Amenorrhoea/Oligomenorrhoea

Primary Amenorrhoea: Failure to menstruate by 16yrs of age.

Secondary Amenorrhoea: Absence of menstruation for 6 months

Oligomenorrhoea: Menstrual cycle length > 32 days

This is actually a very simple topic: the key is to use your logic and remember the causes by thinking about the Hypothalamic-Pituitary-Ovarian (HPO) axis. Think about what can possibly go wrong in each of the stages H, P and O. Anything that goes wrong in the HPO axis can cause Amenorrhoea/Oligomenorrhoea. If you know the causes, you can work out what questions to ask in a history, what to look for in examination and what tests to order to reach the diagnosis.

Causes

Secondary Amenorrhoea = pregnancy until proven otherwise!

After that, think of the HPO axis, and physical barriers that might prevent the egg from making its way out of the reproductive tract. (i.e. out flow tract abnormalities)

H : Weight loss, stress (physical & emotional), iatrogenic, Sheehan’s syndrome, Primary GNRH deficiency (eg. Kallman’s syndrome)

 

P : Micro/Macroadenomas (Most common being Prolactinomas), Hyper/Hypothyroidism, iatrogenic

 

O: PCOS, Testicular Feminisation aka End organ resistance (Ovaries irresponsive to androgens), Ovarian dysgenesis (Most commonly due to 45XO ie Turners), Menopause, Premature ovarian failure, iatrogenic.

 

Outflow Tract: Imperforated hymen, Ashermann’s syndrome, vaginal septum

History

When faced with an amennorhoea history, be confident. Have an imaginary map of the HPO axis in your head and work your way from top to bottom, starting with the most important question:

 

"Is there any chance you could be pregnant?"

 

If the patient says no, make sure to clarify;

  • Date of last menstrual period (LMP)
  • Date of last intercourse and type pf contraception used

H: How is their mood? Consider subjective and objective measures. What is their diet like? Have they recently lost any weight, and was this intentional?  Is the patient under considerable stress at the moment (exams, relationships, breavement, house moves)? How is their sense of smell? This can be lost in Kallman’s syndrome.

 

P: Is the patient experiencing problems with their vision? (adenomas) Is there any nipple discharge? (Prolactinoma) Is the patient currently breastfeeding? Are there any thyroid symptoms?

 

O: Is the patient suffering from greasy skin, hirsuitism, acne or weight gain? This may indicate PCOS. Are there any menopausal symptoms?  

 

Outflow Tract: Ask about menarche, dysmenorrhoea and distension; These can all occur in the presence of obstruction.

 

 

Then take the rest of your history as you would for any other gynaecological history and it will cover all the other causes:

  • Drug history for dopamine antagonists, contraceptives or GNRH analouges
  • Medical and surgical history for iatrogenic causes such as oophrectomy or radiotherapy to any of the HPO sites as well as history of chronic illness
  • Family history for Kallman’s syndrome or Turner’s syndrome

Examination

H: Are there secondary sexual charteristics present? If not, consider primary GnRH deficiency.

 

P: Examine the visual fields (adenomas), perform a thyroid examination (thyroid disease) and check for any nipple discharge (prolactinoma).

 

O:Height (↓ in Turner’s syndrome, ↑  in testicular feminization), BMI, signs of virilisation.

 

Outflow tract: Abdominal exam for any masses, bimanual examination for vaginal septum or imperforate hymen.

 

 

Dysmenorrhoea

Dysmenorrhoea: Excessive pain experienced during menstruation

Primary Dysmenorrhoea: Dysmenorrhoea without an organic cause

Secondary Dysmenorrhoea: Dysmenorrhoea due to underlying pathology.

 

Dysmenorrhoea affects 45-95% of mensturating women (wide range owing to suspected unreported cases).

 

Causes/History

Investigation

Treatment

For secondary dysmenorrhoea, treat the underlying cause.

 

For primary dysmenorrhoea:

  • Pain relief - analgesia (particularly NSAID's e.g. Mefanamic acid 500mg TDS), hot water bottles
  • The combined oral contraceptive pill
  • Mirena coil

 

If this is ineffective, GnRH analogoues / surgical intervention may be used.

 

Menorrhagia

Blood loss greater than 80ml per menstruation. In reality this is very difficult to quantify so when the patient complains of heavy periods, then we assume they are heavy.  

 

Primary menorrhagia - no cause can be found for the heavy bleeding.

Secondary menorrhagia - the heavy bleeding is due to underlying organic cause.

 

History

Quantify blood loss – Do they use tampons? Pads? Or both? How many do they go through? Do they change tampons/pads because it’s soaked through? Does it soak through the bed at night? How long does bleeding lasts 

 

Effects on QoL – Does it stop them from doing daily activities? Do they take time off work because of the bleeding? Is the patient anaemic? (Elicit a few symptoms of anaemia)

 

Duration of symptoms – When did this first start? Has the patient suffered from this all her life?

Symptoms pointing towards secondary causes - lumps, back pain, previous bleeding problems (e.g. tooth extractions), family history, recent weight gain and tiredness.

 

Elicit other gynaecological symptoms

 

Then take the rest of the history as for your normal gynaecology history. This will include or exclude other causes of secondary menorrhagia.

Investigation

  •  Urine Beta HCG to rule out pregnancy. (MUST)
  •  FBC to ascertain whether patient is anaemic. (MUST)
  •  TFTs, clotting screen if clinically 
  •  Pelvic ultrasound for those who does not respond to initial treatment, or those whom is suspicious of endometrial pathology.

 

Examination

The following examinations should be performed in a patient complaining of menorrhagia:

 

Management of primary menorrhagia

 

Medical:

  •  NSAIDs: Mefenamic acid
  •  Anti-fibrinolytics: Tranexamic acid
  •  Hormonal: COCP or Mirena 

 

Surgical:  

  •  Endometrial ablation
  •  Hysterectomy

 

References

1)Collins S, Arulkumeran S, Hayes K, et al. Oxford Handbook of Obstetrics and Gynaecology, 2nd ed. Oxford. Oxford University Press 2008. p.486-488

2)Edmonds K, Norman J, Gebbie AE, Purdie DW, Hay P, et al. Gynaecology By Ten Teachers. 18th ed. London. Hodder Education. p.50-53

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