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AMENORRHOEA ((CHECK SERUM FOR LH, FSH, PRL, TEST, THYROXINE, TSH, ARARANGE…

- - - - Due to failure of the Mullerian ducts to develop
    - - Menstrual blood is retained within vagina (haematocolpos)
      - leads to cyclical lower abdo pain each month at time of mens
    - - PROGESTOGEN CHALLENGE TEST
        
        given orally for 5 days - withdrawal should lead to vaginal bleed
        
        if occurs can reassure that spontaneous menstruation is likely to occur
        
        an abdo US may be reassuring to confirm uterus and ovaries are normal
  - - - primary hyperthyroidism
      - adrenal hyperplasia
      - adrenal tumour
    - - imperforate hymen
      - uterovaginal agenesis
    - - true agenesis
      - premature ovarian failure
      - radiation/chemotherapy/autoimmune
      - polycystic ovaries
      - virilizing ovarian tumours
    - - pituitary adenoma
      - empty sella syndrome
      - hyperprolactinaemia
      - trauma/surgery
      - partial/total hypopituitarism
    - - Physiological delay
      - weight loss/anorexia/heavy exercise
      - isolated GnRH deficiency
      - congenital CNS defects
      - Intracranial tumours
    - - 46 XY DSD
      - Ovotesticular DSD
      - XO - Turner syndrome
- - - - Partial/total hypopituitarism
      - Trauma/Surgery
      - Hyperprolactinaemia => galactorrhoea
        
        if PRL >1000 then imagin with CT or preferred MRI should be dome
        
        treatment usually dopamine agonist BROMOCRIPTINE/CABERGOLINE - suppress PRL and regress prolactinoma
        
        transnasal transsphenoidal microsurgical excision of an adenoma is rarely required
        
        causes:
        
        pituitary adenoma
        
        macroadenoma
        
        microadenoma
        
        secondary to other causes
        
        primary hypothyroidism
        
        chronic renal failure
        
        pituitary stalk compression
        
        PCOS
        
        drugs (phenothiazines, haloperidol, metoclopramide, cimetidine, methyldopa, antihistamine, morphine)
        
        idiopathic
    - - Premature Ovarian Failure - before 40y/o
        
        preg via IVF may be possible with donor oocytes
      - Surgery/Radiotherapy/Chemotherapy
      - PCOS
        
        AT LEAST 2 OF 3 CRITERIA:
        
        US appearance of large volume ovaries (>10cm^3) and or multiple small follicles (12 or more <10mm)
        
        clinical evidence of excess androgens (Acne, hirsutism) or biochemical evidence (raised testosterone)
        
        Oligo- or amenorrhoea
        
        principle underlying disorder is insulin resistance = resultant hyperinsulinaemia stimulating excess ovarian androgen production.
        
        predisposed to non-insulin dependent diabetes and CVD in later life
        
        MANAGE
        
        COCP used to regulate menses
        
        Hirsutism managed by cosmetic means, COCP, antiandrogen CYPROTERONE ACETATE - risk of teratogenicity so take contraception for at least 3 months after treatment
        
        CLOMIFENE used to induce ovulation in women with anovulation infertility
        
        if unsuccessful - INJECTIONS OF GONADOTROPHINS or by LAPARASCOPIC LASER or DIATHERMY to the ovary
        
        weight reduction => reduces insulin resistance = corrects the hormone imbalance and promotes ovulation
        
        long term there is an increased risk of endometrial hyperplasia and endometrial carcinoma as a consequece of the effects of anovulation with unopposed oest stimulation of the endometrium
        
        also an inc risk of noninsulin dependent DM and CVD so may benefit from early screening for CV RF particularly HTN and glucose intolerance.
      - Resistant Ovary Syndrome
      - Virilizing Ovarian Tumours
    - - weight loss/anorexia
      - heavy exercise
      - stress
      - if not related to low body weight and preg is not desired then oest replacement therapy is advised as oral contraceptive pill. if wish to become pregnant then ovulation can be induced by pulsatile GnRH therapy or exog gonadotrophins
    - - primary hypothyroidism
      - adrenal hyperplasia [due to deficiency in 21-hydroxylase]
      - adrenal tumour
    - - Lactation
      - Menopause
      - Pregnancy
    - - surgery - hysterectomy
      - endometrial ablation
      - progestogen intrauterine device
      - asherman syndrome
        
        uterine adhesions form due to excessive curettage
        
        treat by breaking down adhesions through a hysteroscope with or without inserting an IUD to defer reformation