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PCOS & Infrequent / Absent Menstruation - Coggle Diagram
PCOS & Infrequent / Absent Menstruation
Amenorrhoea
Definitions
Amenorrheoa
The absence or cessation of menstruation
May be physiological (before menarch / after menopause / pregnancy)
May be postoperative (hysterectomy)
Primary Amenorrhoea
Menses have not occured by the time of expected menarch
14 y/o
in the absence of secondary sexual characteristics
16 y/o if other features are developing normally
Secondary Amenorrhoea
Menstruation has pviously occured but has stopped
Usually 6 consecutive montths - longer where menses have previously been infrequent
Primary Amenorrhoea
Causes
2nd Sex Characteristics Present
Costitutional delay
No abnormality but later than peers
Genitorurinary Malformation
Imperforate hymen
Transverse vaginal septum
Absence of uterus or vagina - Mullerian agenesis
Testicular feminisation
Androgen resistance syndrome in XY karyotype
Hyperprolactinaemia
Hypothyroidism
Medication
Pituitary tumour
Pregnancy
Causes
2nd Sex Characteristics Absent
Ovarian failure
Chemotherapy
Irradiation
Chromosomal gonadal abnormality
Hypothalamic failure
Chronic illness
Excessive exercise
Stress
Significantly underweight
Other failures of HPA axis
Tumours
Irradiation
Infection
Head injury involving hypothalamus or pituitary
Secondary Amenorrheoa
Epidemiology
Most common cause of amenorrhoea in women of childbearing age
Causes with No Androgen Excess
Physiological
Pregnancy
Lactation
Menopause
Premature Ovarian Failure
Autoimmune
Radiotherapy
Chemotherapy
Premature menopause defined as occuring before 40yrs
Depot / Implant / IUCD
Cervical stenosis and intrauterine adhesions - Asherman's yndrome
Hypothalmamic dysfunction
Stress
Excessive exercise
Eating disoders
Depression
Chronic illness
Tumours
Weight loss
Pituitary disease and hyperprolactinaemia
Prolactinoma
Medication
Recreational drugs
Tumours
Trauma
Cranial irradiation
Sarcoidosis
Tuberculosis
Sheehan's syndrome
Acute pituitary infection due to PPH
Thyroid disease
Hypo or hyper
Iatrogenic
Surgery
Iradiation
"Post-pill" amenorrhoea
Causes with Signs of Androgen Excess
Features
Hirsutism
Acne
Virilisation
PCOS 30%
May be overweight
Insulin resistance
Cushing's syndrome
Spontaneous
Iatrogenic
Adrenal / Ovarian carinoma
Can produce androgens
Mayer-Rokitansky-Kuster-Hause Syndrome
Mullerian Agenesis
Pathophysiology
Congenital absence of upper 2/3 of vagina
Uterus absent or rudimentary
Presentation
Primary amenorrhoea in female with 46XX karyotype and normal 2nd sex characteristics
Associated abnormalities
Kidneys
Skeletal system
Heart
Auditory system
Epidemiology
Incidence 1 in 4000-5000
Common in women presenting with primary amenorrhoea
Management
Psychological support
Creaction of neovagina for sexual function
Fertility options
Invitro Fertilisation
Surrogacy
Adoption
Uterine transplants have been reported
Imperforate Hymen
Pathophysiology
Failure of perforation in fetal life
Menstrual blood collects behind membrane and vagina distends
Presentation
Often painless until vagina sufficiently distended
Haemotocolpos - discomfort
May affect micturition and defaecation
May be palpable adbominally
Inspection - blue membrane with darkened blood transilluminating through thin membrane
Surgical Management
Cruciate incision to relieve obstruction
Haematocolpos will drain in 3-5 days
Usually no sequelae in cases presenting early
Turner's Syndrmoe
Epidemiology
Most common sex chromosome aneuploidy in women
Karyotype
45XO
Monosomy X with complement of autosomes
Features
Short stature 30%
Webbed neck
Skeletal abnormalities
Renal abnormalities
Cardiac anomalies - Co-arctation
Early loss of ovarian function
Ovarian hypofunction / premature ovarian failure
Most do not undergo puberty without HRT
Fertility
Few with TS + Mosaic TS continue to have ovarian activity - chance of natural conception
Ovarian stimulation with Gonanotrophins with / following pituitary suppression
Invitri fertilisation and embryos cultured
May have reduced ovarian reserve at referral - may require multiple cycles of IVF
Donor oocytes / embryos
Polycyctic Ovarian Syndrome (PCOS)
Epidemiology
Significant health issue with reporductive, metabolic, psychological features
Affects 8-13% women of reprofuctive age
70% undiagnosed
High risk populations - indigenous women
Higher prevalence and complications
Most common cause of anovulation
Presentation / Presenting complaints
Infertility
Amenorrhoea
Acne
Hirsutism
Pathophysiology
Unclear - likely multifactorial
Essential changes
Excess androgens produced by theca cells of ovaries
Due to hyperinsulinaemia or increased LH
Insulin resistance and hyperinsulinaemia
Weight gain through insulin resistance
Insulin resistance causes:
Increased androgen production through more than 1 mechanism
Reduced preduction of sex hormone-binding globulin (SHBG) in liver
Raised free testosterone (testosterone usaully bound to SHBG)
Raised LH due to increased production from anterior pituitary
Symptoms
Oligomenorrhoea
Infertility / subfertility
Acne (hyperandrogenism)
Hirsuitism (hyperandrogenism)
Alopecia (hyperandrogenism)
Obesity / difficulty loosing weight
Psych symptoms
Modd swings
Depression
Anxiety
Poor self-esteem
Sleep apnoea
Psychosexual dysfunction
Signs
Hirsuitism 60%
Male-pattern balding, alopecia
Obesity with central distribution
Acanthosis nigricans - sign of insulin resistance
Clitoromegaly
Increased muscle mass
Deep voice
Complications / Consequences
T2DM
Screen in :
BMI > 25
BMI <25 with risk factors (age >40, hx GDM, Fhx T2DM)
2 hour post 75g OGTT
Test annuallly in impaired glucose tolerance / impaie fasting glucose
Endometrial cancer
Unopposed oestrogen - 2-6x increased risk
Low threshold for investigation
Prevention: medroxyprogesterone acetate
to induce a withdrawal bleed at least every 3 to 4 months in not on a COCP
Gestational DM
Screen for GDM at 24-28 weeks gestation
OSA
Associated with obesity, adrogen levels, insulin resistance
Contributes to insulin resistance
CPAP improves insulin sensitivity
Screen for OSA - Snoring, daytime fatigue / somnolence
CVD
Assess individual risk factors
Treat hypertension
Lipid -lower tx not recommended routinely
Diagnostic Criteria
2/3 criteria met
Clinical or biochemic features of
Hyperandrogenism
Oligo-ovulation or anovulation (Menstrual cycle disturbance)
Polycystic ovaries on US
Requires exclusion of undelrying diseasae of adrenal / pituitary glands
And exclusion of other causes of menstrual cycle irregularity secondary to hyopthalmic, pituitary, ovarian dysfunction
Irregular Menstrual Cycles
Normal in 1st yr post menarch as part of pubertal transition
1-3 yrs post menarche
Less than 21 days or
More than 45 days
3 yrs - Perimenopause
Less than 21 days or
More than 35 days
Less tha 8 cycles per year
More than 1yr post menarche
Over 90 for any one cycle
Biochemical Hyperandrogenism
Assessment
Calculated free testosterone
Free androgen index
Calculated bioavailable testosterone
Exception
Reliable assessment not possible in women on
hormonal contraception
Effects on SHBG and altered gonadotrophin-dependent androgen production
Management
Assess other causes of hyperandrogenism - Neoplasia
Polycystic Ovarian Morphology
12 or more follicles measuring 2-9mm throughout entire ovary
Or
Ovarian volume ≥ 10cm3
May be numerous small cyst less than 5mm on periphery -
string of pearls
appearance
Metabolic Abnormalities
Presence of insulin resistence, central obesity, dyslipidaemia - higher risk of DM or CVD
Insulin resistance defined as a reduced glucose response to a given amount of insulin and may occure secondary to resistance at the insulin receptore, decreased hepatic clearance of insulin and/or increased pancreatic sensitivity
Oilgomenorrhoea - more likely to be insulin resistant irrespective of BMI
Management
Endometrial Cancer
Recommended treatment with progesterone to induce withdrawal bleed every 3-4 months
Predisposed to endometrial hyperplasia and carcinoma
Fertility
Epidemiology
5-10% weight loss can restore regular ovulation
Prevalence of miscarriage appears increased in PCOS
Most common cause of anovulation
70% of those with PCOS suffer anovulation
Letrozole
1️⃣ Line pharmacological tx for ovulation induction
Laparoscopic Ovarian Drilling
Risks
Reduced ovarian reserve
Loss of ovarian function
Adhesions
Use
Singleton birth in women with PCOS
IVF
Consider after failed ovulation induction treatment
3️⃣rd line
Psychological Wellbeing
Facilitate referral, appropriate care, lifestyle and preventitive strategies
Epidemiology
↑ Risk of depressive and anxiety symptoms - distress of PCOS
↑ Prevalence and severity of psychosexual dysfunction
↑ Prevalence of negative body image
Screen for depression /anxiety
Treatment
Exercise and Weight Control
1️⃣ Line treatment
Diet
Target sugar - insulin resistance
Low glycaemic index carbs
Frequent small smeals - lower mean serum insulin concentration
Hypocalorific diet
Spironolactone
Dose
100-200mg
MOA
Diuretic, blocks androgen action
S/E
Frequent urination
Dizziness
Erratic periods (partial progesterone action)
Hypokalaemia - monitor kidney fx
Use
Regulates Androgen
Reduces excess hair growth
Reduces blood pressure
Finasteride
Dose
2.5mg OD
1mg in hairloss
MOA
Blocks Conversion of testosterone to dihydrotestosterone
Alleviates consequences of androgen excess
Metformin
Use
Weight reduction
Treatment of hormonal and metabolic outcomes
Treatment of impaired glucose tolerance
Bariatric Surgery
Use
Weight loss
Improve comorbidities associated with PCOS
Dianette (Cyproterone acetate 2mg /ethinylestradiol 35mcg)
COCP
USe
Reduces excessive hair
Acne treatment
Antiandrogen
Acne
Topical benzoyl peroxide
Retinoids
Antibiotics
Oral isotretinoin - persistent severe non responding acne
Cyproterone acetate 2mg / Ethinylestradiol 35mc (Dianette)
OCP containing antiandrogen
Higher risk of clots 1.5-2x
Hirsuitism
Laser hair removal
Brown / black hair
Electrolysis
White / blonde hair
Shaving
Plucking / waxing / threading / epilator
Hair bleaching
Hair removal cream
Cyproterone acetate 2mg / Ethinylestradiol 35mc (Dianette)
Menstrual Irregularity
COCP
Redularisation of cycle
Help amelioration of hyperandrogenism
Decreases gonadotropin secretion + increases SHBG - reduces bioavailable testosterone by 40-60%
Types
Yasmin
30 mcg ethynilestradiol and 3 mg drospirenone
Drospirenone is a 17-α progestagen derived from spironolactone
Good cycle control
Reduces hair growth
Treats acne
Periodic progesterone
In contraindications of oestrogen
Causes periodic endometrial shedding
