Menstruation and Menstrual Disorders - Amenorrhoea

Question 1

What is Amenorrhoea?
What is Primary Amenorrhoea?
What is Secondary Amenorrhoea?

Answer 1

A lack of menstrual periods.
PRIMARY - Never Developed Periods.
SECONDARY - Previously had periods but now have stopped.

Question 2

What is Primary Amenorrhoea?

Answer 2

Not starting menstruation by the age of 13 (if there is no other evidence of pubertal development) or by the age of 15 (where there are other signs of puberty e.g. breast bud development).

Question 3

What is Hypogonadism?

Answer 3

A lack of sex hormones (Oestrogen and Progesterone). They normally rise during puberty - a deficiency in these hormones causes a delay in puberty.

Question 4

What is Hypogonadotrophic Hypogonadism?

Answer 4

A deficiency of Oestrogen due to a deficiency of LH and FSH (Gonadotrophins).

Question 5

Give 7 causes of Hypogonadotrophic Hypogonadism.

Answer 5

1. Hypopituitarism.
2. Damage to the Hypothalamus/Pituitary Gland (Radiotherapy, Surgery, Cancer).
3. Significant Chronic Conditions e.g. CF, IBD.
4. Excessive Exercise/Dieting.
5. Constitutional Delay in Growth and Development.
6. Endocrine Disorders e.g. GH Deficiency, Hypothyroidism, Cushing’s, Hyperprolactinaemia.
7. Kallman Syndrome.

Question 6

What is Kallman Syndrome?

Answer 6

A genetic condition that causes hypogonadotrophic hypogonadism with a failure to start puberty, characterised by anosmia or hyposmia (reduced/absent sense of smell).

Question 7

Management of Hypogonadotrophic Hypogonadism.

Answer 7

Pulsatile GnRH to induce ovulation and menstruation and fertility.

Question 8

Management of Hypogonadotrophic Hypogonadism if Pregnancy is Not Desired.

Answer 8

Replacement sex hormones can be taken up by using the COCP to induce regular menstruation and prevent Oestrogen deficiency.

Question 9

What is Hypergonadotrophic Hypogonadism?

Answer 9

A deficiency of Oestrogen due to a lack of response to LH and FSH (gonadotrophins).

Question 10

Give 4 causes of Hypergonadotrophic Hypogonadism.

Answer 10

1. Previous Damage to the Gonads (Torsion, Cancer, Infection e.g. Mumps).
2. Congenital Absence of Ovaries.
3. Gonadal Dysgenesis (commonest cause e.g. Turner’s Syndrome).
4. Imperforate Hymen.

Question 11

What is Androgen Insensitivity Syndrome?

Answer 11

A condition where an XY individual has tissues unable to respond Androgen hormones and so develops with a female phenotype (external genitalia and breast tissue). Internally, there are testes in the abdomen or inguinal canal and an absent uterus, vagina, Fallopian tubes and ovaries.

Question 12

What effect does structural pathology of the pelvic organs have on menstruation?

Answer 12

1. Accumulation of menses (blood) leads to cyclical abdominal pain.
2. Examples : Imperforate Hymen, Vaginal Septae; Vaginal Agenesis; Absent Uterus; FGM.

Question 13

What is Secondary Amenorrhoea?

Answer 13

No menstruation for more than 3 months after regular menstrual periods.

Question 14

When should investigations be started in Secondary Amenorrhoea? (2)

Answer 14

1. Previously regular menstrual periods - after 3-6 months.

2. Previously infrequent irregular menstrual periods - after 6-12 months.

Question 15

Give 7 causes of Secondary Amenorrhoea.

Answer 15

1. Pregnancy - commonest.
2. Menopause (and Premature Ovarian Insufficiency).
3. Physiological Stress (e.g. Excessive Exercise; Low Body Weight; Chronic Disease; Psychosocial Factors).
4. Endocrine Disease e.g. PCOS, Thyroid Abnormalities, Cushing’s.
5. Medications e.g. Hormonal Contraceptives (POP, IUS).
6. Pituitary Pathology e.g. Failure (Trauma, Radiotherapy, Surgery, Sheehan Syndrome) and Hyperprolactinaemia (Tumour).
7. Sheehan Syndrome.

Question 16

Why is hypergonadotrophic hypogonadism a protective mechanism?

Answer 16

It prevents pregnancy in a body that would be unable to manage it.

Question 17

What is a prolactinoma?

Answer 17

Prolactin secreting pituitary tumour..

1. High levels act on Hypothalamus to prevent the release of GnRH.
2. Low GnRH inhibits release of LH and FSH.

Question 18

Hyperprolactinaemia :-

• Epidemiology.
• Aetiology.
• Investigations.
• Management.

Answer 18

Epidemiology : Only 30% of women with high Prolactin levels have galactorrhea.

Aetiology : Pituitary Adenoma secreting Prolactin (commonest cause).

Investigations : CT/MRI of Brain to assess for Tumour (often a micro adenoma that only appears on follow-up scans).

Management : Not required but Dopamine agonists e.g. Bromocriptine and Cabergoline.

Question 19

Investigations in Amenorrhoea (6).

Answer 19

1. Urine/Blood hCG = Pregnancy.
2. High FSH = Primary Ovarian Failure.
3. High LH or LH:FSH Ratio = PCOS.
4. High Prolactin = Prolactinoma.
5. Thyroid Changes.
6. High Testosterone = PCOS, AIS, CAH.

Question 20

What is important about the management of PCOS Amenorrhoea?

Answer 20

Withdrawal bleed every 3-4 months to reduce the risk of endometrial hyperplasia and endometrial cancer - use Medroxyprogesterone for 14 days or use the COCP regularly.

Question 21

What is a complication of amenorrhoea?

Answer 21

Osteoporosis (due to low Oestrogen). If it lasts more than 12 months, treatment is indicated (either adequate intake of Vitamin D, Calcium, HRT, COCP).