Amenorrhoea

Absence of menstrual bleeding.

Primary amenorrhoea refers to never having menstrual period i.e. absence of the menarche.  By age 16 in a girl with normal secondary sexual characteristics e.g. breast development, pubic hair etc (age 14 if these are absent), if the menses have not occurred, this can be considered primary amenorrhoea.

Secondary amenorrhoea refers to the absence of menstrual bleeding for 6 months (12 if prior oligomenorrhagia) having previously had a regular menstrual cycle.

NB Oligomenorrhoea is defined by NICE as menses occurring less frequently than every 35 days.  Most causes of amenorrhoea are also causes of oligomenorrhoea.

IMPORTANT: In women of reproductive age, the most common cause of amenorrhoea is PREGNANCY.  All women in this category should be investigated for pregnancy to include/exclude this diagnosis prior to (or at the same time as) further investigation.

History

  • As always, ask name and date of birth, and parity
  • Ask about how long? (in general, investigations/treatments are done if there has been no bleeding for more than 3 months
    • If there has been any bleeding, describe this (e.g. regular/irregular, light (spotting)/heavy (flooding))
    • Try and establish how the menses have changed i.e. what was normal
      • how many days between, how many days bleeding, how light/heavy, how regular etc
    • Also ask specifically about:
      • age of menarche
      • contraceptive use
        • If the patient is using contraception (in particular, hormonal contraception), where appropriate, ask how they are using it
        • Ask about the possibility of pregnancy
  • Ask about associated symptoms/causes
    • Symptoms of the menopause
      • Hot flushes, headaches, vaginal dryness, loss of libido, sleeping problems, change in mood
      • NB menopause would be the most common cause of secondary amenorrhagia in patients >50.  In patients <40 with these symptoms, premature ovarian failure may be the cause
    • Symptoms of pregnancy
      • Nausea, change in appetite, breast tenderness
    • Ask about weight loss/exercise
      • Anorexia and excess exercise can be a cause of amenorrhoea (hypothalamic)
        • patients will either usually have a BMI of <17 or exercise >4 hours/day
        • usually underlying psychiatric condition (e.g. anorexia nervosa or body dysmorphic disorder etc)
    • Symptoms of PCOS
      • Excessive (male-pattern) hair growth, weight gain, hair loss/thinning (male pattern), acne/oily skin
    • Thyroid symptoms
      • Heat intolerance, tremor, weight loss, goitre, irritability, fatigue
      • Weight gain, lethargy,
    • Any other symptoms?
      • Visual disturbance, galactorrhoea
      • Change in libido
      • Any infertility issues?
      • Stress/depression
  • Ask about PMHx
    • Any previous episodes of amenorrhoea?
    • Cervical screening up to date?
      • Any abnormalities +/- treatments?
        • D&C can rarely cause Asherman’s syndrome
    • Any other gynaecological history?
    • Any infertility problems?
    • Drugs
      • Particularly antiemetics and antipsychotics (containing phenothiazines/metcoclopramide) which can raise prolactin
      • Steroids
      • Chemotherapy/radiotherapy (the latter can be to the pelvis or to the brain)
    • Other PMHx/RHx
      • e.g. epilepsy and anti-epileptic drugs; diabetes
  • Ask about Family history
    • Premature menopause
    • PCOS
    • Other
    • In primary amenorrhoea, another diagnosis of Turner’s syndrome
  • Ask about social history
    • Diet, exercise, smoking, alcohol, occupation etc
    • Illicit drug use
    • In primary amenorrhoea, ask about progress at school, childhood development and milestones etc
  • If appropriate, ask about sexual history

Examination

  • Take height/weight (calculate BMI)
  • Look at the hands for any signs of
    • thyroid disease- acropachy, palmar erythema, tremor
  • Look at the skin for any
    • acanthosis nigricans (of PCOS or adrenal insufficiency)
    • hirsutism
    • thin skin and striae, easy bruising (Cushings syndrome)
  • Look for any dysmorphic features of Turners
    • Short stature, web neck, low-set ears, pubertal delay (delayed breast development; NB Turner’s normally has normal pubic hair development), short 4th metacarpal, high-arched palat, cubitus valgus)
  • Examine the neck for any thyroid abnormalities
  • Examine the visual fields

Investigations

  •  Pregnancy test
  • Serum LH and FSH
    • High levels of both on more than one occasion suggests premature ovarian failure/menopause
    • Normal/low levels suggest hypothalamic cause
    • Normal FSH and increased LH may suggest PCOS
  • Prolactin
    • May be abnormally high (>1000mIU/l) in prolactinoma tumours
    • Other causes of raised prolactin include
      • Stress
      • Drugs (e.g. antipsychotics, antidepressants, antihypertensives, antihistamines, metachlopramide)
      • PCOS
  • TFTs (TSH, free T4)
  • Total testosterone and sex-hormone binding globulin
    • And calculate free androgen index
      • Total testosterone / total sex-hormone binding globulin
      • Can be raised in PCOS
  • Other tests can be done
    • Oestrodiol
      • May help to differentiate between ovarian and hypothalamic dysfunction (i.e. if oestrogen low and LH/FSH high)
    • USS
      • Can be useful in PCOS
      • Also should be used to assess girls who have not been sexually active (primary)
    • Karyotyping
    • Occasionally you can do progestegen +/- oestrogen challenges
      • i.e. put the patient on the pill for 2-3 weeks and then see if she has a withdrawal bleed.

Causes of Amenorrhoea

Primary

  • Constitutional delay (family history)
  • Genitourinary malformation
    • e.g. imperforate hymen; absent uterus or vagina (usually cyclical pain)
  • Testicular feminisation
    • XY karyotype but with androgen insensitivity
  • Turners syndrome
  • Anorexia nervosa
  • Congenital adrenal hyperplasia
  • Kallman’s syndrome
  • Hypothyroidism
  • Prolactinoma

Secondary

  • Pregnancy
  • Premature Ovarian Failure
  • Contraception
  • Asherman’s syndrome
  • Anorexia Nervosa
  • Polycystic ovaries
  • Hyperprolactinaemia
  • Sheehan’s syndrome
  • Cushing’s syndrome
  • CAH

huhu.

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