Amenorrhoea

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Amenorrhoea

  1. 1. Amenorrhoea – A Clinician’s Approach Max Brinsmead PhD FRANZCOG October 2008
  2. 2. Definitions • Primary amenorrhoea – Failure to menstruate by age 16 • Secondary amenorrhoea – Absence of menstruation for >6 months
  3. 3. Primary Amenorrhoea – Common Causes • Constitutional delay • Chromosomal e.g. 45XO, 46XY • Pituitary tumour e.g craniopharyngioma • Congenital adrenal hyperplasia • Genital tract anomaly • (Plus all the causes of secondary amenorrhoea)
  4. 4. Primary Amenorrhoea – Clues to diagnosis • Constitutional delay • Chromosomal e.g. 45XO, 46XY • Pituitary tumour e.g craniopharyngioma • Congenital adrenal hyperplasia • Genital tract anomaly • Secondary sexual characteristics slow • Stigmata of Turners S • Visual field defect • Virilisation • Imperforate hymen
  5. 5. Primary amenorrhoea – Diagnostic steps • Height, weight and BP • Evaluate secondary sexual characteristics • Look for signs of androgen excess • Do visual fields • Chromosomes • FSH, LH and E2 • Maybe HydroxyPROG, Androgens, PRL, TSH • Maybe CT pituitary
  6. 6. Secondary amenorrhoea – Common causes • Hypothalamic • “Stress” • Weight loss/gain (Anorexia) • Post Pill and Depo Provera • PCO Syndrome (1:20 women) • Premature Menopause • Idiopathic • Iatrogenic • Resistant ovary syndrome • Hyperprolactinaemia • Physiological • Pituitary adenoma • Drug induced • Remember also pregnancy & progestins!
  7. 7. Secondary amenorrhoea – Uncommon causes • Kallman’s Syndrome • Sheehan’s Syndrome • Cushing’s Syndrome • Other Pituitary Tumours • Post encephalitis/trauma • Thyroid disease • Androgen-producing Tumours • Asherman’s Syndrome • Cervical stenosis
  8. 8. Secondary amenorrhoea – Clinical evaluation 1 • History – Life events – Weight/Exercise history – Pregnancy – Drugs – Galactorrhoea – Hot flushes – Headaches/Vision
  9. 9. Secondary amenorrhoea – Clinical evaluation 2 • Examination – Height/Weight BP – 20 Sexual characteristics – Hirsutism/Virilisation – Visual fields – Galactorrhoea – Genital tract oestrogenisation – Cervical stenosis
  10. 10. Secondary amenorrhoea – Clinical evaluation 3 • Primary Tests – FSH LH E2 TSH PRL – Androgens – Ultrasound pelvis – Visual fields – Progesterone challenge test
  11. 11. Secondary amenorrhoea – Clinical evaluation 4 • Secondary Tests – CT Pituitary – Other pituitary hormones – Dexamethasone suppression – HydroxyPROG – Hysteroscopy or HSG – Laparoscopy & ovarian biopsy

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