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Amenorrhoea (Complications (CVD Low oestrogen, Infertility No ovulation,…
Amenorrhoea
Complications
CVD
Low oestrogen
Infertility
No ovulation
Osteoporosis
Low oestrogen, thus increased
bone resorption and low BMD
Psychological
Anxiety, depression,
self esteem
Diagnosis
Examination
Abdo
Masses, tenderness
Pelvic
Clitoromegaly, imperforate hymen, blind ending
vaginal septum, absent cervix or uterus
Only if sexually active
General
BMI, hirsuitism, secondary sexual characteristics (Tanner),
endocrinopathy stigmata, virilisation (deep voice, male pattern balding)
Neuro
Reduced acuity, reduced visual fields,
CN defects
Inveestigations
Urine
Pregnancy test
Bloods
FBC (anaemia), U+E LFT, B12/folate (nutrition),
TFTs (thyroid disorder), hormones (GnRH, FSH/LH, oestrogen, testosterone, SHBG, PRL), karyotyping (Turner's)
Imaging
Pelvic USS (congenital, Asherman's, PCOS,
haematometra, endometrial atrophy)
Pelvic CT/MRI (masses)
Bedside
Observations
Height and weight (BMI for anorexia, Turner's)
History
PMH/PSH
Thyroid disease, previous pelvic/abdo surgery
DH
DA agonists, allergies
POH
Gravidy/parity, conception, delivery, complications
FH
Late periods, early menopause, endocrine disorder, cancers
PGH
Known disorders, menses, sex, STIs, contraception, smears
SH
Occupation, drug/alcohol, smoking, support
PC/HPC
Menses, menopause symptoms (hot flushes, night sweats), androgenic symptoms (weight gain, acne, hirsuitism),
headache, visual problems, galactorrhoea (prolactinaemia)
psych symptoms (eating, exercise)
Management
Medical
Hormone therapy (PCOS, POF)
Bromocriptine.carbergoline (hyperprolactinaemia)
Surgery
Genital tract obstruction
Tumours
Conservative
Identify cause
Information and advice
Lifestyle (weight loss/gain, exercise, diet, stop smoking)
Referral to gynae/endo for investigation and tx
Genetic counselling if appropriate
Pathophysiology
Secondary
Absence menses for >6m in someone with prior menses
Variety of causes
Primary
Lack of menses by 16y despite secondary sexual characteristics or 14y without secondary sexual characteristics
HPO axis dysfunction or structural outflow problem
Aetiology
Primary
Congenital/genetic
Systemic:
Turner's syndrome (X)
Hypo:
Kallman's syndrome (GnRH deficiency)
Uterus/ovaries:
androgen insensitivity syndrome (testicular feminisation)
Cervix/vagina:
vaginal agenesis, cervical stenosis, transverse septum, imperforate hymen
Functional
Anorexia/bulimia
Exessive exercise
Idiopathic
Familial (constitutional delay)
Endocrine
Ovaries:
PCOS
Systemic:
hypo/hyperthyroidism, hyperprolactinaemia,
Cushing's syndrome, CAH
Trauma
Head injury
Metabolic
Severe liver/renal disease
Diabetes
Coeliac disease
Secondary
Vascular
Hypo/pit:
stroke
Iatrogenic
Contraceptives (prostagenic, cont COCP, GnRH analogues)
Surgery (CNS, ovarian, endometrial)
Radiotherapy
Trauma
CNS: head trauma
Uterus:
Asherman's syndrome (adhesions)
Cervix/vagina:
cervical stenosis
Neoplastic
Hypo/pit:
CNS/pituitary tumour
Ovaries:
ovarian tumour
Other:
adrenal tumour, paraneoplastic
Infection
Hypo/pit:
CNS infection/cyst
Uterus:
Uterine TB
Endocrine
Pituitary:
hyperprolactinaemia, Sheehan's syndrome
Uterus:
pregnancy
Ovaries:
PCOS, premature ovarian failure
Systemic:
hyper/hypothyroidism, Cushing's, CAH
Functional
Anorexia/bulimia
Stress
Increased exercise
Drugs
Contraceptives
Antipsychotics (high PRL)
Cocaine, opiates
Epidemiology
Primary is very rare (<0.5%)
Secondary is uncommon (4%)
Definition
Absence or cessation
of menstruation
Clinical
presentation
Nil menses