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OBSTETRICS AND GYNAECOLOGY COPY > AMENORRHOEA, OLIGOMENORRHOEA AND PCOS > Flashcards

AMENORRHOEA, OLIGOMENORRHOEA AND PCOS Flashcards

1
Q

What is the difference between primary and secondary amenorrhoea?

A

Primary is when menstruation has not started by the age of 16. Relatively uncommon.

Secondary is when menstruation has occurred in the past, but has then been absent for 6 months or more.

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2
Q

What are the causes of primary amenorrhoea?

A

Delayed puberty

Genital tract anomaly

Turner syndrome or other gonadal dysgenesis

Androgen insensitivity syndrome

Congenital adrenal hyperplasia

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3
Q

What is Turner syndrome?

A

A condition in which a female is partly or completely missing an X chromosome.

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4
Q

What are the features of Turner syndrome?

A

Short stature

Webbed neck

Widely spaced nipples

Bicuspid aortic valve

Coarctation of the aorta

Primary amenorrhoea

Cystic hygroma

High arched palate

Short fourth metacarpal

Multipigmented naevi

Lymphoedema in neonates

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5
Q

What is congenital adrenal hyperplasia?

A

Type 1 is the most common and denotes a deficiency in 21-hydroxylase which leads to deficiency of cortisol and aldosterone. No cortisol therefore to suppress release of ACTH. ACTH continues to stimulate adrenal gland leading to hyperplasia and excessive release of androgens.

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6
Q

What are the features of congenital adrenal hyperplasia?

A

Excess androgen release

Increased plasma 17-hydroxyprogesterone levels
Increased plasma 21-deoxycortisol levels
Increased urinary adrenocorticosteroid metabolites

Precocious puberty in males (sometimes as early as 6 months) and some females - this can cause early bone epiphyseal fusion and therefore short adult height.

Virilism - masculinisation in females (similar to polycystic ovarian syndrome) - masculine body shape, balding of temporal skull, increased bulk, deepening of voice, enlargement of clitoris.

Obesity

Oligomenorrhea/amenorrhoea

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7
Q

What is androgen insensitivity syndrome

A

A condition that results in the partial or complete inability of the cell to respond to androgens. This therefore only affects those born XY. However, often this is not discovered until puberty where the patient does not begin menstruation as they do not have ovaries.

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8
Q

At what age should you investigate primary amenorrhoea?

A

If they have no secondary sexual characteristics then investigate from 14

If they have otherwise normal sexual characteristics then investigate from 16

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9
Q

What are the causes of secondary amenorrhoea?

A

Physiological

Hypothalamic

Androgen secreting tumours

Hyperprolactinaemia

Premature ovarian failure

Polycystic ovary syndrome

Congenital adrenal hyperplasia (often primary but can also cause precocious puberty followed by amenorrhea)

Not related to changes in sex hormones

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10
Q

What are the physiological causes of secondary amenorrhoea?

A

Pregnancy

Lactation

Menopause

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11
Q

What are the causes of hypothalamic amenorrhoea (relating to reduced function of the hypothalamus or pituitary gland)?

A

Weight loss - ED

Stress

Athlete

Systemic illness

Sheehan’s syndrome

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12
Q

What is Sheehan’s syndrome and how do we treat it?

A

This is where there is hypopituitarism caused by ischemic necrosis due to blood loss and hypovolemic shock during and after childbirth. A major complication of PPH.

Requires oestrogen replacement therapy in the form of the COCP or HRT to prevent osteoporosis. Addition of other pituitary hormones might also be necessary.

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13
Q

Where are androgen secreting tumours that cause secondary amenorrhoea usually found?

A

Ovaries

Adrenal glands

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14
Q

What are the causes of premature ovarian failure?

A

Idiopathic

Post-chemotherapy

Post-radiotherapy

Oophorectomy

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15
Q

What is the pathogenesis of polycystic ovarian syndrome?

A

Polycystic ovaries develop when the ovaries are stimulated to produce excessive amounts of male hormones (androgens), in particular testosterone, by either:

Excessive luteinizing hormone (LH) by the anterior pituitary gland
High levels of insulin in the blood in women whose ovaries are sensitive to this stimulus

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16
Q

What are the features of polycystic ovarian syndrome?

A

Subfertility / infertility

Delayed puberty

Menstrual disturbances: oligomenorrhea and amenorrhoea

Hirsutism, acne (due to hyperandrogenism)

Obesity

Acanthosis nigricans (due to insulin resistance)

Some overlap with metabolic syndrome

Symptoms include mild headache since menarche

17
Q

What is acanthosis nigricans?

A

Darkened, thickened patches of skin that develop in the armpit and around the groin and neck. Caused by a number of conditions including PCOS, insulin resistant diabetes, hypothyroidism and Cushing’s disease.

18
Q

What investigations should be done for someone with suspected PCOS and what would you expect to find?

A

USS - multiple cysts on ovaries

Blood tests:

Raised LH and normal FSH

Raised LH:FSH ratio

Normal prolactin

Testosterone is either normal or mildly elevated. If it is markedly elevated consider other causes.

Anti-Mullerian hormone is raised -

Raised DHEA

Reduced sex hormone binding globulin

OGTT - must be offered to all women with PCOS

19
Q

What are the Rotterdam diagnostic criteria for PCOS?

A

Two of:

Oligo/anovulation

Clinical or biochemical signs of hyperandrogenism

Polycystic ovaries (12+ peripheral follicles or increased volume)

20
Q

How should you manage someone diagnosed with PCOS?

A

Encourage weight loss - this is first line in fertility treatment

COCP will help acne and hirsutism but may not be appropriate if infertility is the presenting complaint

To help with fertility issues, NICE recommends Clomifene citrate or Metformin or Clomifene in combination with metformin.

COCP or long term progesterone use (Levonorgestrel) can help with prevention of endometrial cancer

21
Q

What are the long term complications of PCOS?

A

Endometrial hyperplasia and cancer

Type II diabetes

Cardiovascular pathology

Hirsutism and acne

22
Q

A woman with a BMI of 41 has recently been diagnosed with PCOS. She tells you that she has read online that as she has PCOS, she will not be able to become pregnant. What is the best advice to give her?

The combined oral contraceptive pill will help to regulate her cycle and therefore her fertility

Women with PCOS have no more problems with subfertility than any other group

Her concerns are correct and you will refer her immediately to a fertility specialist

Almost all women with PCOS need clomiphene to encourage ovulation

The majority of patients with PCOS do get pregnant. The best thing she could do is to lose weight before conception.

A

The majority of patients with PCOS do get pregnant. The best thing she could do is to lose weight before conception.

Lifestyle modification is the cornerstone to managing PCOS, especially in overweight women. PCOS can be greatly improved by losing excess weight. Weight loss of just 5% of total body weight can lead to a significant improvement in the symptoms of PCOS.

Clomifene and metformin are second line

23
Q

A woman with a diagnosis of PCOS is started on clomifene as despite weight loss she is still struggling to get pregnant. What should she be warned about with regard to pregnancy and clomifene use?

A

Can increased likelihood of multiple pregnancy

24
Q

A woman with a BMI of 41 and a diagnosis of PCOS is trying to become pregnant. Which medication is the most relevant and important at this stage?

Folic acid 5mg once daily

Folic acid 400 micrograms once daily Incorrect

Metformin 500mg once daily

Vitamin A supplementation

Metformin 500mg three times daily with meals

A

Folic acid 5mg once daily

Some groups of women are at higher risk than others - the recommended dose of folic acid for these women is 5mg daily:

Women who are obese

Women with diabetes

Women with epilepsy

Women with a previous child who has been affected by a neural tube defect

25
Q

What are the causes of hyperprolactinaemia?

A

Pituitary tumour

Drug induced

26
Q

What are the drugs that can cause hyperprolactinaemia?

A

Antipsychotics - phenothiazines, haloperidol

Antidepressants - tricyclic antidepressants

Antihypertensives - methyldopa, reserpine

Oestrogens - COCP

Anti-histamines (H2) - Cimetidine, Ranitidine, Metoclopramide, Domperidone

27
Q

What are the non-sex hormone related causes of secondary amenorrhoea?

A

Asherman’s syndrome

Cervical stenosis

Thyroid disease - both hypo and hyper

Diabetes

28
Q

What is Asherman’s syndrome?

A

A condition characterized by adhesions and/or fibrosis of the endometrium particularly but can also affect the myometrium. It is often associated with dilation and curettage (ERPC) of the intrauterine cavity.

OBSTETRICS AND GYNAECOLOGY COPY (34 decks)

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