Amenorrhoea

Question 1

Probability diagnosis

Answer 1

Pregnancy

Perimenopause/menopause

Constitutional delay of puberty

Breast feeding

Physiological e.g. excessive exercise, weight loss

Drugs esp. iatrogenic

Polycystic ovarian syndrome

Question 2

Serious disorders not to be missed

Answer 2

Infection:

• Severe systemic illness
• Pelvic inflammatory disease

Cancer:

• Cellular—lymphoma, leukaemia, myeloma
• Pituitary tumours e.g. prolactinoma
• Ovarian tumours/cancer

Other:

• Brain injury

Question 3

Pitfalls (often missed)

Answer 3

Imperforate hymen (haematocolpos)

Anorexia nervosa

Primary ovarian failure

Hyperprolactinaemia

Rarities:

• Congenital adrenal hyperplasia
• Genital malformations
• Gonadal dysgenesis
• Asherman’s syndrome
• Turner’s syndrome

Question 4

Masquerades checklist

Answer 4

Drugs e.g.

• OCP
• cytotoxics
• metoclopramide
• antipsychotics
• valproate

Anaemia

Thyroid/other endocrine: adrenal, pituitary disorders

Question 5

Is the patient trying to tell me something?

Answer 5

Consider eating disorders, pseudocyesis

Question 6

Key history

Answer 6

Take menstrual (if any) history

• primary or secondary amenorrhoea
• age of thelarche
• detailed menstrual history and associations.
• strenuous exercise activities.

Systems review; endocrine/pituitary features, e.g. headache, galactorrhoea, visual defects, weight changes, fatigue, voice changes, cold/heat intolerance, libido and other.

PMHx; obstetric and gynaecological surgery.

Drug hx esp. OCP, LARCs, other hormones, opioids

Family, psychological and social history.

Question 7

Key examination

Answer 7

appearance of pt

vital signs

BMI, skin, body hair distribution, signs of virulisation (i.e. note any secondary sex characteristics)

brief neurological assessment incl. visual fields

breast examination

pelvic examination

Question 8

Key investigations

Answer 8

First line:

HCG/pregnancy test

• FBE
• U&E
• FSH/LH
• TFTs
• prolactin

Consider:

• testosterone
• oestradiol
• chromosomal analysis
• ultrasound e.g. ovary
• CT/MRI pituitary fossa

Question 9

Diagnostic tips

Answer 9

Consider anorexia nervosa, heavy dieting, PCOS, delayed puberty, imperforate hymen, pregnancy and drugs (iatrogenic and social).

Hypothalamic amenorrhoea is usually functional and caused by weight loss, psychological stress or excessive exercise.

Consider a serious intracranial disorder if headache and visual disturbance.