AMENORRHOEA Primary & Secondary DR. AMRO BANNAN OBS-GYNE DEMONSTRATOR.
The Gynaecology Clinic Michaelmas term year 2. This session will: Cover definitions of amenorrhoea...
Transcript of The Gynaecology Clinic Michaelmas term year 2. This session will: Cover definitions of amenorrhoea...
The Gynaecology Clinic
Michaelmas term year 2
This session will:
• Cover definitions of amenorrhoea and oligomenorrhoea
• Explain the genetic, anatomical and endocrine causes of these disorders
• Offer a plan for their clinical assessment
Case 1
• A 17 year old comes with her mother as she has not yet had a period
• What might the causes of this be and how would you investigate it?
Primary amenorrhoea= may be due to :• Disorders of outflow tract/uterus (Mullerian
abnormalities/agenesis)• Disorders of ovary (karyotypic abnormality: XO,
androgen insensitivity XY)• Disorder of anterior pituitary e.g Cushing’s,
prolactin secreting adenomas. Congenital adrenal hyperplasia
• CNS disorder: hypothalamic, wt. loss, eating disorder, exercise
And …
• Don’t forget pregnancy
Plan for investigation• History: ?thelarche, pubarche. Wt
changes, eating habits, exercise. Consider the possibility of pregnancy
• Examination: 2y sexual characteristics (inc. external genitalia), wt.
• Ultrasound can assess size and shape of uterus and ovaries. MRI can provide closer imaging of Mullerian abnormalities
• Bloods: Karyotype: XO, XY, hCG, FSH/LH, 17-OH progesterone
Rokitansky-Mayer-Küster-Hauser (RMKH) syndrome: absent uterus
and vagina
Case 2
• A 23 year old comes to see you as her periods stopped 4 months ago.
• What could be the cause and how would you investigate?
Causes of secondary amenorrhoea/oligomenorrhoea
• Pregnancy• Disorders of outflow? Asherman’s• Disorders of ovaries? PCO, resistant ovary
syndrome, premature ovarian failure, hormone secreting ovarian tumour. XO mosaic
• Anterior pituitary? Prolactinoma, thyroid disease Sheehan’s syndrome
• CNS? Hypothalamic causes; wt. Loss anorexia, bulimia
Plan for investigation:
• History ?pregnancy, wt change, eating, exercise, drugs (inc substance abuse)
• Examination: wt. Hirsutism
• Imaging: ultrasound for PCO
• Bloods: gonadotrophins, TSH, prolactin
• Karyotype if FSH elevated++
After investigation..
• This patient had polycystic ovaries on ultrasound. She weighed 120kg and had mild hirsutism
• Blood tests showed an elevated LH:FSH ratio
Case 3
• A couple come to see you as they want to have a baby, and no pregnancy has occurred after 2 years.
Causes of subfertility
• Ovulatory: consider the causes as above
• Tubal
• Male factor
• Non-consummation
• unexplained
Planned investigations:
• History: primary or secondary subfertility? Previous surgery or infection
• Other symptoms e.g pain
• Blood tests: FSH/LH, prolactin, TSH, se progesterone
• Ultrasound, hysterosalpingogram
• Seminal analysis
Semen analysis• Volume >2ml
• Count 20-150 x106 /ml
• Motility >60%
• Progressive motillity >50%
Hysterosalpingogram
Case 4
• A 48 year old comes to see you as her periods have become less frequent over the past year and she hasn’t had one now for 4 months.
• Has she reached the menopause and should anything further be done?
The menopause: the last period• Climacteric: period of life when ovulatory
function declines
• Hypothalomo-pituitary function increases from around 10 years before the menopause to maintain ovulation
• Low oestrogen levels lead to symptoms: flushes, lack of energy, night sweats, joint pains, vaginal dryness, urinary urgency
Sequelae of menopause:
• Osteporosis
• Cardiovascular disease
• UTIs
• Dyspareunia
• ?Alzheimer’s disease
Advantages/disadvantages of HRT
• Prevents osteoporosis
• Reduces risk of Alzheimer’s
• Corrects symptoms
• Reduces risk of colon cancer
• Increases risk of breast cancer (most in cyclical preparations)
For our patient:• It is not possible to know if she has really
had her last period yet, but it is likely she is in the climacteric
• Other reasons for anovulation may need to be considered (e.g. thyroid disease)
• Might still be pregnant!
• Re HRT: patients need to weigh up risks and benefits