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.
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
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;
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?
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:
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.
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).
For secondary dysmenorrhoea, treat the underlying cause.
For primary dysmenorrhoea:
If this is ineffective, GnRH analogoues / surgical intervention may be used.
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.
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.
The following examinations should be performed in a patient complaining of menorrhagia:
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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