1. The Gynaecology Clinic Michaelmas term year 2

2. This session will: Cover definitions of amenorrhoea and oligomenorrhoea Explain the genetic, anatomical and endocrine causes of these disorders Offer a plan for their clinical assessment

3. Case 1 A 17 year old comes with her mother as she has not yet had a period What might the causes of this be and how would you investigate it?

4. Primary amenorrhoea= may be due to : Disorders of outflow tract/uterus (Mullerian abnormalities/agenesis) Disorders of ovary (karyotypic abnormality: XO, androgen insensitivity XY) Disorder of anterior pituitary e.g Cushing’s, prolactin secreting adenomas. Congenital adrenal hyperplasia CNS disorder: hypothalamic, wt. loss, eating disorder, exercise

5. And … Don’t forget pregnancy

6. Plan for investigation History: ?thelarche, pubarche. Wt changes, eating habits, exercise. Consider the possibility of pregnancy Examination: 2y sexual characteristics (inc. external genitalia), wt. Ultrasound can assess size and shape of uterus and ovaries. MRI can provide closer imaging of Mullerian abnormalities Bloods: Karyotype: XO, XY, hCG, FSH/LH, 17-OH progesterone

7. Rokitansky-Mayer-Küster-Hauser Rokitansky-Mayer-Küster-Hauser (RMKH) syndrome: absent uterus and vagina

8. Case 2 A 23 year old comes to see you as her periods stopped 4 months ago. What could be the cause and how would you investigate?

9. Causes of secondary amenorrhoea/oligomenorrhoea Pregnancy Disorders of outflow? Asherman’s Disorders of ovaries? PCO, resistant ovary syndrome, premature ovarian failure, hormone secreting ovarian tumour. XO mosaic Anterior pituitary? Prolactinoma, thyroid disease Sheehan’s syndrome CNS? Hypothalamic causes; wt. Loss anorexia, bulimia

10. Plan for investigation: History ?pregnancy, wt change, eating, exercise, drugs (inc substance abuse) Examination: wt. Hirsutism Imaging: ultrasound for PCO Bloods: gonadotrophins, TSH, prolactin Karyotype if FSH elevated++

11. After investigation.. This patient had polycystic ovaries on ultrasound. She weighed 120kg and had mild hirsutism Blood tests showed an elevated LH:FSH ratio

12. Case 3 A couple come to see you as they want to have a baby, and no pregnancy has occurred after 2 years.

13. Causes of subfertility Ovulatory: consider the causes as above Tubal Male factor Non-consummation unexplained

14. Planned investigations: History: primary or secondary subfertility? Previous surgery or infection Other symptoms e.g pain Blood tests: FSH/LH, prolactin, TSH, se progesterone Ultrasound, hysterosalpingogram Seminal analysis

15. Semen analysis Volume >2ml Count 20-150 x10 6 /ml Motility >60% Progressive motillity >50%

16. Hysterosalpingogram

17. Case 4 A 48 year old comes to see you as her periods have become less frequent over the past year and she hasn’t had one now for 4 months. Has she reached the menopause and should anything further be done?

18. The menopause: the last period Climacteric: period of life when ovulatory function declines Hypothalomo-pituitary function increases from around 10 years before the menopause to maintain ovulation Low oestrogen levels lead to symptoms: flushes, lack of energy, night sweats, joint pains, vaginal dryness, urinary urgency

19. Sequelae of menopause: Osteporosis Cardiovascular disease UTIs Dyspareunia ?Alzheimer’s disease

20. Advantages/disadvantages of HRT Prevents osteoporosis Reduces risk of Alzheimer’s Corrects symptoms Reduces risk of colon cancer Increases risk of breast cancer (most in cyclical preparations)

21. For our patient: It is not possible to know if she has really had her last period yet, but it is likely she is in the climacteric Other reasons for anovulation may need to be considered (e.g. thyroid disease) Might still be pregnant! Re HRT: patients need to weigh up risks and benefits