Presentation is loading. Please wait.

Presentation is loading. Please wait.

Amenorrhoea & PCOS Dr H McMillan MBCHb MSc MRCOG MFSRH Dip Med Ed

Similar presentations

Presentation on theme: "Amenorrhoea & PCOS Dr H McMillan MBCHb MSc MRCOG MFSRH Dip Med Ed"— Presentation transcript:

1 Amenorrhoea & PCOS Dr H McMillan MBCHb MSc MRCOG MFSRH Dip Med Ed
Consultant in Obstetrics & Gynaecology CUMH/ Mercy University Hospital 4th Year Medical Student Lecture March 2011 Amenorrhoea & PCOS

2 Introduction Relevant to : Obstetrics & Gynaecology GP
General Medicine Cardiology Endocrinology General Surgery

3 Overview Basic Science Amenorrhoea PCOS Puberty Menstrual Cycle
Primary Secondary PCOS

4 Puberty Thelarche- breast development Adrenarche- axillary +pubic hair
Menarche- start of periods

5 Anatomy- Secondary Sexual Characteristics
Pubic Hair development Tanner Stages

6 Physiology- Pituitary
Anterior lobe Adenohypophysis Secretes Follicle Stimulating FSH Luteinising Hormone LH (also TSH, GH, Prolactin, ACTH, MSH) Posterior lobe Neurohypohysis Stores and releases Oxytocin and vasopressin

7 Menstrual cycle

8 Menstrual cycle in action

9 Menstrual Cycle Day 1 is 1st day of bleeding Days 1-4 FSH high
Signals to develop follicle in ovary Follicle produces OESTROGEN Oestrogen causes - Cervical mucus to be receptive to sperm Endometrium “proliferative” Down-regulates FSH

10 Menstrual Cycle Day 14 (if 28 day cycle) OESTROGEN so high
Positive feedback to pituitary leads to LH surge LH stimulates ovulation egg released from matured follicle

11 Menstrual Cycle Rest of follicle = corpus luteum (cyst) secretes PROGESTERONE Progesterone causes - Endometrium to thicken “secretory” ready for implantation Cervical mucus becomes hostile FSH down-regulated No more follicles recruited

12 Menstrual Cycle If ovum not fertilized + no implantation
Corpus luteum breaks down Oestrogen and progesterone falls Endometrium not being maintained so sloughs off = period

13 Amenorrhoea Primary Absence of Menarche No period by age 14
with absence of secondary sexual characteristics No period by age 16 with normal secondary sexual characteristics

14 Primary Amenorrhoea Differential Diagnosis- Work it out
Anatomical sieve

15 Hypothalamic- Pituitary axis
Pineal gland Smell See Stress

16 Hypothalamic- Pituitary axis

17 Primary Amenorrhoea (Constitutional delay) (Chronic systemic illness)
Chromosomal Hypothalamic Hypopituitarism Congenital Adrenal Hyperplasia Premature Ovarian failure/ Ovarian cysts/ PCOS Uterine anomalies- absence of uterus/ vagina Vaginal anomalies- Imperforate hymen

18 Primary Amenorrhoea Diagnosis -Work it out T- Trauma I- Infection
N-Neoplasia C- Connective Tissue A- Autoimmune N –Naughty Drs (Iatrogenic) B – Blood Disorders E- Endocrine D –Drugs/ Diet

19 Primary Amenorrhoea Trauma (Pituitary /Ovarian Trauma) Infection
Neoplasia Pituitary Tumour Prolactin Microadenoma Connective Tissue Uterine Vagina- Imperforate Hymen Absent uterus norm ovaries Rokintansky XX Automimmune Myasthenia Gravis, Crohns , Addison’s 39% co-exist Naughty Drs ( Iatrogenic) Chemotherapy Radiotherapy Blood - Endocrine Congenital Adrenal Hyperplasia Ovarian cyst/ PCOS Hypothalamic hypopituitarism 21 hydroxlylase deficiency (more 17OH progesterone) Kallman’s Syndrome (Anosmia) Drugs/ Diet Anorexia / Underweight Galactosaemia Chromosomal Androgen Insensitivity Swyers Turner’s Syndrome XY absent uterus xlinked rec XY uterus present X0 uterus present

20 Androgen Insensitivity

21 Primary Amenorhhoea - Cause Investigation Treatment Chromosomal
Karyotype HRT Adoption Surgical removal of XY gonads Hypothalamic FSH, LH, Prolactin, TFTs, Oestradiol, FAI Increase weight Decrease excess exercise Hypothalmic FSH, LH ,Prolactin, Growth Hormone Growth Hormone replacement Induce menarche Induce puberty

22 Primary Amenorrhoea Cause Investigation Treatment Pituitary tumour
MRI head (Sella Turcica) Pituitary Surgery Radiotherapy Congenital Adrenal Hyperplasia 17OH Progesterone DHEA FAI ACTH stimulation test COCP Steroids

23 Primary Amenorrhoea Cause Investigation Treatment Ovarian cysts PCOS
Prem Ovarian Failure Ultrasound Pelvis FAI SHBG (FSH:LH) + FSH LH Oestradiol Surgery – cystectomy Cons/ Medical/ Surgical HRT, Egg donation Induce puberty Uterine anomalies Absent uterus Absent vagina MRI Pelvis Laparoscopy Surrogacy – egg collection from normal ovaries Dilators/ Surgery Imperforate Hymen External examination Surgery- Incision and drainage of haematometra

24 Primary Amenorrhoea 1y Amen No sexual development Low FSH LH Low E2
Constitutional Chronic Illness High FSH LH 45 X0 46XY Uterus present Swyer syndrome gonadal dysgenesis Gonadectomy Induce puberty HRT Sexual development 46XX Prem Ovarian failure Induce puberty Andirogen Insensitivity Vaginal reconstruction Gonadectomy Oes only HRT Normal FSH Lh Normal E2 Uterus present Vaginal septum Surgery Uterus absent Rokitansky Kuster hauser

25 Secondary Amenorrhoea
Absence of menses after menarche NOT Oligomenorrhoea ( infrequent menses)

26 Secondary Amenorrhoea
Absence of menses after a preceding Menarche Exclude obvious causes: Pregnancy Menopause Contraception GnRha

27 Hypothalamic- Pituitary axis

28 Hypothalamic Pituitary Ovarian Axis

29 Secondary Amenorrhoea
Provide a brief summary of your presentation Cause Investigation Treatment Hypothalamic Stress/ anorexia Alleviate stress Diet Pituitary tumour MRI head (Sella Turcica) Pituitary Surgery Radiotherapy Hypothyroidism TFTs Thyroid replacement Congenital Adrenal Hyperplasia 17Beta Oestradiol DHEA FAI ACTH COCP Cortisol/ Fludrocortisone As for PCOS Ovarian cysts PCOS Prem Ovarian Failure Ultrasound Pelvis + FAI SHBG + FSH LH Oestradiol Surgery – cystectomy Cons/ Medical/ Surgical HRT, Egg donation Induce puberty


31 PCOS Incidence Genetics Definition Investigation Treatment

32 PCOS Incidence 7% in UK 52% of South Asian Immigrants in UK

33 PCOS Familial Inheritance Genetic link Probably Autosomal Dominant
Male line- Premature baldness Cholesterol side chain cleavage (CYP11a) Polymorphisms in INSR gene- insulin receptor function VNTR on chromosome 11p15.5 on nearby microsattelite locus

34 PCOS Definition?

35 PCOS Clinical definition (Old fashioned) 1) Hyperandrogensim
Acne, hirsuite, alopecia – not virilisation 2) Menstrual irregularity 3) Anovulatory Infertility Usually associated with obesity

36 Hypothalamic- Pituitary –Ovarian axis
SHBG are the buses of the blood stream that carry androgens. If there are fewer buses there is more free androgen free to cause symptoms

37 PCOS- Obese Women Obese women
adipose tissue –peripheral conversion of oestrone, which increase LH secretion Insulin insensitivity- leads to hyperinsulinaemia – less SHBG, more free androgen

38 PCOS & Obesity Weight Loss

39 PCOS – Lean women Lean women with PCOS – LH hypersecretion

40 PCOS Diagnostic definition – ESHRE / ASRM /Rotterdam Criteria
2 out of 3 criteria 1) US features of PCOS 2) Oligo or anovulation 3) Clinical or biochemical hyperandrogenism With exclusion of other aetologies

41 1. Ultrasound of Polycystic Ovaries
(> 12 peripheral follicles 2-9mm, per ovary >10cm3 volume) Truly a “polyfollicular ovary” Seen in 20-33% of general population

42 1. Ultrasound of Polycystic ovaries
“Ring of pearls”

43 2. Oligomenorrhoea or Anovulation

44 3. Clinical Hyperandrogenism
Ferriman Gallwey Hirsuitism Score

45 3. Biochemical Hyperandrogenism
Weight Loss

46 PCOS - Pathophysiology
Gynae presentation of a metabolic disease insulin- ovarian axis Insulin resistance (obese) LH (slim)

47 PCOS Investigations USS Pelvis
Day 21 Progesterone (Anovulatory subfertility) Day 2-5 bloods LH:FSH ≥ 3:1ratio Free Androgen Index >5 Decreased SHBG <16 If total testosterone > 5 check other androgens

48 PCOS Investigations to exclude other causes 17OH Progesterone (CAH)
DHEA Androstenedione Prolactin TFTs GTT/ Lipid profile D&C/ Pipelle for endometrial hyperplasia

49 Differential Diagnosis Menstrual Disturbance
Weight gain> 10% NIDDM/ IGT Hypothalamic stress, over-exercise, eating disorder Pituitary causes Perimenopausal Hypothyroidism

50 Differential Diagnosis Menstrual Disturbance
Endometrial pathology (>45y D&C) PID (Endocervical swabs) Cervical disease (Speculum) Ovarian disease (USS pelvis) Endometriosis

51 PCOS- Menstrual Treatment
For cycle control: Diet and Exercise (PCOS Diet) Dianette/ cOCP (if <70kg) Cyclical norethisterone (non-contraceptive) Metformin For heaviness: Tranexamic acid +Mefenamic acid Mirena

52 Differential Diagnosis of Hirsuitism
Androgen secreting tumours- rapid CAH Thyroid disease Acromegaly, Cushings Syndrome Hyperprolactinaemia Drugs – phenytoin

53 PCOS-Treatment for hirsuitism
Diet and Exercise (PCOS) COCP- Dianette +Further cyproterone acetate for 10/7 (LFTs) Yasmin ( Drosperinone) Spironolactone Metformin Flutamide Finasteride

54 PCOS Treatment for subfertility
Diet & Exercise PCOS diet book by Colette Harris Clomid* – Anti-oestrogen days 2-6 of cycle with follicle tracking Metformin start at 250mg od increase to max 500mg tds GnRHa* Laparoscopic ovarian drilling * Risk of OHSS

55 PCOS Long term management
NIDDM Yearly GTT CVS disease Yearly BP/ Weight Dyslipidaemia Yearly lipid profile Endometrial hyperplasia induce a regular bleed/ Mirena/ D&C Breast cancer due to elevated endogenous oestrogens Breast examinations/ screening

56 Useful websites www. www.


Download ppt "Amenorrhoea & PCOS Dr H McMillan MBCHb MSc MRCOG MFSRH Dip Med Ed"

Similar presentations

Ads by Google