Amenorrhoea – A Clinician’s Approach

1. Amenorrhoea – A Clinician’s Approach Max Brinsmead PhD FRANZCOG July 2012

2. Definitions • Primary amenorrhoea • Failure to menstruate by age 16 • Secondary amenorrhoea • Absence of menstruation for >6 months

3. 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) Primary Amenorrhoea – Common Causes

4. 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 Primary Amenorrhoea – Clues to diagnosis

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. 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. 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. Secondary amenorrhoea – Clinical evaluation 1 • History • Life events • Weight/Exercise history • Pregnancy • Drugs • Galactorrhoea • Hot flushes • Headaches/Vision

9. Secondary amenorrhoea – Clinical evaluation 2 • Examination • Height/Weight BP • 20 Sexual characteristics • Hirsutism/Virilisation • Visual fields • Galactorrhoea • Genital tract oestrogenisation • Cervical stenosis

10. Secondary amenorrhoea – Clinical evaluation 3 • Primary Tests • FSH LH E2 TSH PRL • Androgens • Ultrasound pelvis • Visual fields • Progesterone challenge test

11. Secondary amenorrhoea – Clinical evaluation 4 • Secondary Tests • CT Pituitary • Other pituitary hormones • Dexamethasone suppression • HydroxyPROG • Hysteroscopy or HSG • Laparoscopy & ovarian biopsy