1. Amenorrhoea – A Clinician’s Approach Max Brinsmead MB BS PhD May 2015

2. Definitions Primary amenorrhoea –Failure to menstruate by age 16 Secondary amenorrhoea –Absence of menstruation for >6 months

3. Primary Amenorrhoea – Common Causes Constitutional delay Chromosomal e.g. 45XO, 46XY Pituitary tumour e.g craniopharyngioma Congenital adrenal hyperplasia Genital tract anomaly (Plus all the causes of secondary amenorrhoea)

4. Primary Amenorrhoea – Clues to diagnosis Constitutional delay Chromosomal e.g. 45XO, 46XY Pituitary tumour e.g craniopharyngioma Congenital adrenal hyperplasia Genital tract anomaly Secondary sexual characteristics slow Stigmata of Turners S Visual field defect Virilisation Imperforate hymen

5. Primary amenorrhoea – Diagnostic steps Height, weight and BP Evaluate secondary sexual characteristics Look for signs of androgen excess Do visual fields Chromosomes FSH, LH and E2 Maybe HydroxyPROG, Androgens, PRL, TSH Maybe CT pituitary

6. Secondary amenorrhoea – Common causes Hypothalamic “Stress” Weight loss/gain (Anorexia) Post Pill and Depo Provera PCO Syndrome (1:20 women) Premature Menopause Idiopathic or genetic (gene identified) Iatrogenic Resistant ovary syndrome Hyperprolactinaemia Physiological Pituitary adenoma Drug-induced Remember also pregnancy & progestins!

7. Secondary amenorrhoea – Uncommon causes Kallman’s Syndrome Sheehan’s Syndrome Cushing’s Syndrome Other Pituitary Tumours Post encephalitis/trauma Thyroid disease Androgen-producing Tumours Asherman’s Syndrome Cervical stenosis

8. Secondary amenorrhoea – Clinical evaluation 1 History –Life events –Weight/Exercise history –Pregnancy –Drugs –Galactorrhoea –Hot flushes –Headaches/Vision

9. Secondary amenorrhoea – Clinical evaluation 2 Examination –Height/Weight BP –2 0 Sexual characteristics –Hirsutism/Virilisation –Visual fields –Galactorrhoea –Genital tract oestrogenisation –Cervical stenosis

10. Secondary amenorrhoea – Clinical evaluation 3 Primary Tests –FSH LH E2 TSH PRL –Androgens –Ultrasound pelvis –Visual fields –Progesterone challenge test

11. Secondary amenorrhoea – Clinical evaluation 4 Secondary Tests –CT Pituitary –Other pituitary hormones –Dexamethasone suppression –HydroxyPROG –Hysteroscopy or HSG –Laparoscopy & ovarian biopsy