The Gynaecology Clinic

Michaelmas term year 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

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?

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

And …

• Don’t forget pregnancy

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

Rokitansky-Mayer-Küster-Hauser (RMKH) syndrome: absent uterus

and vagina

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?

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

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++

After investigation..

• This patient had polycystic ovaries on ultrasound. She weighed 120kg and had mild hirsutism

• Blood tests showed an elevated LH:FSH ratio

Case 3

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

Causes of subfertility

• Ovulatory: consider the causes as above

• Tubal

• Male factor

• Non-consummation

• unexplained

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

Semen analysis• Volume >2ml

• Count 20-150 x106 /ml

• Motility >60%

• Progressive motillity >50%

Hysterosalpingogram

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?

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

Sequelae of menopause:

• Osteporosis

• Cardiovascular disease

• UTIs

• Dyspareunia

• ?Alzheimer’s disease

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)

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