acne/scalp hair loss
• BMI 20 kg/m2
• No galactorrhoea
• Clinically euthyroid
• Bp 116/74
FT4 17.5 pM, TSH 2.4 mu/L
LH 3.0 mu/L, FSH 4.2 mu/L
Testosterone – within normal limits
Prolactin – within normal limits
Definition
• Secondary amenorrhoea refers to absence of
menses for over 3 months in women who
previously had regular menstrual cycles, or 6
months in women who had irregular menses
Introduction
• The menstrual cycle is susceptible to external
influences, hence, missing a single period is rarely
important
• In contrast, prolonged amenorrhoea may be the
earliest sign of a decline in general health or signal an
underlying medical problem (eg hyperthyroidism)
• Always exclude pregnancy
• HYPOTHALAMIC-
PITUITARY-OVARIAN
AXIS
Hypothalamic dysfunction
-Functional hypothalamic amenorrhoea
-Inflammatory/infiltrative disease
-Tumour
-Traumatic brain injury
Pituitary disease
-hyperprolactinemia
-empty sella
-other sellar masses
-other diseases of the pituitary
Ovarian (PCOS, POF)
Uterine (Asherman)
Approach – history and examination
• Hypothalamic – Eating disorders, high intensity exercise, stress, chronic
severe illness, traumatic brain injury
• Pituitary – Galactorrhoea, drugs
– Symptoms/signs of cushing’s or acromegaly
• Ovarian – Symptoms of oestrogen deficiency
– Hirsutism/acne/scalp hair loss*
• Others – Symptoms of thyroid dysfunction
– Virilization
– Uterine instrumentation
Diagnostic evaluation
• Laboratory investigations
– Gonadotropins, TFT, prolactin
– Consider testosterone, 17OHP
• USS pelvis
– Polycystic ovaries?
– Endometrial thickness
• Progestin withdrawal
History and examination
hCG, TFT, prolactin
abnormal Evaluate for thyroid dysfunction,
hyperprolactinemia FSH
Premature ovarian insufficiency high
Progestin withdrawal
Oestrogen replete
PCOS (+/- pelvic USS)
Oestrogen deplete
Withdrawal bleed No withdrawal bleed
Combined oestrogen and progestin
FHA
Hypothalamic-pituitary
Anatomic defects
*additional tests if clinically indicated Testosterone, 17OHP, ONDST
No withdrawal bleed Withdrawal bleed
• 26/F
• Amenorrhoea 8 months
• Not sexually active
• Menarche age 13, regular until a year ago.
• History of migraines – no regular meds
• No hot flushes, vaginal dryness
• No hirsutism/acne/scalp hair loss
• BMI 20 kg/m2
• No galactorrhoea
• Clinically euthyroid
• Bp 116/74
FT4 17.5 pM, TSH 2.4 mu/L
LH 3.0 mu/L, FSH 4.2 mu/L
Testosterone – within normal limits
Prolactin – within normal limits
Question
Which of the following statements is true?
1. This is not PCOS because testosterone level is not elevated
2. A normal BMI excludes hypothalamic amenorrhoea
3. As blood tests are all normal, no further evaluation is required
4. An USS showing a thin endometrial lining makes PCOS less likely
Rotterdam Criteria
• 2 out of 3:
– Oligo/amenorrhoea and/or anovulation
– Hyperandrogenism
– Polycystic ovaries on USS
PCOS – An Endocrine perspective
High LH - ~ 40% - Marker for anovulation in lean women
High Testosterone - ~ 50% Marker for hirsutism
High Insulin - ~ 30% - Marker for oligomenorrhoea and T2DM
High AMH - ~ 70% - Marker of follicle count
• US – polycystic ovaries, endometrial thickness
3mm, ovarian volume 8ml
• Further history – runner of 15-20km at least 3
times a week
Question
What is the most likely diagnosis?
1. Polycystic ovarian syndrome
2. Functional hypothalamic amenorrhoea
3. Premature ovarian insufficiency
4. Non classic congenital adrenal hyperplasia
Normal gonadotrophin amenorrhoea
Usually PCOS or Hypothalamic Amenorrhea (HA)
PCOS HA
Exercise program? Rare Common
BMI Any - usually > 21 Usually < 21
Androgen excess Common Rare
Suppressed LH Rare Common
Polycystic Ovaries >90% 20%
Endometrial thickness Rare < 5 mm < 5 mm
Management
• Anovulatory cycles and oestrogen replete
– Progesterone every 2-3 months
– Eg Dydrogesterone 10mg BD x 1 week
• Oestrogen deplete
– Combined oestrogen and progesterone (either OCP
or HRT)
Question
DEXA scan shows z score of -2.1 in both left hip
and lumbar spine.
Apart from advising her to reduce exercise, how
would you manage her?
1. OCP
2. HRT
3. Watch and wait
HRT vs OCP
Progesterone
Oestrogen 21
28
HRT REFERENCE SHEET
Sequential oestrogen and progesterone combinations Continuous
combined
Unopposed
oestrogen
Tablets Oestrogen Progesterone Tablets
Trisequens Oestrogen
1,2mg
Norethisterone Activelle
(1mg/0.5mg)
Estrofem
Femoston conti
1/5
Premarin
Progyluton Oestrogen 2mg Norgestrel Progynova
Patch (ug/24
hrs)
Femoston Oestrogen
1,2mg
Dydrogesterone Estraderm
MX (25,50)
HRT REFERENCE SHEET Other oestrogens Type
Oestrogel Oestradiol Gel
Divigel Oestradiol Gel
Norethisterone Norethisterone 5mg Tablets
Provera Medroxyprogesterone
10mg
Tablets
Depot provera Medroxyprogesterone
150mg/3ml injection
Injection
Mirena Levonorgestrel
(20mcg/24hr)
IUS
Duphaston Dydrogesterone 10mg Tablets
Uterogestan Micronized progesterone
100mg
Capsules
Progesterone
injection
Progesterone 50mg/ml
(5-10mg daily)
Deep im injection
Learning points
• Always exclude pregnancy
• Once thyroid dysfunction and hyperprolactinemia are excluded, FSH should be done to distinguish between a primary ovarian pathology vs other causes
• PCOS and HA are the commonest causes of anovulatory cycles.
• Differentiating between them may require a combination of history, examination, biochemical and radiological tests.
References
• Deligeotoglu E, Athanasopoulos N, Tsimaris P, et al. Evaluation and
management of adolescent amenorrhoea. Ann N Y Acad Sci 1205:23-43,
2010
• Laufer MR, Floor AE, Parsons KE et al. Hormone testing in women with
adult onset amenorrhoea. Gynecol Obstet Invest 40:200-203, 1995
• Hendriks ML, Brouwer J, Hompes PG et al. LH as a diagnostic criterion
for polycystic ovary syndrome in patients with WHO II oligo/amenorrhoea.
Reproductive Biomedicine 16:765–771, 2008
• Dewailly D, Lujan ME, Carmina E et al. Definition and significance of
polycystic ovarian morphology: a task force from the Androgen Excess and
Polycystic Ovary Syndrome Society. Human Reproduction Update
20(3):334-52, 2014
• Conway G, Dewailly D, Diamanti-Kandarakis E et al. The polycystic ovary
syndrome: a position statement from the European Society of
Endocrinology. Eur J Endocrinol. 171(4):1-29, 2014
• Marilyn R Richardson. Current Perspectives in Polycystic Ovary
Syndrome. Am Fam Physician. 68(4):697-705, 2003