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ESSAY 293 - Sec amenorrhoea

ESSAY 293 - Sec amenorrhoea Posted by PAUL A.
A healthy 30 year old woman with previously normal menstrual cycles has been referred to the gynaecology clinic because she has not had any menstrual periods for 7 months. (a) Discuss the differential diagnoses [5 marks]. (b) Discuss what additional information from the history and examination is helpful in establishing a diagnosis [9 marks]. (c) Justify which further investigations you would perform to establish the diagnosis [6 marks].
Posted by Shalini  M.
a)The differential diagnosis in this lady could be pregnancy,lactational amenorrhoea,ashermann\'s syndrome due to surgical curettage of the uterus or secondary to infections like tuberculosis or schistosomiasis,hyperprolactinemia due to polycystic ovarian disease or pituitary adenomas,hypogonadotrophic hypogonadism due to anorexia nervosa or excessive exercise(gymnastics,swimming,etc),premature ovarian failure due to chemoradiotherapy for malignancy,turner\'s syndrome or infections like mumps oophoritis.
b)it is essential to begin by eliciting details of her past manstrual cycles-whether delayed previously also to suggest a possible cause like polycystic ovarian syndrome.Also any childbirth and lactation sjould be enquired into.Also contraceptive history should be sought-any unprotected intercourse or irregular contraceptive usage would suggest a possible ongoing pregnancy.Any history of mumps recently or malignancies for which chemoradiotherapy was taken or recent curettage of the uterus should be taken to rule out possible premature ovarian failure and ashermann\'s syndrome.features suggestive of hypothyroidism like slurred speech,slow mentation,weight gain lethargy etc should be asked for.Detailed dietary history should be noted to rule out anorexia nervosa.On examination,features like hirsuitism,truncal obesity would be suggestive of polycyctic ovarian disease while periorbital odema,slow mentation and slurred speech would suggest hypothyroidism as a possible cause.Any nipple discharge which is milky should prompt investigations for hyperprolactinemia and history of regular headaches should prompt a visual field examination as also serum prolactin.Any features of proximal muscle wasting,breast tissue atrophy,loss of buccal fat are suggestive of starvation and anorexia.
c)A urine for pregnancy test to begin with to rule out a pregnancy is a must followed by other invstigations like pelvic ultrasound to see for polycystic ovaries,endometrial hyperplasia which would point to the diagnosis of polycystic ovarian syndrome.also if endometrium is atrophic and irregular it could be ashermann\'s syndrome and could be confirmed by hysteroscopy.Hormonal profile like serum FSH,LH,estrogen would be essential to confirm premature ovarian failure.anorexia nervosa and polycysitc ovarian disease although two serial values two weeks apart would be definitive.Thyroid profile is necessary if features are suggestive of hypothyroidsm.
Posted by robina K.
(A)Causes of secondary amenorrhoea could be physiological due to pregnancy and lactation or pathological due to many causes.There could be hypothalamic causes due to anorexia nervosa,stress,bulimia or strenous exercises. and hyper prolactinemia which could be due to pitutary adenoma,drugs like phenothiazines,antiemetics and methyledopa.Drugs like steroids,danazol ,antihypertensives may induce amenorrhoea.Contraceptives such as depots and mirena may also cause amenorrhoea.Polycystic disease is a recognised cause of menstrual irregularities.Ashermans syndrome due to vigorous curettage,hysteroscopic surgery or intrauterine infection like tuberculosis may cause amenorrhoea.Rarely thyroid dysfunction,cushing,late onset congenital adrenal hyperplasia.ovarian and adrenal tumours are caustive factors.Secondary amenorrhoea could be due to premature ovarian failure due to genetic, autoimmune or iatrogenic cause like BSO,cheme and radiotherapy.(B) A history of previous regular menstrual cycle followed by amenorrho ea with morning sickness may be due to pregnancy. Informations should be obtained about weight loss,anorexia nervosa,any stressful life events and strenous exercise may indicate hopthalamic cause.Headache ,visual disturbances,milky discharge frim breasts suggests pitutary adenoma,however galactorroea could be drug induced which should be inquired about.Patient should be asked about previous intra uterine procedures like TOP, and hysteroscopic procedures.History of chronic cough,fever and infertility suggests tuberculosis.Acne ,baldness,hirsuitism indicates hyperandrogenemia which could be due to polycystic ovarian disease ,ovarian or adrenal tumours .If there is associated virilisation witch could be due to androgen secreting tumours,CAH or abnormal karyatype.A general physical examination should be carried out including height, weight,facial appearance of cushionoid type,acne and hirsutism.Neck examination for acanthosis nigricans.This finding along with acne and hirsutism indicate PCOD,However a rapidly grown hirsutism indicates ovarian or adrenal tumour.Thyroid should be palpated for enlargement.Abdominal examination should be carried out for any adrenal or ovarian tumours.A pelvic examination for hypoestrogenism and clitromegaly and bimanual examination for ovarian tumours should be performed.(C)A urine pregnancy test should be performed to exclude pregnancy.Serum hormonal profile should be perfomed including FSH,LH,estradiol,SHBG, androstenendion for PCOD,prolactin and TFT tsh and free t4 for hyperprolactinemia and thyroid dysfunction.High levels of testosterone and DHEAS indicate ovarian and adrenal tumours respectively.If CAH is suspected 17 hydroxy progesterone need to be done.For pitutary adenomas XR,CT orMRI is advised.If asherman syndrome is suspected then a diagnostic and therapeutic Hysteroscopy is advised.For suspected Tuberculosis XR chest, tuberculin test,hystero-salpingo-graphy and sputum for AFB is advised.If signs of virilisation are found karyotype is indicated.
Posted by Sophia Y.
(a) Secondary amenorrhoea in her case can be due to pregnancy. It can also be due to causes of hypothalamic pituitary axis failure eg over-dieting, anorexia, stress, over-exercising, undiagnosed brain tumour (eg prolactinoma), recent surgery to brain. It can also be due to premature ovarian failure due to eg resistant ovarian syndrome, autoimmune disease. It can be due to iatrogenic causes eg drug-induced eg Depo provera usage, GnRH analogue or surgery to cervix or uterus (ashermanns syndrome). It can also be due to hyperprolactinaemia secondary to eg prolactinoma or drug-induced eg anti-pschotic Rx. It can also be due to PCOS, Sheehan syndrome & idiopathic .


(b) I will also ask if she is dieting, over-exercise, under lots of stress, depressed or anorexic. I will ask her if she has any menopausal symptoms such as vaginal dryness, hot flushes & night sweats. I will ask her if she has any symptoms of increasing mammary discharge, headaches, visual disturbances which might suggest prolactinoma. I will ask about what history of gynae surgery - ERPC, BSO, hysterectomy, endometrial ablation or history of massive PPH. I will also ask if she is taking any drug - prescribed & illegal which may cause amenorrhoea eg Depo provera, anti-psychotics or heroin.

On examination i will check for her height & weight & BMI and look for goitre. I will examine her abdomen to exclude any pelvic mass (which might suggest pregnancy), speculum to exclude any stenosed cervix. I will check for goitre if history suggests any thyroid disease. I will inspect her breast if to exclude galactorrhoea.

(c) I will arrange urine & serum pregnancy test as she might not know that she is pregnant. I will take bloods for FSH, LH & estradiol (E2). Raised FSH & LH with reduced estradiol means that premature ovarian failure is the likely cause. On the other hand, reduced FSH, LH & E2 will mean hypothalamic- pituitary axis failure is the cause.
She will also need to have serum prolactin. Raised prolactin with symtoms of visual disturbances & headache will warrant a CT/ MRI brain to exclude pituitary tumour or prolactinoma. She will also need to have pelvic USS to confirm the presence of ovaries & uterus. In addition, polycystic ovaries might show up on scan with normal FSH/ LH & E2 level.
Posted by Leen K.
A healthy 30 year old woman with previously normal menstrual cycles has been referred to the gynaecology clinic because she has not had any menstrual periods for 7 months. (a) Discuss the differential diagnoses [5 marks]. (b) Discuss what additional information from the history and examination is helpful in establishing a diagnosis [9 marks]. (c) Justify which further investigations you would perform to establish the diagnosis [6 marks].

(A) Differential diagnoses includes pregnancy, polycystic ovarian syndrome (PCOS), hyperprolactinaemia, excessive weight loss or exercise, undiagnosed hypothyroidism and drug-induced amenorrhoea (such as certain hormonal contraception - depoprovera, implanon, Mirena-coil). Premature ovarian failure (POF), hormone secreting tumours (androgen or prolactin forexample) and late onset congenital adrenal hyperplasia (CAH) are other less common causes of secondary amenorrhoea.

(B) Associated symptoms such as signs and symptoms of virilism (for example increase in facial hair, acne, greasy skin or deeper voice) might suggest PCOS or rarely androgen secreting tumours or even late onset CAH. A history of increasing abdominal swelling may suggest a concealed pregnancy or tumour growth. SHe should also be asked about recent weight loss or increase in exercise. Targeted questions on hot flushes, night sweats or changes in mood may point to POF. Galactorrhoea or visual disturbances may suggest prolactinoma. Drug history should also include recent changes in contraception, as depoprovera injections, implanon or levonorgestrel intrauterine system (Mirena coil) can cause amenorrhoea.
Examination should include a general assessment of the patient, such as body mass index (BMI) - low BMI could point to anorexia, high BMI may make the diagnosis of PCOS more likely). Signs of virilism on general examination such as increased male pattern hair growth or deeper voice may suggest PCOS, CAH or androgen secreting tumour. Abdominal mass on examination may help in diagnosing a pregnancy (especially if fetal movements are felt) or pelvic tumour. pelvic examination should include looking for cliteromegaly (increased androgen) and vaginal atrophy (sign of hypoeostrogenism secondary to POF).

(C) First of all, a pregnancy test should be done to exclude a pregnancy. If she is not pregnant, blood tests such as random follicle stimulating hormone (FSH) and luteinising hormone (LH) may help identify PCOS (where LH:FSH ratio is > 3) or POF (FSH high). Androgen studies should be done - in PCOS, androsteinedione and testosterone are raised, and sometimes steroid hormone binding globulin may be decreased. A very high testosterone (> 5 mmol/L) suggests androgen secreting tumour or CAH. A raised17 hydroxyprogesterone suggests an adrenal cause of increased androgen. Prolactin in increased in prolactinomas, and thyroid function tests should be done if she has symptoms suggesting hypothyroidism.
Ultrasound scanning is a non-invasive test that can help identify pregnancy, polycystic ovaries and pelvic tumours. It is usually easily available and cheaper than other imaging methods (Magnetic resonance imaging (MRI) or computed tomography (CT)).
Depending on results of the above initial investigations, further more specialised investigations can be done to aid diagnosis. CT or MRI of the head if prolactin is increased to look for prolactinoma or CT/MRI of abdomen and pelvic to look for hormone-secreting tumours.
Posted by SANCHU R.
sanchu
A)The Differential diagnosis includes a)Hypogonadotropic hypogonadism such a Anorexia nervosa, pituitary tumours, Sheehan\'s syndrome b) Eugonadotropic hypogonadism such as Polycystic ovary syndrome, Hypothyroidism, Hyperprolactinaemia, Hyperandrogenic conditions like Androgen secreting tumours and c)Hypergonadotropic hypogonadism such as Premature Overian Failure which may be due to Turner\'s mosaic , auto-immune, galactosaemia etc. The commonest cause of pregnancy should be excluded.
B)The History would be to ask for other associated symptoms. History of Hirsutism, change of voice, acne to rule out PCOS, Hyperandrogenism, galactorrhea and headache and vomiting to rule out Hyperprolactinaemia, tumors of the pituitary or hypothalamus, history of hot flushes and vaginal dryness to diagnose premature ovarian failure. History of other auto-immune conditions like IDDM, Drug History for drugs like Danazol or Contraceptives like Mirena or Depot-Provera which may cause amenorrhea, Occupation since athletes are prone for hypogonadotropism, any social issues and eating habits to look for anorexia and stress.
The Clinical examination would be to look for BMI, Hirsutism, galactorrhea, goitre, examination of abdomen and pelvis to look for masses (pregnancy, ovarian or adrenal tumours)and clitoromegaly,vaginal atrophy.
C)Investigations include Urine pregnancy test, FBC to rule out rare hematological causes of amenorrhea ,Thyroid function tests to diagnose hypothyroidism, Serum Prolactin to diagnose hyperprolactinaemia, FSH, LH -Low levels would point towards hypothalamic and pituitary causes. High levels suggest Premature ovarian failure. increased LH:FSH ratio would favour PCOS. Testosterone, DHEAS levels to look for androgen secreting tumors,An ultrasonogram of Abdomen and pelvis to diagnose PCOS or ovarian or adrenal mass, If symptoms suggest or FSH and LH levels are low, an MRI Brain to look for hypothalamic, pituitary tumors.
Posted by SN  K.
SN

(a) Pregnancy is the commonest cause of secondary amenorrhoea in a sexually active woman.
Secondary amenorrhoea could be due to Hpypogonadotrophic hypogonadism such as anorexia nervosa, in athletes or in women involved in strenuous exercises.
Sheehan’s syndrome (Pan hypo-pituitarism following a massive haemorrhage such as a history of post partum haemorrhage) can give rise to amenorrhoea.
Pituitary macro or micro adenomas giving rise to Hyperprolactinaemia can give rise to amenorrhoea. Cerebral tumours/ Cerebrovascular accidents involving hypothalamic Pituitary axis can give rise to amenorrhoea.
Other endocrine disorders such as Hypothyroidism, Cushing’s syndrome, Addison’s disease could give rise to secondary amenorrhoea.
Premature ovarian failure (could be idiopathic or secondary to infections such as mumps or due to radio/chemotherapy. Also mosaic Turner’s may undergo premature ovarian failure), resistant ovarian syndrome are ovarian causes of secondary amenorrhea.
Polycystic ovarian syndrome (PCOS) is a common cause of secondary amenorrhoea.
Hormonal therapy such as Progestogen therapy (e.g. Depo-Medroxy Progesterone acetate therapy, Levenogestrel Intra Uterine systems) can give rise to secondary amenorrhoea.
Asherman’s syndrome due to intrauterine adhesions (following uterine curettage or infection) can give rise to secondary amenorrhoea. Resection of endometrium or abalation of endometrium are other causes.
History of treatment to cervix such as large loop excision or cone biopsy may rarely give rise to cervical stenosis and secondary amenorrhoea.
Some medications may give rise to secondary amenorrhoea.
Also psychological disorders can give rise to secondary amenorrhoea (post traumatic stress disorder, depression).


(b) History of unprotected sexual intercourse and symptoms of pregnancy and examination for a gravid uterus and fetal heart sounds to exclude pregnancy.
History of anorexia nervosa, strenuous exercises and BMI to assess whether amenorrhoea is due to hypogonadotrophic hypogonadism is important.
Past Obstetric History to exclude massive Post partum haemorrhage or a history of miscarriages followed by uterine curettage should be taken.
If pituitary macro-adenoma is suspected, history and examination on visual fields should be done (gives rise to bi-temporal hemianopia). Also Hyperprolactinaemia may give rise to lactation. Therefore breast examination is important in a woman with secondary amenorrhoea (may or may not have a history of milk secretion but examination may reveal milk expression).
History of focal fits or diagnosed central nervous system causes should be elicited.
If suggestive of Hypothyroidism, symptoms and signs as weight gain, heat intolerance, bradycardia, hyporeflexia should be checked.
Other endocrine disorders such as Addison’s (weight loss, hypotension) Cushing’s (weight gain, purple abdominal striae, hypertension) should be excluded.
In premature ovarian failure the woman may have symptoms of menopause such as hot flushes or symptoms of hypo-oestrogenic manifestations such as a dry vagina giving rise to dyspareunia associated with secondary amenorrhoea.
In PCOS there can be a history of androgenic manifestations such as acne, male pattern hair loss and truncal obesity.
History should be taken regarding any hormonal therapy such as progesterone therapy or intake of gonadotrophin releasing hormone analogues (if on treatment for endometriosis).
A drug history should be taken as some medication may give rise to amenorrhoea.
History of pelvic inflammatory disease which can give rise to intrauterine adhesions and secondary amenorrhoea should be taken. Also any history of uterine surgery (endometrial abalation, resection) should be taken.
An abdominal palpation for the size of the uterus and speculum and vaginal examination for visualisation of cervix and to palpate for the size of the uterus is important.



(C) I will do a pregnancy test to exclude pregnancy. If pregnancy test is negative a Hormonal profile should be done according to the final differential diagnosis. This includes Serum FSH (will be high in premature ovarian failure, resistant ovarian syndrome), serum LH (LH: FSH ratio can be high in PCOS), serum Prolactin (can be high in some PCOS. Also if Prolactinoma is suspected), serum DHEAS (dihyroepiandrostenidione) if an androgen secreting tumour is suspected. S. Testosterone may be high in PCOS or markedly elevated in an androgen secreting tumour. S. Oestradiol may be low in premature menopause.
If symptoms and signs are suggestive of Hypothyroidism, thyroid profile should be done. If other endocrine disorders such as Cushing’s or Addison’s are suspected, a 24 hour cortisol levels, short synacthen test respectively.
An US scan if PCOS is suspected as may show polycystic ovaries. Also a haematometra could be diagnosed and endometrial thickness and ovarian masses could be visualised.
If a pituitary macroadenoma is suspected or cerebral space occupying lesion is suspected a CT scan or MRI scan of Brain may be indicated.

Posted by mahin S.
a) Differential diagnosis in this case would be physiological such as pregnancy and lactation,since she is in t.he reproductive age group.Drugs -contraceptives ,DMPA,Implanon or LNG-IUS,.Disturbance in hypothalamo-pituitary ovarian axis need to be considered.Hypothalamic causes such as stress,excessive excercise and eating disorders may supress the GnRH.Piyuitary causes may be hyperprolactinemia,pituitary-ovarian cause PCOS,or the woman muy be going into premature ovarian failure.Post D&C uerine adhesion causing Asherman syndrome,although rare ,could be a possibility.Cervical stenosis after LLETZ or conization may be apossibilty.
b) Menstrual history should be taken including age at menarche,LMP,length and regularity of her periods.Contraceptive hisrory for long acting contraceptives,Depomedroxy progesterone acetate,Implanon,or has intraueterine LNG-IUS may be contributing to ammenorrhea.Oral contraceptive pills may also cause post pill ammenorrhea.
Obstetric history,regarding her parity,age of the youngest child and if she is lactating,it may have caused lactational ammenorrhea.History of inferilility with ammenorrhea would be suggestive of PCOS.
History of stressful events,excessive excercise or eating may cause suppression of hypothalamic GnRH.History of galactorrhea or visual disturbance may be found in case of prolactinoma.
History of rapid weight gain,with change of voice ,hirsutism of acne may be found in case of PCOS with hyperandrogenemia.
History of hot flushes and night sweats may be obtained,suggestive of premature ovarian failure.
Family history of premature ovarin failure should be taken
Examination should include note BMI.Any hirsutism or acne- for signs of hyperandrogenemia.Visual fields examined.Thyroid enlargement.and galactorrhea,abormal skin pigmentaion ,Acanthosis nigricans is looked for.
Abdominal examination is done ,uterine enlargement may be found if she is pregnant.presense of any other abdomino pelvic mass is noted.
c)Investigations include endocrine profile,FSH,LH,-may be low in case of hypothalamic disorders,high levels are found in premature ovarian failure.Prolactin levels high in hyperprolactenemia.If levels are more than 1000 ,prolactinoma excluded by doing skull x-ray or CT scan.TFT if there are features suggestive of thyroid dysfunction.
Testosterone,SHBG,and free androgen index.DHEA,DHEAS to find the source of androgens,raised in case of adrenal androgens.CT,MRI of abdomen for any adrenal tumors.
USS pelvis for pregnancy or polycystic ovary.
Posted by dr neelangini G.
It suggests as a case of secondary amenorrhoea. So physiological conditions like pregnancy,can be a possibility Premature ovarian failure can be one of the causes, which may be due to immunogenic, genetics like turners mosaics, constitutional ie familial,Infection like mumps, radiotherapy or chemotherapy for any cancer in the body. ,It can be due to PCOS ,which is associated with obesity, subfertility ,& hirusutism. Late onset CAH & cushings syndrome,hypothyrodism may be the other causes of ammenorrhoea. Uterine causes can be.,ashermans syndrome,which is due to adhesion between uterine wall because of recent surgical termination of pregnancy,myomectomy . Cranio pharyngeoma, prolactinoma ,TB & sarcoma of the pituitary gland , may be the cause .Anorexia nervosa, severe physical exercise, severe stress ,are due to hypothalamic causes,can be another possibility.
Hx of associated hot flushes or other menopausal symptoms for premature ovarian failure.Hx of recent weight gain ,may give an clue towards PCOs Hx of gravidity,parity & its out come should be explored as recently surgical termination might have developed the ashermans syndrome..Late onset CAH & hypothyrodism may cause secondary amenorrhoea,so recent change of voice, ,abnormal hair growth may be due to CAH . Hx of increased sensitivity to cold may help in diagnosing hypothyrodism. .Familial Hx of premature ovarian failure should be explored .Recent Hx of infection like mumps, TB should be found out as mumps may cause premature ovarian failure & TB endometritis,TB pituitary may cause amenorrhoea .Hx of other associated immunogenic disorder like diabetes ,thyroid disease ,Inflammatory bowel disease may give a cjue of ovarian failure . History of Chemotherapy & radio therapy for any cancers in the body may cause pituitary ovarian failure .Hx of dieting, severe outdoor exercise may lead to secondary amenorrhoea Hx of contraceptives in the form of Progestogen IUS(MIRENA) ,Depo provera should be detected . Drug hx like methyldopa,reserpine for HT,any phenothizine group of drugs for any psychological disorders may be the cause of hyperprolactinaemia which may lead to amenorrhoea. Hx of hemianopia, headache ,blurring of vision may suggest craniopharyngioma or prolactinoma...On examinations ,her BMI, may give the evidence of PCOS. Signs of andrenalism like hirusutism, acne ,clitoromegaly, may suggest late onset CAH, & PCOS. Galactorrhoea may suggest possibility of prolactinoma though it is not a must sign. Per abdominal examination may confirm pregnancy by measuring uterine height & any fetal parts ,fetal movement & FHS.
Pregnancy test-serum beta hcg or UPT & USG will confirm if any pregnancy is found. FSH,LH,, & prolactine level & USG ovarian picture(necklace pattern) of PCO may help to diagnose PCOs Androstenedione ,testosterone ,SHBG, may help to detect CAH. Serum TSH, free T3,T4 ,may detect thyroid disorders. Serum prolactine level & plaine Xray of skul may suggest about Prolactinoma. X ray chest ,may diagnose pulmonary TB which may be a focus for distance TB like pituitary or endometrium, & X ray skull may give a clue of pituitary adenoma. CT scan & MRI of skull may give evidence of pituitary tumor. Progestogen challenge test may suggest about ovarian failure.If TB is suspected ,Montoux test & serum for culture of acid fast bacilli ,PCR or ELISA test ,may detect tuberculosis. Histerocsopy may help in identifying uterine pathology like ashermans syndrome.
Posted by DARE A.
a). Pregnancy must be excluded in any patient presenting with secondary amenorrhoea. Last menstrual period is suggestive but, diagnosis must be confirmed by urine pregnancy test.
Secondly, recent weight change is significant because a crucial steady weight is a prerequisite for a functioning hypothalamo-pituitory-ovarian axis. Hence, rapid weight loss is helpful.
I will rule out polycystic ovary disease as a course of patient’s symptom. I will expect this patient to have irregular, sparse menstrual loss, acne, abnormal facial hair growth and patient’s weight. About 40% of patient with polycystic ovary disease are found to be obese.
I will consider lactation amenorrhoea as one of my differential diagnosis. This may occur in patient who is breast feeding exclusively. High levels of prolactin being secreted during lactation inhibit gonadotropins release, thereby resulting in hypoestrogenic state.
Secondary amenorrhoea may also be drug-induced. Contraceptive drugs such medroxy progesterone acetate; implanon and intrauterine system are notorious for this.
Furthermore, I will consider surgical causes such as cervical stenosis from recent cone biopsy, Asherman’s syndrome following overzealous uterine curettage and surgical menopause following bilateral salpingo-oophorectomy.
A rare cause of secondary amenorrhoea is premature menopause. It is defined as occurrence of menopause before 40 years.
b. Even though her last menstrual period was seven months ago, her normal pattern may be helpful. This will include regularity, amount and presence of dysmenorrhoea. A sexual history couple with patient’s choice of contraception and how long she has been using it may be helpful. Past gynaecological history will reveal history of cervical conisation for abnormal smears, recent uterine curettage following either a failed or terminated pregnancy. A recent weight loss will be helpful. This may be planned as in strenuous exercise. I will ask about problems with acne, facial hairs and weight gain.
Patient may be on contraception or psychotropic medication for other ailment.
A past surgical history of bilateral oophorectomy may be elicited.
Examination may reveal presence of acne, facial hairs and male pattern hair distribution. I will weigh patient and calculate her body mass index to identify whether she is underweight or overweight. Abdominal examination may reveal presence of scars from previous operation, or masses which may suggest pregnancy. Generally, pelvic examination may be helpful if a mass is palpated on abdominal examination.
c. A urine pregnancy test should be performed first. It is cheap, non-invasive, and easy to perform. Above all, it will prevent many potentially costly and invasive investigations.
A pelvic ultrasound scan may be helpful to exclude polycystic ovary disease. This may show multiple cysts arranged around the periphery of the ovary, increased ovarian volume greater than 12cm3 and, may demonstrate intrauterine pregnancy to the unwary physician!
In a well informed patient, I will request and obtain blood for hormonal profile. These will include follicle-stimulating hormone, luteinising hormone, oestrogen, progesterone, prolactin, and testosterone. A predominantly elevated luteinising hormone in a ratio greater than 2:1, and high testosterone may be suggestive of polycystic ovary disease. A high serum progesterone, hydroxyprogesterone, testosterone, androstenedione, dehydroepiandrosterone and dehydroepiandrosterone sulphate may suggest adult-onset adrenal hyperplasia. It is caused by 21-hydroxylase deficiency in over 90% of patient. A high urine pregnanetriol and its glucuronides will support this diagnosis.
Hysterosalpingography may be requested in a patient with previous uterine curettage to rule out Asherman’s syndrome. It will demonstrate partial or total occlusion on endometrial lining. It is an invasive investigation and may be complicated by pelvic infection. It should only be requested by specialist gynaecologist. Diagnostic hysteroscopy may demonstrate adhesions within the uterine cavity. Treatment may be carried out at the same time in a well informed patient. This may be complicated by infection, bleeding and uterine perforation. Hence, patient must be well informed and consent obtained.

Posted by Nur Sakina K.
From A:
They may be due to non-gynaecological causes such as pregnancy or gynaecological causes such as hypothalamic amenorrhea which could be due to stress or change in BMI. Other gynae causes include uterine scarring (Ashermans syndrome) PCOS, premature ovarian failure, hyperprolactinemia and an androgen secreting ovarian or adrenal tumour.

Fr B:
In the hx, I’d ask details of her menstrual cycle prior to her current amenorrhea. This is to assess what a “normal” menstrual cycle would be for her. Her past obstetrical and gynae hx is taken to exclude any pregnancy complications such as severe PPH, repeated dilatation and curettage, endometritis and pelvic infections. This is to exclude endometrial scarring (Asherman’s syndrome). I’d also like to ask any other associated symptoms with amenorrhea. I’d look for symptoms such as nausea, vomiting, weight gain, abdominal distension and her sexual history: to assess if she is sexually active and the form of contraception she has been using. This is to assess possibility of a pregnancy. Is there any recent stress, weight loss, dietary restrictions or excessive exercise which could suggest hypothalamic amenorrhea. Menopausal symptoms such as hot flushes, night sweats, vaginal dryness should be elicited to exclude premature ovarian failure. I’d also ask about hyperandrogen symptoms such as acne, hirsutism, weight gain which suggests PCOS. An associated deepening of voice with other hyperandrogenism symptoms suggests an adrenal/ovarian secreting tumor. Is there any galactorrhea, visual disturbances, headaches which may suggest hyperprolactinemia. A drug history for any recent initiation or discontinuation of COCP, other androgenic drugs such as danazol or high dose progestin can cause several months of amenorrhea. Dopamine antagonistic drugs such as metoclopromide, antipsychotics can cause hyperprolactinemia. A family history of premature ovarian failure or PCOS should also be assessed.

Examination involves obtaining her weight and height to calculate the BMI. A low BMI (<18.5) suggests hypothalamic amenorrhea. A high BMI(>30) is commonly seen with PCOS. Physical examination will depend on the associated symptoms but includes breast examination for galactorrhea, genital for evidence of hypoestrogenism as in premature ovarian failure, skin for hirsutism, acne, striae, acanthosis suggesting PCOS. A neuro examination should be performed if neuro symptoms such as headache,visual disturbances are present to exclude any pituitary tumour.

Fr C:
Ix involves bloods for hormone profile, a pelvic ultrasound scan and MRI brain.
A serum beta HCG to exclude pregnancy. If negative, serum FSH to exclude hypothalamic amenorrhea and premature ovarian failure. A level >40u/l is suggestive of premature menopause where else a low se FSH, LH, estradiol suggests hypothalamic hypogonadism from GnRH lack. Serum prolactin level to identify hyperprolactinemia. TSH levels should be taken to rule out hypothyroidism, as 5% patients also have hyperprolactinemia with hypothyroidism. In presence of hyperandrogen symptoms/signs DHEAS and testosterone levels taken for PCOS or androgen secreting tumour. A progestin challenge test (MPA 10 mg od PO for 10 days) can be used to induce uterine bleeding. If bleeding present, an outflow tract obstruction can be ruled out. If this is negative, 0.625mg conjugated estradiol PO for 35 days and MPA 10 mg between days 26-35 is used to induce uterine bleeding. If this too is absent, uterine scarring is highly suspicious. Imaging with HSG or direct visualization of uterine cavity with hysteroscope is performed.
A pelvic ultrasound scan identifies a fetus, polycystic ovaries, and ovarian or adrenal tumours. A brain CT/MRI can be considered if serum prolactin is severely elevated (>1000mIU/l) or presence of neurological signs/symptoms to assess prolactinoma or other pituitary tumour.
Posted by Hassan R.
Arround 85% of cases of secondary amenorrhoea(S.A)may be diagnosed from history. Common causes are pregnancy,lactation & anxiety. Polycystic ovarian syndrome ( PCOS) may be asymptomatic & presents as S. A. Contraception eg.Depo. injections,Mirena may lead to secondary amenorrhoea. Weight gain/loss e.g. anorxia norvosa,heavy exercise may be the presentation. Prolactinoma (excessive prolactine production) may lead to S.A. Asherman Syndrome,Cervical stenosis following cone biopsy may be the cause. Sheehan Syndrome (severe postpartom haemorrhage following delivery ) may be the cause. Medications like phenothiazide & narcotics may be the cause.
Primary ovarian failure (history of hot flushes & breast atrophy) is a rare cause of S.A.

b) Symptoms of pregnany & whether she is lactating or not should be obtained. Information about previous deliveries & any complications like postpartom haemorrhadge,previous misscarriages & curittage & cevical cone biobsy should be obtained. Contraception & medications should be obtained.
Signs of androgin excess like excessive hair grwth, clitormegally. Galactorrhoae may be seen on examination.Signs of oestrogen deficiency may be seen. B.M.I gives the information about weight gain/loss.
c) Investigations are directed by findings from history & examination. Pregnancy test to rule out pregnancy first.Follcle Stimulating Hormone(F.S.H) Lutinizing Hormone(L.H.)Prolactine , Oestradiol levels for integrity of pitutary/ovarian axis & rule out prolactinoma.
Pelvic ultrasoud scan to rule out PCOS.
Posted by SA M.
(a) Absence of menstruation for more than 6 months in a woman with normal menstruation previously is regarded as secondary amenorrhea. Physiological causes of secondary amenorrhea are pregnancy and lactation. Pathological causes are related to hypothalamic pituitary ovarian axis and includes adrenal and uterine pathology. Hypothalamic causes includes excessive weight loss, excessive exercise, severe stress and anorexia nervosa. Pituitary causes include hyperprolactinemia, thryoid dysfunction and hypopituitarism such as Sheehan\'s syndrome. Ovarian causes are polycystic ovarian syndrome which is the most common cause of secondary amenorrhea (35%).
Premature ovarian failure is also a very important cause (25%). It may be due to autoimmune mechanism, idiopathic, iatrogenic due to chemoradiotherapy. It also may be due to mosaicism in Turner\'s syndrome and in galactosemia.
Secondary amenorrhea may also be due to uterine causes such as Asherman\'s syndrome, it may be due to contraception such as Marina IUCD and depot medroxyprogesterone acetate.
Adult onset congenital adrenal hyperplasia, adrenal and ovarian androgen secreting tumors are uncommon causes of secondary amenorrhea.

(b) I would like to ask her if she has done a pregnancy test or if she is lactating, any history of hirsutism, weight gain/loss and galactorrhea. Any of history of hot flashes, night sweats and vaginal dryness and dyspareunia (Menopausal symptoms) will also be sought. Has she noticed any signs of virilization such as reduction in breast size, change in voice, frontal baldness as they point towards hyperandrogenemia.
Detailed menstrual history is important including menarche, flow and whether she is getting periods spontaneously or is it a withdrawal bleeding. Her LMP should be recorded.
Her previous obstetric history including parity, mode of deliveries, history of PPH, age of last child is important to us. Contraception history including use of Merana, IUCD and DPMA should be sought. Any plans for pregnancy in the future should also be asked. The family history is important in view of early menopause in family members,ovarian cancer is important. The result of her recent cervical smear should be asked.
On examination, her BMI, bp and general physical examination is important. If any hirsutism is there, it should be recorded, signs of hyperinsulinemia and acanthosis nigrans should be seen. Signs of virilization should be looked for. Abdominal palpation for distension and to find out any pregnancy should also be done. Any massess should also be seen on abdominal examination. Vaginal examination is to be done to exclude vaginal atrophy, dryness, cervical stenosis, adnexal masses and uterine size.

(c) Investigation include pregnancy test, serum gonadotropins should be done to differentiate between hypo- and hypergonadotropism. Moderately elevated gonadotropins may indicate PCOS but they are excessively high in premature ovarian failure. Serum prolactin levels should be done to rule out hyperprolactinemia. Thyroid function tests should be done. Anti thyroid antibodies can be considered in case of premature ovarian failure. Free testosterone, SHBG, pelvic ultrasound to exclude PCO. DHEA, DHEAS raised in adrenal causes of hyperandrogenism. 17 OH progesterone level will be increased in late onset CAH. Karyotyping can be done in case of suspicion in Turner Syndrome. MRI of brain can be done incases of hyperprolactinemia. CT/MRI of abdomen if suspicion of androgen secreting tumor. If suspicion of Asherman syndrome, hystersocopy should be advised.
Posted by A R.
AR

Amenorrhoea in a healthy woman with previous normal menstrual cycles could be due to many reasons.


1. First and foremost she could be pregnant, or may be having a trophoblastic disease. These conditions can be diagnosed with a urine or serum hCG level and confirmed with an ultrasound examination. In trophoblastic diseases the exceptionally high levels of hCG can be found in the blood. She may be lactating after a childbirth which may be the reason for the amenorrhoea.

It could be due to a disorder of the hypothalamo pituitary axis, like tumours, prolactinemia, steroid intake, presence of stress, following radiation or chemotherapy. These conditions can be diagnosed with a hormore profile where the gonadotrophin releasing hormone level will be lower than normal. Also in women who are on the hormonal contraceptives a similar picture can be seen.

Anovulation is another cause of amenorrhoea in women. Any condition leading to extreme weight gain or weight loss can cause amenorrhoea. for example, in athletes and in anorexia nervosa this can be observed. Another common condition with anovulation is poly cystic ovary syndrome, where there is absence of ovulation leading to amenorrhoea which is generally followed by heavy bleeding due to the endometrial hyperplasia. This has the increased risk of leading to endometrial cancer too. Progesterone treatment is the treatment of choice. The other most important condition is premature ovarian failure and one of the syndromes associated with it Turner\'s syndrome.

Prolactinoma and hypothyroidism are two other conditions that lead to amenorrhoea.

If there had been any surgical procedures in the uterus like dilatation and curettage, there can be a condition called Ashermann\'s syndrome in the woman where all the endometrium is absent leading to amenorrhoea. If there is a history of endometrial ablation then again the absence of adequate endometrium would cause amenorrhoea. If there was a history of post partum shock which may have led to avascular pituitary necrosis, its known as Sheehan\'s syndrome.


2. For diagnosis, additionally I would ask about signs and symptoms of pregnancy and look for them in general examination. I would also ask about any previous pregnancies that were followed by continuous bleeding or abdominal pain to exclude a gestational trophoblastic disease, and this can confirmed with an Ultrasound and serum hCG levels. Also I would like to know if she is lactating which can lead to lactational amenorrhoea. If she is lactating but not after a childbirth, I would like to check her visual fields to exclude a prolactinoma causing amenorrhoea. A history of exposure to radiation or to chemotherapy will rule out amenorrhoea due to these causes.
Inquiring about the medication she is on would give a clue about the amenorrhoea is due a drug related cause like contraceptive usage. I would like also to check with her if she had any drastic weight gain or loss in the recent past or if she had any symptoms of anorexia nervosa. She will be questioned about signs and symptoms of menopause like hot flashes and mood swings, to rule out premature ovarian failure. I would also look for signs and symptoms of poly cystic ovarian disease, like history of infertility, hirsutism, acne etc.
I would ask her about any uterine surgeries like endometrial ablation or curettage which could be the reason for the amenorhoea called Ashermann\'s syndrome which is actually due to intra-uterine adhesions. I would like also to know if she had any problems like shock post partum her previous pregnancy which could have led to Sheehan\'s syndrome, which is avascular necrosis of the pituitary.

Hypothyroidism is another known cause of amenorrhoea, which can be excluded by looking for signs and symptoms like weight gain, lethargy, cold intolerance etc.

Also rule out conditions like Turner\'s syndrome which is due to ovarian failure and conditions like adrenal hyperplasia which leads to virilization of the female.


3. The investigation I would order are blood tests like, Full blood count and blood smear to exclude anaemia, urine and serum hCG levels and an ultrasound examination to exclude pregnancy and trophoblastic diseases. Serum prolactin levels with a pituitary CT would help diagnose a prolactinoma. Serum levels of the following hormones, FSH, LH, Oestradiol, Testosterone, DHEAS to rule a androgen excess or hypogonadism. Thyroid function tests to exclude hypothyroidism. Low levels of all the pituitary hormones confirm diagnosis of Sheehan\'s syndrome...needs replacement of all the pituitary hormones.

Hysteroscopy and adhesiolysis followed by placement of an intra uterine device to prevent recurrence and hormone therapy is the diagnosis and treatment for Ashermann\'s syndrome.

Karyotyping to exclude conditions like Turners syndrome.
Posted by A A.
Part A
It includes physiological causes like pregnancy and lactation. Hypothalamic causes like recent weight loss, eating disorders and excessive exercise will lead to hypogonadotrophic amenorrhoea. Pituitary causes like prolactimon by secreting high prolectin leading to secondary suppression of gonadotrophins. Rarely Sheehan’s syndrome (acute infarction, necrosis of pituitary due to severe haemorrhage leading to amenorrhoea) and compression of pituitary stalk by tumour. Metabolic causes like PCOS cause amenorrhoea by anovulation. Amenorrhoea might be drug induced like use of DMPA and DOPAMINE antagonist. Chromosomal abnormalities like Turner’s Syndrome (premature ovarian failure) and genetic causes like late onset CAH can lead to amenorrhoea. Premature ovarian failure can be caused by autoimmune conditions, thereby amenorrhoea. Ovarian/ adrenal androgen secreting tumours by causing hyperandrogenemia may lead to amenorrhoea. Endocrine abnormalities like thyroid dysfunction and cushing disease can cause it.
Part B
A detailed history regarding her age of menarche, previous menstrual history, regularity of cycle, length of cycle and duration of bleeding and amount of bleeding should be asked. Whether these were spontaneous bleeding or hormonally induced. Contraceptive history like use of DMPA can cause it. History of unprotected intercourse and possibility of pregnancy should also be ruled out by asking symptoms like nausea, vomiting and fetal movements if in mid trimester. Previous obstetric history regarding termination of pregnancy or miscarriages leading to curettage may be suggestive of asherman’s syndrome or cervical stenosis. History for severe PPh may suggest Sheehan syndrome due to pituitary infarction.History of strenuous exercise, recent weight loss (10% to 15%), eating disorders may suggest hypothalamic causes with impaired gonadotrophic secretion. History of headache, visual field changes and glactorrhoea will be suggestive of pituitary causes like prolactinoma. History of hirsuitism, acne and weight gain will point towards PCOS and H/o sudden onset of hirsuitism, deepening of voice and clitoromegaly may suggest adrenal / ovarian tumours or late onset CAH. History of hot flushes and vaginal dryness may suggest premature ovarian failure. Family history of Congenital Adrenal Hyperplasia, chromosomal disorders like Turner’s syndrome and premature ovarian failure (autoimmune conditions may run in family) should be taken. In examination check for BMI (< 19 BMI will point hypothalamic cause. Acne, Hirsuitism and increased BMI will point towards PCOS. visual field defects (bitemporal hemianopia) and expression of breast milk will point towards Hyperprolectinemia.
Presence of breast atrophy, muscular hypertrophyand clitomegaly is suggestive of Ovarian and Adrenal tumour. Moonface, truncal obesity and skin’s striaes,hypertension maybe suggestive of cushing disease. Abdominal examination should be done for ovarian/adrenal masses. Local pelvic examination may show vaginal dryness in premature ovarian failure or cervical stenosis and examination of adnexas may show enlarged ovaries in ovarian tumour.
Part C,
In majority of the cases causes of secondary amenorrhoea can be found out by history and examination. A pregnancy test is important to rule out pregnancy.FSH,LH ,prolactin levels and testosterone should be done.High FSH and LH may suggest premature ovarian failure and should be confirmed by repeat testing.karyotyping may be offered to confirmTurner syndrome.Low FSH and LH may suggest hypopituitarism.A prolactine level of 1500-4000 may suggest pituitary adenoma andrequire further investigation like CTscan/MRI of brain.For polycystic ovariesUSGpelvis and serum testosterone,DHEA,DHEAS,SHBGand free androgen index may be mildly elevated.High DHEAS levels > 20mmol/l may suggest adrenal androgen secreting tumour and increased testosterone level > 7 nmol/l is suggestive of ovarian androgen secreting tumour therefore these women may require CT Scan / MRI of abdomen/pelvis to rule out these tumours.For late onset CAH serum 17-OH progesterone should be done and if markedly elevated ACTH stimulation test should be done to confirm it.If sign and symptoms are suggestive of Cushing disease 24hrs urinary steroid should be done and if markedly elevated Dexamethasone suppression test needs to be done.A positive test will confirm it.
Posted by Johnson  O.
Pregnancy would be a differential in a woman with previous norma menstrual cycle and healthy. Premature ovarian failure due to genetic factor like mosaic Turner syndrome, inherited or idiopathic. If she is athletic engaging in strenous exercise. Anorexia nervsoa. Contraception like depot medroxyprogestereone or mirena coil can cause amenorrhea. Polycystic ovarian disease. Other differential include Asherman syndrome where endometrial lining is close due to excessive curreting. sheehan syndrome due to previous post partum haemorrhage.
B/
Symptoms of hot flushes and night sweating to exclude premature ovarian failure. What she is using for contraception and compliance. I would ask if she thinks it may be pregnancy.
Any psychological disturbance at home or place of work. It is important to know if she is on medications psychotic drugs. Obstetric history, any children mode of delivery and any complication like postpartum haemorrhage. I would ask for any gyneacological treatment like LLetz, Dilatation and curretage.
Examination would include weight, height and her BMI. Abdominal examination for any palpable mass like pregnancy.
C/
Urine pregnancy test to exclude preganancy
FSH, LH and Oestradiol level to exclude premature ovarian failure.
Prolactin level if hyperprolactinaemia is suspected.
Skull-X-ray, CT scan or MRI of the skull for sella turcica.
Pelvic ultrasound scan looking for polycystic ovaries.
Hysterosalphingogram if Asherman syndrome is suspected.
Posted by ELIZA SHIREEN E.
a)
This is a case of secondary amenorrohoea if she has history of unprotected coitus.If this woman use injectable contraceptives Depo-medroxyprogesterone acetate 150mg ,it can cause amenorrhoea (30% after 1st dose, 55% after 4th dose).If she exercise or dieting vigorously .these subpress hypothalamus inhibit ovulation and prouduce amenorrhoea. History of vigorous curettage prior to this amenorrhoea indicates amenorrhoea due to asherman syndrome. Premature ovarian failure may be a cause .In this case she may felt hot flush orother menopausal symptom or family history .Sometimes subclinical thyroid disorder presents with secondary amenorrhea.
b)
I would enquire about her menstrual cycle such as the last menstrual period, cycle length, blood flow.
History of symptoms of pregnancy ,feeling of fetal movement should be asked .
The obstetric history should include parity, mode of delivery,any recent history of miscarriage, uterine curratage and if she is currently breast feeding .
Details about her contraception COCP or injection DMPA ,duration of use.
Is she an athlet, or a member of rowing team.History of vigorous exercise or severe dieting should be asked.
Family history of premature ovarian failure ,PCOS should also be enquired.
Has she any previous history of meningitis or head injury?
Clinical examination includes pulse for tachycardia body weight,low BMI,presence of acne, hirsuitism.
Thyroid gland( for goiter ,any bruit), ,jerk,tremor , presence of any discharge from breast should be examined.
A careful abdominal examination should be done to look for enlarged uterus.
c)
I will ask for investigation like urine for pregnancy test to exclude pregnancy.
Ultrasound scan to look for pregnancy, poly cystic ovary.
If pregnancy test negative the progesterone challenge test – 10mg oral medroxyprogesterone acetate for 5 days is to be done. If a withdrawal bleed is induced then a diagnosis of anovulation.It is either due to PCOS or due to stress , exercise, weight loss or hypothalamic-pituitary dysfunction .
Negative progesterone challenge test –indicates lack of oestrogen stimulation to endometrium .This may be due to premature ovarian failure.
Base-line serum prolactin, thyroid function tests and gonadotrophin levels isto be done.FSH level around 40 mliu/ml means premature ovarian failure,LH,FSH ratio 3;1 or more suggests PCOS.
Karyotyp to find out mosaic turner.

Posted by ELIZA SHIREEN E.
a)
This is a case of secondary amenorrohoea.Previously she is a normaly menstruating woman.Therefore the first think is that she is pregnant if she has history of unprotected coitus.If this woman use injectable contraceptives Depo-medroxyprogesterone acetat ,it can cause amenorrhoea (30% after 1st dose, 55% after 4th dose).If she exercise or dieting vigorously .these can suppress hypothalamus inhibit ovulation and prouduce amenorrhoea. History of vigorous curettage prior to this amenorrhoea indicates amenorrhoea due to asherman syndrome. Premature ovarian failure may be a cause .In this case she may felt hot flush orother menopausal symptom or family history .Sometimes subclinical thyroid disorder or hyperprolactenaemia presents with secondary amenorrhea.
b)
I would enquire about her menstrual cycle such as the last menstrual period, cycle length, blood flow.
History of symptoms of pregnancy ,feeling of fetal movement should be asked .
The obstetric history should include parity, mode of delivery,any recent history of miscarriage, uterine curratage and if she is currently breast feeding .
Details about her contraception COCP or injection DMPA ,duration of use.
Is she an athlet, or a member of rowing team.History of vigorous exercise or severe dieting should be asked.
Family history of premature ovarian failure ,PCOS should also be enquired.
Has she any previous history of meningitis or head injury?
Clinical examination includes pulse for tachycardia body weight,low BMI,presence of acne, hirsuitism.
Thyroid gland( for goiter ,any bruit), ,jerk,tremor , presence of any discharge from breast should be examined.
A careful abdominal examination should be done to look for enlarged uterus.
c)
I will ask for investigation like urine for pregnancy test to exclude pregnancy.
Ultrasound scan to look for pregnancy, poly cystic ovary.
If pregnancy test negative the progesterone challenge test – 10mg oral medroxyprogesterone acetate for 5 days is to be done. If a withdrawal bleed is induced then a diagnosis of anovulation.It is either due to PCOS or due to stress , exercise, weight loss or hypothalamic-pituitary dysfunction .
Negative progesterone challenge test –indicates lack of oestrogen stimulation to endometrium .This may be due to premature ovarian failure.
Base-line serum prolactin, thyroid function tests and gonadotrophin levels isto be done.FSH level around 40 mliu/ml means premature ovarian failure,LH,FSH ratio 3;1 or more suggests PCOS.
Karyotyp to find out mosaic turner.

Posted by Manoj M.

(a) Physicological causes like undiagnosed pregnancy and lactational amenorrhoea with continued lactation.
Hypothalamic causes like excess weight gain (or) weight loss or tumors of brain like craniopharngioma but unlikely with out other neurological symptoms.
Pituitary causes like prolactinoma like microprolactinoma may not have any pressure effects and without other neurological symptoms
pituitary ovarian axis like polycystic ovarian syndrome.
ovarian causes like resistant ovarian syndrome or premature ovarian failure.
uterine causes like ashermann syndrome with previous uterine currettings or cervical stenosis with previous cervical trauma
Undiagnosed pelvic tuberculosis may also cause uterine synechiae and amenorrhoea
Drug induced causes like depot medoxyprogesterone acetate or levorgesterol intrauterine devises for contraception can cause amenorrhoea.
endocrine causes like thyroid disease, cushings syndrome or late onset congenital adrenal hyperplasia are other possibilities

(b) History of recent pregnancy and breatfeeding to exclude lactational amenorhoea, history of pregnancy and likelyhood should be excluded with a urine pregnancy test.
History of significant weight gain or loss e.g. h/o excessive exercise.
History of stress may suggest cause for hyperprolactinaemia induced amenorrhoea. H/o headache may suggest neurological causes like macroprolactinoma and may be associated with visual field defects like bitemporal hemianopia.
H/O hirsutism, hair loss may suggest PCOS or androgen secreting tumors(rapid onset)
h/o of current contraception to exclude causes with DMPA/ Mirena.
Past h/o uterine/cervical procedures may suggest ashermanns syndrome with uterine synechiae and / cervical trauma.
Examination findings with raised BP with striae/ moonface etc. may suggest cushingoid features. BMI to assess weight gain or loss.
speculum examination to exclude cervical abnormalities
abdomino-pelvic palpation may suggest ovarian or adrenal tumours.
visual field examination as directed by history to exclude optic chiasma compression causing bitemporal hemianopia.

(c)Urine pregnancy test to exclude pregnancy.
Blood investigation for thyroid function test (with history of thyroid disease) and prolactin test to exclude any throid diseases and hyperprolactinaemia.
Testosterone levels , if raised above 5 then exclude androgen secreting tumours.
SHBG along with testosterone with calculated raised free androgen index will help diagnose PCOS.
MRI/ CT of brain if clinical assessment suggestive of brain tumours.
Pelvic and abdominal ultrasound and or CT abdomen and pelvis if clinical assessment suggestive or adrenal or ovarian tumours.
Pelvic ultrasound may also suggest ultrasound features of polycystic ovaries to aid diagnosis.
Hysteroscopy if assessment suggestive of uterine synechaie to confirm diagnosis and treat the same.
Laparoscopy may aid confirmation of pelvic infection with microbiological confirmation e.g. tuberculosis of pelvic organs
Posted by Shabana H.
A)Differential diagnosis can be pregnancy if sign symptom presented with morning sickness, lactitional amenorrhooea if history of lactation,can be poly cystic ovary if presented with acne ,hirsutism &baldness.hyperprolactinaemia if there is milky discharge from nipple,anorexia nervosa if present with eating disorder,hypothyroidism if patient has weight gain,lethergy,cold intolerence.premature ovarian failure if presented with menopausal like symptom.it can be due to use of contraception like long acting medroxy progesterone acetate&LNG-system.It can be asherman syndrom if history of vigorous curettage.B)History-of morning sickness,nausea, vomiting&feeling of unwell&tierdness sugest pregnancy,history of child birth&lactation sugest lactionan amenorrhoea.use of contraception like medroxy progesterone&LNG-system.history of oligomenorrhoea,sub fertility&use of fertility induction drug previously sugest poly cystic ovary.galactorrhoea,headach,visual disturbance sugest hyper prolactinaemia.history of weigt gain,cold intolerence,lethergy can be hypothyroidism.history of radiotherapy&chemotherapy can cause premature ovarian failure&presentedwith menopausal symptom.history of vigorous curettae sugest asherman syndrom,history of postpertum haemorrhage sugest sheehan syndrome.Examination-Height,weight,body mass index(BMI) if low BMI suggestive of anorexia nervosa or excessive exercise related amenorrhoea.presence of high bp sugest cushing synrome,acne,hirsutism&balding sugest polycystic ovary.visual field defect&galactorrhoea is hyperprolactinaemia.per abdomen exam -palpable abdominal mass sugest pregnancy,per vaginal on ins pection vaginal dryness sugest estrogen deficiency it can be for POF,hyperprolactinaemia.C)Investigation-pregnancy test to confirm pregnancy,hormonal analysis for FSH,LH&estrogen if FSH high&low estrogen it can be POF.Thyroid function test-decrease free t3&t4&increase TSHsugest hypothyroidism.USG-to dx PCO&pregnancy,MRI&CT scan to confirm pituitary micro¯o adenoma.HSG&Hysteroscopy to dx Asherman syn drome.
Posted by Albert A.
A healthy 30 year old woman with previously normal menstrual cycles has been referred to the gynaecology clinic because she has not had any menstrual periods for 7 months. (a) Discuss the differential diagnoses [5 marks]. (b) Discuss what additional information from the history and examination is helpful in establishing a diagnosis [9 marks]. (c) Justify which further investigations you would perform to establish the diagnosis [6 marks].

(a) The main differential diagnoses for amenorrhea in this patient will include Pregnancy, Polycystic Ovarian Syndrome (PCOS), which is common in this age group, and Premature Menopause.
Other causes to consider will be - Post Pill (oral contraceptives) or less likely the Depot Provera injection, which is associated with amenorrhea during its use, as well as afterwards.
Stress, Anxiety and extreme weight loss/exercise
Obesity induced amenorrhea
Hyperprolactinaemia from a pituitary adenoma or drug induced, with suppression of gonadotrophins and gonadotrophin releasing hormones.
Rare causes like a testosterone secreting tumour should be thought of.
As this patient has been healthy, causes from chronic illness, other endocrine diseases and iatrogenic ovarian failure are unlikely.

(b) History would include her menarche, as late menarche is associated with premature menopause, parity and any prior subfertility, which would point towards PCOS; as would a history of acne, male pattern hirsutism.
Her medical and surgical history for any possible causes of iatrogenic ovarian failure, as well as her contraceptive and other drug history should be noted. Galactorrhea, headaches and visual disturbances would point towards a pituitary adenoma.
A family history of premature menopause should be noted.
Clinical examination would include her body mass index and observation of any hirsutism, abdominal and pelvic examination for any palpable adnexal masses.
Features of other endocrine conditions should be noted, if present eg thyroid eye signs, goitre, cushinoid features etc.

(c) Investigations would include a urine pregnancy test to exclude pregnancy, a pelvic ultrasound to diagnose polycystic ovaries and other adnexal masses. This should be preferably transvaginal as it is associated with a higher sensitivity for ovarian pathology, especially in obese patients.
Blood tests for serum gonadotrophins- LH, FSH, testosterone and a sex hormone binding globulin would be adjuncts to diagnosing polycystic ovarian syndrome according to the Rotterdam Criteria.
A high FSH (>30iu/ml), would indicate premature ovarian failure, though this needs to be repeated after six months for confirmation.
Further investigation would be based on clinical suspicion with serum prolactin, thyroid function tests, MRI for pituitary masses and a CT scan for adrenal causes.
Posted by Ron C.
RnRn

A.
Uterine causes are rare; Asherman syndrome following curettage may lead to amenorrhea. Most common ovarian cause is polycystic ovary syndrome (PCOS), causing amenrrhea through anovulation. Another ovarian cause is premature menopause. On pituitary-hypothalamus level causes include adenoma (most commonly prolactinoma), hypothyroidism, post-pill amenorrhea, weight changes to extremes of both ends or physical exercise. Rare is Sheenan-syndrome causing pan hypopituarism after severe haemorrhage. Late onset CTH is possible. Iatrogenic through medication is possible.

B.
History and examination are aimed at identifying possible causes. Detailed cycle history including menarche and use of contraception, in particular COCP. Family history including premature menopause and menopausal symptoms. Previous infertility treatment, pregnancies, deliveries – in particular severe post-partum haemorrhage – miscarriages and uterine instrumentation are asked for. I’ll enquire regarding weight changes, exercise, voice change or hirsutism, symptoms of hypothyroidism (fatigue, constipation, hair loss, cold), and presence of visual symptoms. Use of any medication, presence of medical problems such as auto-immune disease, previous chemotherapy or abdominal radiotherapy.
On examination I’ll assess blood pressure & pulse rate, weight & height for BMI, visual field testing, overall inspection for body habitus (obesity, underweight), distribution of hair-pattern (hirsutism), breast assessment for galactorrhea. I’ll examine the abdomen for palpable masses. Speculum examination to assess cervix, vaginal examination to identify pelvic mass.

C.
Baseline investigations include bloods; LH-FSH, as raised in ovaraian causes like premature menopause and LH:FSH ration increased in PCOS. Free testosterone; increased in PCOS, late onset AC. For the latter also 17-alfa-hydroxyprogesterone. TSH & fT4 to identify thyroid disorders and prolactine for prolactinoma. If a pituitary adenoma is suspected, CT brain can be considered, which is also helpful in suspected Sheenan syndrome. Ultrasound examination; may show PCOS-like ovaries, can identify normal anatomy uterus, haematometra, any pelvic mass. If Asherman syndrome is suspected, hysteroscopy can be considered. In premature ovaraian failure, karyotyping can be considered (eg X0-mosaicism), though <10% of premature ovaraian failure caused by abnormal karyotype.
Posted by Ron C.
sorry, CTH in A. should be CAH, as in section C where I accidentally typed late onset AC instead of CAH
Posted by PAUL A.
a) The differential diagnosis in this lady could be pregnancy,lactational amenorrhoea,ashermann\'s syndrome due to surgical curettage of the uterus or secondary to infections like tuberculosis or schistosomiasis,hyperprolactinemia due to polycystic ovarian disease or pituitary adenomas,hypogonadotrophic hypogonadism due to anorexia nervosa or excessive exercise(gymnastics,swimming,etc),premature ovarian failure due to chemoradiotherapy for malignancy,turner\'s syndrome or infections like mumps oophoritis this is a list, not a discussion .
b)it is essential to begin by eliciting details of her past manstrual cycles-whether delayed previously also to suggest a possible cause like polycystic ovarian syndrome.Also any childbirth and lactation sjould be enquired into ? significance .Also contraceptive history should be sought-any unprotected intercourse or irregular contraceptive usage would suggest a possible ongoing pregnancy (1) .Any history of mumps recently or malignancies for which chemoradiotherapy was taken or recent curettage of the uterus should be taken to rule out possible premature ovarian failure ? menopausal symptoms and ashermann\'s syndrome.features suggestive of hypothyroidism like slurred speech,slow mentation what is this? ,weight gain lethargy etc no marks for this should be asked for.Detailed dietary history should be noted to rule out anorexia nervosa (1) .On examination,features like hirsuitism,truncal obesity BMI would be suggestive of polycyctic ovarian disease while periorbital odema,slow mentation and slurred speech would suggest hypothyroidism as a possible cause.Any nipple discharge which is milky should prompt investigations for hyperprolactinemia and history of regular headaches should prompt a visual field examination (1) as also serum prolactin.Any features of proximal muscle wasting,breast tissue atrophy,loss of buccal fat are suggestive of starvation and anorexia.
c)A urine for pregnancy test (1) to begin with to rule out a pregnancy is a must followed by other invstigations like pelvic ultrasound to see for polycystic ovaries, endometrial hyperplasia is this a criterion for the diagnosis of PCOS?? which would point to the diagnosis of polycystic ovarian syndrome.also if endometrium is atrophic and irregular it could be ashermann\'s syndrome and could be confirmed by hysteroscopy.Hormonal profile like serum FSH,LH,estrogen would be essential to confirm premature ovarian failure what will you expect FSH / LH to be? High or low? .anorexia nervosa and polycysitc ovarian disease are FSH / LH useful in the diagnosis of PCOS? although two serial values two weeks apart would be definitive why? Why would you do any endocrine test involving the hypothalamic-pituitary-ovarian axis 2 weeks apart? (-1) .Thyroid profile is necessary if features are suggestive of hypothyroidsm.

Your level of factual knowledge needs to be improved
Posted by PAUL A.
(A)Causes of secondary amenorrhoea could be physiological due to pregnancy and lactation (1) or pathological due to many causes.There could be hypothalamic causes (1) due to anorexia nervosa,stress,bulimia or strenous exercises. and hyper prolactinemia which could be due to pitutary adenoma,drugs like phenothiazines,antiemetics and methyledopa.Drugs like steroids,danazol ,antihypertensives may induce amenorrhoea.Contraceptives such as depots and mirena may also cause amenorrhoea. Polycystic disease ? polycystic what? is a recognised cause of menstrual irregularities.Ashermans syndrome due to vigorous curettage,hysteroscopic surgery or intrauterine infection like tuberculosis may cause amenorrhoea.Rarely thyroid dysfunction,cushing,late onset congenital adrenal hyperplasia.ovarian and adrenal tumours are caustive factors.Secondary amenorrhoea could be due to premature ovarian failure (1) due to genetic, autoimmune or iatrogenic cause like BSO,cheme and radiotherapy.(B) A history of previous regular menstrual cycle followed by amenorrho ea with morning sickness may be due to pregnancy. Informations should be obtained about weight loss,anorexia nervosa,any stressful life events and strenous exercise may indicate hopthalamic cause (1) .Headache ,visual disturbances,milky discharge frim breasts suggests pitutary adenoma (1) ,however galactorroea could be drug induced which should be inquired about.Patient should be asked about previous intra uterine procedures like TOP, and hysteroscopic procedures.History of chronic cough,fever and infertility suggests tuberculosis.Acne ,baldness,hirsuitism indicates hyperandrogenemia which could be due to polycystic ovarian disease (1) ,ovarian or adrenal tumours .If there is associated virilisation witch could be due to androgen secreting tumours,CAH or abnormal karyatype.A general physical examination should be carried out including height, weight BMI ,facial appearance of cushionoid type,acne and hirsutism.Neck examination for acanthosis nigricans.This finding along with acne and hirsutism indicate PCOD (1) ,However a rapidly grown hirsutism indicates ovarian or adrenal tumour.Thyroid should be palpated for enlargement.Abdominal examination should be carried out for any adrenal or ovarian tumours.A pelvic examination for hypoestrogenism and clitromegaly and bimanual examination for ovarian tumours should be performed (1) .(C)A urine pregnancy test should be performed to exclude pregnancy (1) . Serum hormonal profile should be perfomed including FSH,LH,estradiol,SHBG, androstenendion for PCOD,prolactin and TFT tsh and free t4 for hyperprolactinemia and thyroid dysfunction what is the value of FSH, LH or oestradiol in the diagnosis of PCOS? .High levels of testosterone and DHEAS indicate ovarian and adrenal tumours respectively.If CAH is suspected 17 hydroxy progesterone need to be done (1) .For pitutary adenomas XR,CT orMRI is advised.If asherman syndrome is suspected then a diagnostic and therapeutic Hysteroscopy is advised.For suspected Tuberculosis XR chest, tuberculin test,hystero-salpingo-graphy and sputum for AFB is advised.If signs of virilisation are found karyotype is indicated. HOW WOULD YOU DIAGNOSE PREMATURE OVARIAN FAILURE, PCOS (SCAN FOR POLYCYSTIC OVARIES)?
Posted by PAUL A.
(a) Secondary amenorrhoea in her case can be due to pregnancy (1) . It can also be due to causes of hypothalamic pituitary axis failure eg over-dieting, anorexia, stress, over-exercising (1) , undiagnosed brain tumour (eg prolactinoma), recent surgery to brain. It can also be due to premature ovarian failure due to eg resistant ovarian syndrome, autoimmune disease (1) . It can be due to iatrogenic causes eg drug-induced eg Depo provera usage, GnRH analogue or surgery to cervix or uterus (ashermanns syndrome). It can also be due to hyperprolactinaemia secondary to eg prolactinoma or drug-induced eg anti-pschotic Rx. It can also be due to PCOS this is the most likely cause yet you present it as part of a list including extremely rare causes!! , Sheehan syndrome & idiopathic .


(b) You will probably start by taking a detailed menstrual history I will also ask if she is dieting, over-exercise (1) , under lots of stress, depressed or anorexic. I will ask her if she has any menopausal symptoms (1) such as vaginal dryness, hot flushes & night sweats. I will ask her if she has any symptoms of increasing mammary discharge (1) , headaches, visual disturbances which might suggest prolactinoma. I will ask about what history of gynae surgery - ERPC, BSO, hysterectomy, endometrial ablation or history of massive PPH. I will also ask if she is taking any drug - prescribed & illegal which may cause amenorrhoea eg Depo provera, anti-psychotics or heroin. you cannot complete your history without detailed menstrual, sexual or contraceptive history

On examination i will check for her height & weight & BMI ? hirsutism and look for goitre . I will examine her abdomen to exclude any pelvic mass (which might suggest pregnancy) (1) , speculum to exclude any stenosed cervix. I will check for goitre if history suggests any thyroid disease. I will inspect her breast if to exclude galactorrhoea.

(c) I will arrange urine & serum pregnancy test (1) as she might not know that she is pregnant. I will take bloods for FSH, LH & estradiol (E2). Raised FSH & LH with reduced estradiol means that premature ovarian failure (1) is the likely cause. On the other hand, reduced FSH, LH & E2 will mean hypothalamic- pituitary axis failure is the cause.
She will also need to have serum prolactin. Raised prolactin with symtoms of visual disturbances & headache will warrant a CT/ MRI brain to exclude pituitary tumour or prolactinoma (1) . She will also need to have pelvic USS to confirm the presence of ovaries & uterus why should you suspect they will be absent? . In addition, polycystic ovaries 1 in 4 women have polycystic ovaries – how do you diagnose PCOS as opposed to PCO?? might show up on scan with normal FSH/ LH & E2 level.
Posted by PAUL A.
A healthy 30 year old woman with previously normal menstrual cycles has been referred to the gynaecology clinic because she has not had any menstrual periods for 7 months. (a) Discuss the differential diagnoses [5 marks]. (b) Discuss what additional information from the history and examination is helpful in establishing a diagnosis [9 marks]. (c) Justify which further investigations you would perform to establish the diagnosis [6 marks].

(A) Differential diagnoses includes pregnancy, polycystic ovarian syndrome (PCOS), hyperprolactinaemia, excessive weight loss or exercise, undiagnosed hypothyroidism and drug-induced amenorrhoea (such as certain hormonal contraception - depoprovera, implanon, Mirena-coil). Premature ovarian failure (POF), hormone secreting tumours (androgen or prolactin forexample) and late onset congenital adrenal hyperplasia (CAH) are other less common causes of secondary amenorrhoea. you were not asked to list

(B) you will start with a detailed menstrual history – age at menarche, previous cycles… Associated symptoms such as signs and symptoms of virilism (for example increase in facial hair, acne, greasy skin these are not signs / symptoms of virilisation or deeper voice) might suggest PCOS you do not get virilisation in PCOS or rarely androgen secreting tumours or even late onset CAH. A history of increasing abdominal swelling may suggest a concealed pregnancy or tumour growth. SHe should also be asked about recent weight loss or increase in exercise (1) . Targeted questions on hot flushes, night sweats (1) or changes in mood may point to POF. Galactorrhoea or visual disturbances may suggest prolactinoma (1) . Drug history should also include recent changes in contraception, as depoprovera injections, implanon or levonorgestrel intrauterine system (Mirena coil) can cause amenorrhoea.
Examination should include a general assessment of the patient, such as body mass index (BMI) - low BMI could point to anorexia, high BMI may make the diagnosis of PCOS more likely). Signs of virilism on general examination such as increased male pattern hair growth or deeper voice may suggest PCOS if you have made a diagnosis of PCOS in a woman with virilisation, you should recall her as a matter of urgency (-1) , CAH or androgen secreting tumour. Abdominal mass on examination may help in diagnosing a pregnancy (especially if fetal movements are felt) or pelvic tumour (1) . pelvic examination should include looking for cliteromegaly (increased androgen) and vaginal atrophy (sign of hypoeostrogenism secondary to POF).

(C) First of all, a pregnancy test should be done to exclude a pregnancy (1) . If she is not pregnant, blood tests such as random follicle stimulating hormone (FSH) and luteinising hormone (LH) may help identify PCOS (where LH:FSH ratio is > 3) this is NO LONGER a criterion for the diagnosis of PCOS – SEE NOTES or POF (FSH high). Androgen studies should be done - in PCOS, androsteinedione and testosterone are raised, and sometimes steroid sex hormone binding globulin may be decreased. A very high testosterone (> 5 mmol/L) suggests androgen secreting tumour or CAH. A raised17 hydroxyprogesterone suggests an adrenal cause of increased androgen (1) . Prolactin in increased in prolactinomas, and thyroid function tests should be done if she has symptoms suggesting hypothyroidism (1) .
Ultrasound scanning is a non-invasive test that can help identify pregnancy, polycystic ovaries (1) and pelvic tumours. It is usually easily available and cheaper than other imaging methods (Magnetic resonance imaging (MRI) or computed tomography (CT)).
Depending on results of the above initial investigations, further more specialised investigations can be done to aid diagnosis. CT or MRI of the head if prolactin is increased to look for prolactinoma or CT/MRI of abdomen and pelvic to look for hormone-secreting tumours (1) .
Posted by PAUL A.
sanchu
A) The Differential diagnosis includes a)Hypogonadotropic hypogonadism such a Anorexia nervosa, pituitary tumours, Sheehan\'s syndrome b) Eugonadotropic hypogonadism such as Polycystic ovary syndrome, Hypothyroidism, Hyperprolactinaemia, Hyperandrogenic conditions like Androgen secreting tumours and c)Hypergonadotropic hypogonadism such as Premature Overian Failure which may be due to Turner\'s mosaic , auto-immune, galactosaemia etc. you have simply written lists The commonest cause of pregnancy should be excluded.
B)The History would be to ask for other associated symptoms. History of Hirsutism, change of voice, acne to rule out PCOS, Hyperandrogenism, galactorrhea and headache and vomiting to rule out Hyperprolactinaemia, tumors of the pituitary or hypothalamus, history of hot flushes and vaginal dryness to diagnose premature ovarian failure this is a single sentence. Poor punctuation makes it meaningless. Women with PCOS do not have voice changes . History of other auto-immune conditions like IDDM read the question – HEALTHY woman , Drug History for drugs like Danazol or Contraceptives like Mirena or Depot-Provera which may cause amenorrhea, Occupation since athletes are prone for hypogonadotropism, any social issues and eating habits to look for anorexia and stress (1) You have not taken a menstrual history in a woman presenting with secondary amenorrhoea!! .
The Clinical examination would be to look for BMI, Hirsutism, galactorrhea, goitre, ? relevance. How will the examiner know that you know the value of BMI or hirsutism? examination of abdomen and pelvis to look for masses (pregnancy, ovarian or adrenal tumours) (1) and clitoromegaly,vaginal atrophy.
C)Investigations include Urine pregnancy test (1) , FBC to rule out rare hematological causes of amenorrhea like what? , you use an upper case letter after a full stop (.) not after a comma (,). Poor punctuation makes it impossible for the examiner to understand what you are writing Thyroid function tests to diagnose hypothyroidism, Serum Prolactin to diagnose hyperprolactinaemia, FSH, LH -Low levels would point towards hypothalamic and pituitary causes. High levels suggest Premature ovarian failure (1) . increased LH:FSH ratio would favour PCOS NO – SEE NOTES ON PCOS . Testosterone, DHEAS levels to look for androgen secreting tumors these are more likely to assist the diagnosis of PCOS ,An ultrasonogram of Abdomen and pelvis to diagnose PCOS ultrasound would identify PCO and in combination with symptoms / biochemistry lead to the diagnosis of PCOS or ovarian or adrenal mass, If symptoms suggest or FSH and LH levels are low, an MRI Brain to look for hypothalamic, pituitary tumors hyperprolactinaemia would be the trigger .
Posted by PAUL A.
SN

(a) Pregnancy is the commonest cause of secondary amenorrhoea in a sexually active woman (1) .
Secondary amenorrhoea could be due to Hpypogonadotrophic hypogonadism such as anorexia nervosa, in athletes or in women involved in strenuous exercises (1) .
Sheehan’s syndrome (Pan hypo-pituitarism following a massive haemorrhage such as a history of post partum haemorrhage) can give rise to amenorrhoea.
Pituitary macro or micro adenomas giving rise to Hyperprolactinaemia can give rise to amenorrhoea. Cerebral tumours/ Cerebrovascular accidents involving hypothalamic Pituitary axis can give rise to amenorrhoea.
Other endocrine disorders (1) such as Hypothyroidism, Cushing’s syndrome, Addison’s disease could give rise to secondary amenorrhoea.
Premature ovarian failure (1) (could be idiopathic or secondary to infections such as mumps or due to radio/chemotherapy. Also mosaic Turner’s may undergo premature ovarian failure), resistant ovarian syndrome are ovarian causes of secondary amenorrhea.
Polycystic ovarian syndrome (PCOS) (1) is a common cause of secondary amenorrhoea.
Hormonal therapy such as Progestogen therapy (e.g. Depo-Medroxy Progesterone acetate therapy, Levenogestrel Intra Uterine systems) can give rise to secondary amenorrhoea.
Asherman’s syndrome due to intrauterine adhesions (following uterine curettage or infection) can give rise to secondary amenorrhoea. Resection of endometrium or abalation of endometrium are other causes.
History of treatment to cervix such as large loop excision or cone biopsy may rarely give rise to cervical stenosis and secondary amenorrhoea.
Some medications may give rise to secondary amenorrhoea.
Also psychological disorders can give rise to secondary amenorrhoea (post traumatic stress disorder, depression).


(b) History of unprotected sexual intercourse and symptoms of pregnancy and examination for a gravid uterus and fetal heart sounds to exclude pregnancy (1) .
History of anorexia nervosa, strenuous exercises and BMI to assess whether amenorrhoea is due to hypogonadotrophic hypogonadism is important.
Past Obstetric History to exclude massive Post partum haemorrhage or a history of miscarriages followed by uterine curettage should be taken.
If pituitary macro-adenoma is suspected how would you suspect this BEFORE taking a history? , history and examination on visual fields should be done (gives rise to bi-temporal hemianopia). Also Hyperprolactinaemia may give rise to lactation. Therefore breast examination is important in a woman with secondary amenorrhoea (may or may not have a history of milk secretion but examination may reveal milk expression).
History of focal fits or diagnosed central nervous system causes should be elicited ? meaning?? .
If suggestive of Hypothyroidism what will suggest this BEFORE you have taken a history or examined the woman? , symptoms and signs as weight gain, heat intolerance, bradycardia, hyporeflexia should be checked.
Other endocrine disorders such as Addison’s (weight loss, hypotension) Cushing’s (weight gain, purple abdominal striae, hypertension) should be excluded.
In premature ovarian failure the woman may have symptoms of menopause such as hot flushes or symptoms of hypo-oestrogenic manifestations such as a dry vagina giving rise to dyspareunia associated with secondary amenorrhoea.
In PCOS there can be a history of androgenic manifestations such as acne, male pattern hair loss and truncal obesity (1) .
History should be taken regarding any hormonal therapy such as progesterone therapy or intake of gonadotrophin releasing hormone analogues (if on treatment for endometriosis). read the question - HEALTHY
A drug history should be taken as some medication may give rise to amenorrhoea.
History of pelvic inflammatory disease which can give rise to intrauterine adhesions and secondary amenorrhoea should be taken. Also any history of uterine surgery (endometrial abalation, resection) should be taken.
An abdominal palpation for the size of the uterus and speculum and vaginal examination for visualisation of cervix and to palpate for the size of the uterus is important.
YOU NEED TO MODIFY YOUR STYLE – you take a full history then examine the woman. You do not take a history of pregnancy symptoms then examine her abdomen to exclude pregnancy, then take a history of abdominal mass then examine her to exclude ovarian / adrenal mass…


(C) I will do a pregnancy test to exclude pregnancy (1) . If pregnancy test is negative a Hormonal profile should be done according to the final differential diagnosis. This includes Serum FSH (will be high in premature ovarian failure (1) , resistant ovarian syndrome), serum LH (LH: FSH ratio can be high in PCOS) not a diagnostic criterion , serum Prolactin (can be high in some PCOS. Also if Prolactinoma is suspected), serum DHEAS (dihyroepiandrostenidione) if an androgen secreting tumour is suspected. S. Testosterone ??? may be high in PCOS or markedly elevated in an androgen secreting tumour. S. Oestradiol may be low in premature menopause.
If symptoms and signs are suggestive of Hypothyroidism, thyroid profile should be done. If other endocrine disorders such as Cushing’s or Addison’s are suspected, a 24 hour cortisol levels, short synacthen test respectively.
An US scan if PCOS is suspected as may show polycystic ovaries (1) . Also a haematometra could be diagnosed and endometrial thickness and ovarian masses could be visualised.
If a pituitary macroadenoma is suspected or cerebral space occupying lesion is suspected a CT scan or MRI scan of Brain may be indicated (1) .
Posted by PAUL A.
a) Differential diagnosis in this case would be physiological such as pregnancy and lactation,since she is in t.he reproductive age group (1) .Drugs -contraceptives ,DMPA,Implanon or LNG-IUS,.Disturbance in hypothalamo-pituitary ovarian axis need to be considered.Hypothalamic causes such as stress,excessive excercise and eating disorders (1) may supress the GnRH.Piyuitary causes may be hyperprolactinemia,pituitary-ovarian cause PCOS,or the woman muy be going into premature ovarian failure (1) .Post D&C uerine adhesion causing Asherman syndrome,although rare ,could be a possibility.Cervical stenosis after LLETZ or conization may be apossibilty.
b) Menstrual history (1) should be taken including age at menarche,LMP,length and regularity of her periods.Contraceptive hisrory for long acting contraceptives,Depomedroxy progesterone acetate,Implanon,or has intraueterine LNG-IUS may be contributing to ammenorrhea. Oral contraceptive pills may also cause post pill amenorrhea NO – THERE IS NO SUCH THING .
Obstetric history,regarding her parity,age of the youngest child and if she is lactating,it may have caused lactational ammenorrhea.History of inferilility with ammenorrhea would be suggestive of PCOS symptoms of hyperandrogenism would suggest PCOS .
History of stressful events,excessive excercise or eating (1) may cause suppression of hypothalamic GnRH.History of galactorrhea or visual disturbance may be found in case of prolactinoma (1) .
History of rapid weight gain,with change of voice ,hirsutism of acne may be found in case of PCOS with hyperandrogenemia.
History of hot flushes and night sweats may be obtained,suggestive of premature ovarian failure (1) .
Family history of premature ovarin failure should be taken
Examination should include note BMI.Any hirsutism or acne- for signs of hyperandrogenemia (1) .Visual fields examined.Thyroid enlargement.and galactorrhea (1) ,abormal skin pigmentaion ,Acanthosis nigricans is looked for.
Abdominal examination is done ,uterine enlargement may be found if she is pregnant.presense of any other abdomino pelvic mass is noted (1) .
c)Investigations include endocrine profile,FSH,LH,-may be low in case of hypothalamic disorders,high levels are found in premature ovarian failure (1) ? pregnancy test .Prolactin levels (1) high in hyperprolactenemia.If levels are more than 1000 ,prolactinoma excluded by doing skull x-ray or CT scan.TFT if there are features suggestive of thyroid dysfunction.
Testosterone,SHBG,and free androgen index this is just a list with no context .DHEA, DHEAS to find the source of androgens,raised in case of adrenal androgens are both DHEA & DHEA-S indicative of adrenal source? .CT,MRI of abdomen for any adrenal tumors.
USS pelvis for pregnancy or polycystic ovary (1)

good answer - you had more time & space to earn more marks by explaining why you were undertaking examination / investigations
.
Posted by PAUL A.
It suggests as a case of secondary amenorrhoea. So physiological conditions like pregnancy,can be a possibility (1) Premature ovarian failure (1) can be one of the causes, which may be due to immunogenic, genetics like turners mosaics, constitutional ie familial,Infection like mumps, radiotherapy or chemotherapy for any cancer in the body. ,It can be due to PCOS (1) ,which is associated with obesity, subfertility ,& hirusutism. Late onset CAH & cushings syndrome,hypothyrodism may be the other causes of ammenorrhoea. Uterine causes can be.,ashermans syndrome,which is due to adhesion between uterine wall because of recent surgical termination of pregnancy,myomectomy . Cranio pharyngeoma, prolactinoma ,TB & sarcoma of the pituitary gland , may be the cause .Anorexia nervosa, severe physical exercise, severe stress ,are due to hypothalamic causes,can be another possibility simply saying A can be the cause and B can also be the cause is not a discussion .
A WOMAN PRESENTS WITH SECONDARY AMENORRHOEA AND YOUR HISTORY DOES NOT INCLUDE A MENSTRUAL HISTORY! Hx of associated hot flushes or other menopausal symptoms for premature ovarian failure (1) .Hx of recent weight gain ,may give an clue towards PCOs Hx of gravidity,parity & its out come should be explored as recently surgical termination might have developed the ashermans syndrome..Late onset CAH & hypothyrodism may cause secondary amenorrhoea,so recent change of voice, ,abnormal hair growth may be due to CAH . Hx of increased sensitivity to cold may help in diagnosing hypothyrodism. .Familial Hx of premature ovarian failure should be explored .Recent Hx of infection like mumps, TB should be found out as mumps may cause premature ovarian failure & TB endometritis,TB pituitary may cause amenorrhoea .Hx of other associated immunogenic disorder like diabetes ,thyroid disease ,Inflammatory bowel disease may give a cjue of ovarian failure HEALTHY woman . History of Chemotherapy & radio therapy for any cancers in the body may cause pituitary ovarian failure does chemotherapy cause pituitary failure? .Hx of dieting, severe outdoor exercise may lead to secondary amenorrhoea (1) Hx of contraceptives in the form of Progestogen IUS(MIRENA) ,Depo provera should be detected . Drug hx like methyldopa,reserpine for HT,any phenothizine group of drugs for any psychological disorders HEALTHY may be the cause of hyperprolactinaemia which may lead to amenorrhoea. Hx of hemianopia, headache ,blurring of vision may suggest craniopharyngioma or prolactinoma...On examinations ,her BMI, may give the evidence of PCOS. Signs of andrenalism like hirusutism, acne ,clitoromegaly, may suggest late onset CAH, & PCOS do you get cliteromegaly in PCOS? . Galactorrhoea may suggest possibility of prolactinoma though it is not a must sign. Per abdominal examination may confirm pregnancy by measuring uterine height & any fetal parts ,fetal movement & FHS ?? .
Pregnancy test (1) -serum beta hcg or UPT & USG will confirm if any pregnancy is found. FSH,LH,, & prolactine level & USG ovarian picture(necklace pattern) of PCO may help to diagnose PCOs how do prolactin, FSH & LH help in the diagnosis of PCOS? Androstenedione ,testosterone ,SHBG, may help to detect CAH do they? If you were to do one test to diagnose CAH it will not be any of these . Serum TSH, free T3,T4 ,may detect thyroid disorders. Serum prolactine level & plaine Xray of skul may suggest about Prolactinoma. X ray chest ,may diagnose pulmonary TB which may be a focus for distance TB like pituitary or endometrium, & X ray skull may give a clue of pituitary adenoma. CT scan & MRI of skull may give evidence of pituitary tumor. Progestogen challenge test may suggest about ovarian failure.If TB is suspected ,Montoux test & serum for culture of acid fast bacilli ,PCR or ELISA test ,may detect tuberculosis. Histerocsopy may help in identifying uterine pathology like ashermans syndrome this is a UK exam and TB will not appear on your list of differential diagnoses in a healthy woman with secondary amenorrhoea. Your factual knowledge on endocrine investigations needs to improve .
Posted by PAUL A.
a). Pregnancy must be excluded in any patient presenting with secondary amenorrhoea (1) . Last menstrual period is suggestive but, diagnosis must be confirmed by urine pregnancy test.
Secondly, recent weight change is significant because a crucial steady weight is a prerequisite for a functioning hypothalamo-pituitory-ovarian axis. Hence, rapid weight loss is helpful or weight gain; eating disorders .
I will rule out polycystic ovary disease (1) as a course of patient’s symptom. I will expect this patient to have irregular, sparse menstrual loss question says no periods for 7 months , acne, abnormal facial hair growth and patient’s weight. About 40% of patient with polycystic ovary disease are found to be obese.
I will consider lactation amenorrhoea as one of my differential diagnosis. This may occur in patient who is breast feeding exclusively. High levels of prolactin being secreted during lactation inhibit gonadotropins release, thereby resulting in hypoestrogenic state.
Secondary amenorrhoea may also be drug-induced. Contraceptive drugs such medroxy progesterone acetate; implanon and intrauterine system are notorious for this.
Furthermore, I will consider surgical causes such as cervical stenosis from recent cone biopsy, Asherman’s syndrome following overzealous uterine curettage and surgical menopause following bilateral salpingo-oophorectomy.
A rare cause of secondary amenorrhoea is premature menopause (1) . It is defined as occurrence of menopause before 40 years.
b. Even though her last menstrual period was seven months ago, her normal pattern may be helpful need full menstrual Hx including age at menarche . This will include regularity, amount and presence of dysmenorrhoea. A sexual history couple with patient’s choice of contraception and how long she has been using it may be helpful how? what will this tell you? . Past gynaecological history will reveal history of cervical conisation for abnormal smears, recent uterine curettage following either a failed or terminated pregnancy. A recent weight loss will be helpful. This may be planned as in strenuous exercise (1) . I will ask about problems with acne, facial hairs and weight gain how will this help you? .
Patient may be on contraception or psychotropic medication for other ailment healthy woman .
A past surgical history of bilateral oophorectomy may be elicited will you expect to be referred a woman with a previous BSO because of secondary amenorrhoea? .
Examination may reveal presence of acne, facial hairs and male pattern hair distribution what will this tell you? How does the examiner know that you know what these signs indicate? . I will weigh patient and calculate her body mass index to identify whether she is underweight or overweight. Abdominal examination may reveal presence of scars from previous operation, or masses which may suggest pregnancy. Generally, pelvic examination may be helpful if a mass is palpated on abdominal examination (1) .
c. A urine pregnancy test (1) should be performed first. It is cheap, non-invasive, and easy to perform. Above all, it will prevent many potentially costly and invasive investigations.
A pelvic ultrasound scan may be helpful to exclude polycystic ovary disease does it? What are the criteria for diagnosing PCOS? . This may show multiple cysts arranged around the periphery of the ovary, increased ovarian volume greater than 12cm3 and, may demonstrate intrauterine pregnancy to the unwary physician!
In a well informed patient ? meaning? Who is giving the information and why should any patient not be well informed? , I will request and obtain blood for hormonal profile. These will include follicle-stimulating hormone, luteinising hormone, oestrogen, progesterone, prolactin, and testosterone. A predominantly elevated luteinising hormone in a ratio greater than 2:1 not a diagnostic criterion , and high testosterone may be suggestive of polycystic ovary disease (1) . A high serum progesterone, hydroxyprogesterone, testosterone, androstenedione, dehydroepiandrosterone and dehydroepiandrosterone sulphate may suggest adult-onset adrenal hyperplasia. It is caused by 21-hydroxylase deficiency in over 90% of patient. A high urine pregnanetriol and its glucuronides will support this diagnosis.
Hysterosalpingography may be requested in a patient with previous uterine curettage to rule out Asherman’s syndrome. It will demonstrate partial or total occlusion on endometrial lining. It is an invasive investigation and may be complicated by pelvic infection. It should only be requested by specialist gynaecologist. Diagnostic hysteroscopy may demonstrate adhesions within the uterine cavity. Treatment may be carried out at the same time in a well informed patient. This may be complicated by infection, bleeding and uterine perforation. Hence, patient must be well informed and consent obtained You are trying to diagnose very rare causes like Asherman’s syndrome (not seen a single case in 15 years) while ignoring causes like hyperprolactinaemia or other untreated endocrine disorders .
Posted by PAUL A.
From A:
They may be due to non-gynaecological causes such as pregnancy (1) or gynaecological causes such as hypothalamic amenorrhea which could be due to stress or change in BMI. Other gynae causes include uterine scarring (Ashermans syndrome) PCOS, premature ovarian failure, hyperprolactinemia and an androgen secreting ovarian or adrenal tumour you were not asked to write a list. You have 5 marks and half of an A4 page .

Fr B:
In the hx, I’d ask details of her menstrual cycle prior to her current amenorrhea (1) . This is to assess what a “normal” menstrual cycle would be for her. Her past obstetrical and gynae hx is taken to exclude any pregnancy complications such as severe PPH, repeated dilatation and curettage, endometritis and pelvic infections. This is to exclude endometrial scarring (Asherman’s syndrome) this is an extremely rare condition which should only be discussed if you run out of ideas . I’d also like to ask any other associated symptoms with amenorrhea. I’d look for symptoms such as nausea, vomiting, weight gain, abdominal distension and her sexual history: to assess if she is sexually active and the form of contraception she has been using. This is to assess possibility of a pregnancy (1) . Is there any recent stress, weight loss, dietary restrictions or excessive exercise which could suggest hypothalamic amenorrhea (1) . Menopausal symptoms (1) such as hot flushes, night sweats, vaginal dryness should be elicited to exclude premature ovarian failure. I’d also ask about hyperandrogen symptoms such as acne, hirsutism, weight gain which suggests PCOS (1) . An associated deepening of voice with other hyperandrogenism symptoms suggests an adrenal/ovarian secreting tumor. Is there any galactorrhea, visual disturbances, headaches which may suggest hyperprolactinemia (1) . A drug history for any recent initiation or discontinuation of COCP, other androgenic drugs such as danazol or high dose progestin can cause several months of amenorrhea. Dopamine antagonistic drugs such as metoclopromide, antipsychotics can cause hyperprolactinemia why should a healthy woman be taking these drugs? . A family history of premature ovarian failure or PCOS should also be assessed.

Examination involves obtaining her weight and height to calculate the BMI. A low BMI (1) (<18.5) suggests hypothalamic amenorrhea. A high BMI(>30) is commonly seen with PCOS. Physical examination will depend on the associated symptoms but includes breast examination for galactorrhea (1) , genital for evidence of hypoestrogenism as in premature ovarian failure, skin for hirsutism, acne, striae, acanthosis suggesting PCOS (1) . A neuro examination should be performed if neuro symptoms such as headache,visual disturbances are present to exclude any pituitary tumour.

Fr C:
Ix involves bloods for hormone profile, a pelvic ultrasound scan and MRI brain.
A serum beta HCG to exclude pregnancy (1) . If negative, serum FSH to exclude hypothalamic amenorrhea and premature ovarian failure. A level >40u/l is suggestive of premature menopause (1) ovarian failure where else a low se FSH, LH, estradiol suggests hypothalamic hypogonadism from GnRH lack. Serum prolactin level to identify hyperprolactinemia. TSH levels should be taken to rule out hypothyroidism, as 5% patients also have hyperprolactinemia with hypothyroidism (1) . In presence of hyperandrogen symptoms/signs DHEAS and testosterone levels taken for PCOS or androgen secreting tumour (1) . A progestin challenge test (MPA 10 mg od PO for 10 days) can be used to induce uterine bleeding. If bleeding present, an outflow tract obstruction can be ruled out. If this is negative, 0.625mg conjugated estradiol PO for 35 days and MPA 10 mg between days 26-35 is used to induce uterine bleeding. If this too is absent, uterine scarring is highly suspicious. Imaging with HSG or direct visualization of uterine cavity with hysteroscope is performed.
A pelvic ultrasound scan identifies a fetus, polycystic ovaries, and ovarian or adrenal tumours. A brain CT/MRI can be considered if serum prolactin is severely elevated (1) (>1000mIU/l) or presence of neurological signs/symptoms to assess prolactinoma or other pituitary tumour.

Good answer – would have been excellent if you spent some time discussing in (a) rather than just writing a list
Posted by PAUL A.
Arround 85% of cases of secondary amenorrhoea(S.A)may be diagnosed from history not necessary . Common causes are pregnancy,lactation & anxiety. Polycystic ovarian syndrome ( PCOS) may be asymptomatic & presents as S. A. Contraception eg.Depo. injections,Mirena may lead to secondary amenorrhoea. Weight gain/loss e.g. anorxia norvosa,heavy exercise may be the presentation. Prolactinoma (excessive prolactine production) may lead to S.A. Asherman Syndrome,Cervical stenosis following cone biopsy may be the cause. Sheehan Syndrome (severe postpartom haemorrhage following delivery ) may be the cause. Medications like phenothiazide & narcotics may be the cause.
Primary ovarian failure (history of hot flushes & breast atrophy) is a rare cause of S.A
this is not a discussion. All you have written is: A is a common cause, B may be the cause, C is a cause… .

b) Symptoms of pregnany how does the examiner know that you know which symptoms to ask for in the history? & whether she is lactating or not should be obtained. Information about previous deliveries & any complications like postpartom haemorrhadge,previous misscarriages & curittage & cevical cone biobsy should be obtained. Contraception & medications should be obtained.
Signs of androgin excess like excessive hair grwth, clitormegally (1) . Galactorrhoae may be seen on examination.Signs of oestrogen deficiency may be seen what does this tell you? . B.M.I gives the information about weight gain/loss.
c) Investigations are directed by findings from history & examination. Pregnancy test to rule out pregnancy (1) first.Follcle Stimulating Hormone(F.S.H) Lutinizing Hormone(L.H.)Prolactine , Oestradiol levels for integrity of pitutary/ovarian axis & rule out prolactinoma Do FSH / LH help rule out prolactinoma? .
Pelvic ultrasoud scan to rule out PCOS (1)

You have 20 marks and 2 sides of A4 – your answer lacks basic details. See good answer above
.
Posted by PAUL A.
(a) Absence of menstruation for more than 6 months in a woman with normal menstruation previously is regarded as secondary amenorrhea not necessary . Physiological causes of secondary amenorrhea are pregnancy and lactation (1) . Pathological causes are related to hypothalamic pituitary ovarian axis and includes adrenal and uterine pathology ? meaning . Hypothalamic causes includes excessive weight loss, excessive exercise, severe stress and anorexia nervosa (1) . Pituitary causes include hyperprolactinemia, thryoid dysfunction and hypopituitarism such as Sheehan\'s syndrome. Ovarian causes are polycystic ovarian syndrome which is the most common cause of secondary amenorrhea (35%) (1) .
Premature ovarian failure (1) is also a very important cause (25%). It may be due to autoimmune mechanism, idiopathic, iatrogenic due to chemoradiotherapy. It also may be due to mosaicism in Turner\'s syndrome and in galactosemia.
Secondary amenorrhea may also be due to uterine causes such as Asherman\'s syndrome, it may be due to contraception such as Marina IUCD and depot medroxyprogesterone acetate.
Adult onset congenital adrenal hyperplasia, adrenal and ovarian androgen secreting tumors are uncommon causes of secondary amenorrhea.

(b) I would like to ask her if she has done a pregnancy test or if she is lactating, any history of hirsutism, weight gain/loss and galactorrhea are pregnancy, hirsutism, weight loss and galactorrhoea related? You have discussed them all inna single short sentence . Any of history of hot flashes, night sweats and vaginal dryness and dyspareunia (Menopausal symptoms) will also be sought what does this tell you? . Has she noticed any signs of virilization such as reduction in breast size, change in voice, frontal baldness as they point towards hyperandrogenemia.
Detailed menstrual history (1) is important including menarche, flow and whether she is getting periods spontaneously or is it a withdrawal bleeding. Her LMP should be recorded.
Her previous obstetric history including parity, mode of deliveries, history of PPH, age of last child is important to us. Contraception history including use of Merana, IUCD and DPMA should be sought. Any plans for pregnancy in the future should also be asked. The family history is important in view of early menopause in family members, ovarian cancer is important why? Just saying this is important and that is important will not earn you marks . The result of her recent cervical smear should be asked.
On examination, her BMI, bp and general physical examination is important why? . If any hirsutism is there, it should be recorded how does recording it help you if you do not know its significance? , signs of hyperinsulinemia and acanthosis nigrans should be seen what are the signs of hyperinsulinaemia? . Signs of virilization should be looked for why? . Abdominal palpation for distension and to find out any pregnancy should also be done. Any massess should also be seen on abdominal examination. Vaginal examination is to be done to exclude vaginal atrophy, dryness, cervical stenosis, adnexal masses and uterine size. you have not attached any clinical significance to any history or examination findings

(c) Investigation include pregnancy test (1) why discuss pregnancy test and serum gonadotrophins in the same sentence?, serum gonadotropins should be done to differentiate between hypo- and hypergonadotropism. Moderately elevated gonadotropins may indicate PCOS not criteria for diagnosis but they are excessively high in premature ovarian failure (1) . Serum prolactin (1) levels should be done to rule out hyperprolactinemia. Thyroid function tests should be done. Anti thyroid antibodies can be considered in case of premature ovarian failure. Free testosterone, SHBG, pelvic ultrasound to exclude PCO when you do these 3 tests, are you excluding PCO or PCOS?? . DHEA, DHEAS raised in adrenal causes of hyperandrogenism. 17 OH progesterone level will be increased in late onset CAH. Karyotyping can be done in case of suspicion in Turner Syndrome. MRI of brain can be done incases of hyperprolactinemia (1) . CT/MRI of abdomen if suspicion of androgen secreting tumor. If suspicion of Asherman syndrome, hystersocopy should be advised.

See Good answer above
Posted by PAUL A.
AR

Amenorrhoea in a healthy woman with previous normal menstrual cycles could be due to many reasons.


1. First and foremost she could be pregnant, or may be having a trophoblastic disease will this present with secondary amenorrhoea? . These conditions can be diagnosed with a urine or serum hCG level and confirmed with an ultrasound examination. In trophoblastic diseases the exceptionally high levels of hCG can be found in the blood. She may be lactating after a childbirth which may be the reason for the amenorrhoea.

It could be due to a disorder of the hypothalamo pituitary axis, like tumours, prolactinemia, steroid intake, presence of stress, following radiation or chemotherapy. These conditions can be diagnosed with a hormore profile where the gonadotrophin releasing hormone level will be lower than normal. Also in women who are on the hormonal contraceptives a similar picture can be seen which type of hormonal contraceptives? Do you have the same endocrine profile following chemotherapy and say stress / eating disorders? .

Anovulation is another cause of amenorrhoea in women. Any condition leading to extreme weight gain or weight loss can cause amenorrhoea. for example, in athletes and in anorexia nervosa this can be observed (1) does this differ from hypothalamic causes (stress) mentioned above?. Another common condition with anovulation is poly cystic ovary syndrome, where there is absence of ovulation leading to amenorrhoea which is generally followed by heavy bleeding due to the endometrial hyperplasia. This has the increased risk of leading to endometrial cancer too. Progesterone treatment is the treatment of choice. The other most important condition is premature ovarian failure (1) and one of the syndromes associated with it Turner\'s syndrome.

Prolactinoma (1) you mentioned prolactinoma earlier and hypothyroidism are two other conditions that lead to amenorrhoea.

If there had been any surgical procedures in the uterus like dilatation and curettage, there can be a condition called Ashermann\'s syndrome in the woman where all the endometrium is absent leading to amenorrhoea. If there is a history of endometrial ablation then again the absence of adequate endometrium would cause amenorrhoea. If there was a history of post partum shock which may have led to avascular pituitary necrosis, its known as Sheehan\'s syndrome.


2. For diagnosis, additionally I would ask about signs and symptoms do you ask about signs or identify them on examination? Which symptoms will you ask about? of pregnancy and look for them in general examination. I would also ask about any previous pregnancies that were followed by continuous bleeding or abdominal pain to exclude a gestational trophoblastic disease, and this can confirmed with an Ultrasound and serum hCG levels. Also I would like to know if she is lactating which can lead to lactational amenorrhoea. If she is lactating but not after a childbirth, I would like to check her visual fields to exclude a prolactinoma causing amenorrhoea (1) . A history of exposure to radiation or to chemotherapy will rule out amenorrhoea due to these causes.
Inquiring about the medication she is on would give a clue about the amenorrhoea is due a drug related cause like contraceptive usage. I would like also to check with her if she had any drastic weight gain or loss in the recent past or if she had any symptoms of anorexia nervosa (1) how does the examiner know that you know which symptoms to ask for? Will you just ask: do you have any symptoms of anorexia??. She will be questioned about signs you ask about symptoms and elicit clinical signs and symptoms of menopause like hot flashes and mood swings, to rule out premature ovarian failure (1) . I would also look for signs and symptoms of poly cystic ovarian disease, like history of infertility, hirsutism, acne (1) etc ?? if it is relevant then the examiner needs to know .
I would ask her about any uterine surgeries like endometrial ablation or curettage which could be the reason for the amenorhoea called Ashermann\'s syndrome which is actually due to intra-uterine adhesions. I would like also to know if she had any problems like shock post partum her previous pregnancy which could have led to Sheehan\'s syndrome, which is avascular necrosis of the pituitary a woman presents with secondary amenorrhoea and you do not take a menstrual Hx!! .

Hypothyroidism is another known cause of amenorrhoea, which can be excluded by looking for signs and symptoms like weight gain, lethargy, cold intolerance etc.

Also rule out conditions like Turner\'s syndrome which is due to ovarian failure and conditions like adrenal hyperplasia which leads to virilization of the female.


3. The investigation I would order are blood tests like, Full blood count and blood smear to exclude anaemia why? , urine and serum hCG levels (1) and an ultrasound examination to exclude pregnancy and trophoblastic diseases. Serum prolactin (1) levels with a pituitary CT would help diagnose a prolactinoma. Serum levels of the following hormones, FSH, LH, Oestradiol, Testosterone, DHEAS to rule a androgen excess or hypogonadism which of these rule out androgen excess and which rule out hypogonadism? . Thyroid function tests to exclude hypothyroidism. Low levels of all the pituitary hormones confirm diagnosis of Sheehan\'s syndrome...needs replacement of all the pituitary hormones.

Hysteroscopy and adhesiolysis followed by placement of an intra uterine device to prevent recurrence and hormone therapy is the diagnosis and treatment for Ashermann\'s syndrome.

Karyotyping to exclude conditions like Turners syndrome.

you have not demonstrated a clear understanding of the investigation of secondary amenorrhoea. How will you diagnose premature ovarian failure or PCOS? You have ignored these relatively common conditions but have discussed Asherman’s syndrome

Your answer is too wordy due to poor organisation. You take a history then examine the woman. You do not ask about one symptom then examine her then ask about another symptom then examine her….
Posted by PAUL A.
Part A
It includes physiological causes like pregnancy and lactation (1) . Hypothalamic causes like recent weight loss, eating disorders and excessive exercise (1) will lead to hypogonadotrophic amenorrhoea. Pituitary causes like prolactimon (1) by secreting high prolectin leading to secondary suppression of gonadotrophins. Rarely Sheehan’s syndrome (acute infarction, necrosis of pituitary due to severe haemorrhage leading to amenorrhoea) and compression of pituitary stalk by tumour. Metabolic causes like PCOS (1) cause amenorrhoea by anovulation. Amenorrhoea might be drug induced like use of DMPA and DOPAMINE antagonist HEALTHY woman . Chromosomal abnormalities like Turner’s Syndrome (premature ovarian failure) and genetic causes like late onset CAH can lead to amenorrhoea. Premature ovarian failure can be caused by autoimmune conditions (1) , thereby amenorrhoea. Ovarian/ adrenal androgen secreting tumours by causing hyperandrogenemia may lead to amenorrhoea. Endocrine abnormalities like thyroid dysfunction and cushing disease can cause it.
Part B
A detailed history regarding her age of menarche, previous menstrual history (1) GOOD , regularity of cycle, length of cycle and duration of bleeding and amount of bleeding should be asked. Whether these were spontaneous bleeding or hormonally induced. Contraceptive history like use of DMPA can cause it. History of unprotected intercourse and possibility of pregnancy (1) should also be ruled out by asking symptoms like nausea, vomiting and fetal movements if in mid trimester. Previous obstetric history regarding termination of pregnancy or miscarriages leading to curettage may be suggestive of asherman’s syndrome or cervical stenosis. History for severe PPh may suggest Sheehan syndrome due to pituitary infarction.History of strenuous exercise, recent weight loss (10% to 15%), eating disorders may suggest hypothalamic causes (1) with impaired gonadotrophic secretion. History of headache, visual field changes and glactorrhoea will be suggestive of pituitary causes like prolactinoma (1) . History of hirsuitism, acne and weight gain will point towards PCOS (1) and H/o sudden onset of hirsuitism, deepening of voice and clitoromegaly may suggest adrenal / ovarian tumours or late onset CAH. History of hot flushes and vaginal dryness may suggest premature ovarian failure (1) . Family history of Congenital Adrenal Hyperplasia, chromosomal disorders like Turner’s syndrome and premature ovarian failure (autoimmune conditions may run in family) should be taken. In examination check for BMI (< 19 BMI will point hypothalamic cause. Acne, Hirsuitism and increased BMI will point towards PCOS (1) . visual field defects (bitemporal hemianopia) and expression of breast milk will point towards Hyperprolectinemia (1) .
Presence of breast atrophy, muscular hypertrophyand clitomegaly is suggestive of Ovarian and Adrenal tumour. Moonface, truncal obesity and skin’s striaes,hypertension maybe suggestive of cushing disease. Abdominal examination should be done for ovarian/adrenal masses. Local pelvic examination may show vaginal dryness in premature ovarian failure or cervical stenosis and examination of adnexas may show enlarged ovaries in ovarian tumour (1) .
Part C,
In majority of the cases causes of secondary amenorrhoea can be found out by history and examination. A pregnancy test (1) is important to rule out pregnancy.FSH,LH ,prolactin levels and testosterone should be done.High FSH and LH may suggest premature ovarian failure (1) and should be confirmed by repeat testing.karyotyping may be offered to confirmTurner syndrome.Low FSH and LH may suggest hypopituitarism.A prolactine level of 1500-4000 may suggest pituitary adenoma andrequire further investigation like CTscan/MRI (1) of brain.For polycystic ovariesUSGpelvis and serum testosterone,DHEA,DHEAS,SHBGand free androgen index (1) may be mildly elevated.High DHEAS levels > 20mmol/l may suggest adrenal androgen secreting tumour and increased testosterone level > 7 nmol/l is suggestive of ovarian androgen secreting tumour therefore these women may require CT Scan / MRI of abdomen/pelvis to rule out these tumours (1) .For late onset CAH serum 17-OH progesterone should be done and if markedly elevated ACTH stimulation test should be done to confirm it.If sign and symptoms are suggestive of Cushing disease 24hrs urinary steroid should be done and if markedly elevated Dexamethasone suppression test needs to be done.A positive test will confirm it.

EXCELLENT ANSWER!! This should be a model answer for others. It demonstrates the level of detail and organisation required
Posted by PAUL A.
Pregnancy (1) would be a differential in a woman with previous norma menstrual cycle and healthy. Premature ovarian failure (1) due to genetic factor like mosaic Turner syndrome, inherited or idiopathic. If she is athletic engaging in strenous exercise then what? . Anorexia nervosa this is a post-graduate exam. You do not get marks for just writing a diagnosis – you were asked to DISCUSS . Contraception like depot medroxyprogestereone or mirena coil can cause amenorrhea. Polycystic ovarian disease . Other differential include Asherman syndrome where endometrial lining is close due to excessive curreting how can you write a sentence about a very rare condition and then for a common and important condition like PCOS simply write it without any discussion?? This indicates a lack of understanding of the relative importance of these conditions . sheehan syndrome due to previous post partum haemorrhage.
B/
Symptoms of hot flushes and night sweating to exclude premature ovarian failure (1) . What she is using for contraception and compliance. I would ask if she thinks it may be pregnancy do you think she will think she is pregnant yet attend a referral for sec amenorrhoea? .
Any psychological disturbance at home or place of work. It is important to know if she is on medications psychotic drugs HEALTHY . Obstetric history, any children mode of delivery and any complication like postpartum haemorrhage. I would ask for any gyneacological treatment like LLetz, Dilatation and curretage.
Examination would include weight, height and her BMI. Abdominal examination for any palpable mass like pregnancy.
C/
Urine pregnancy test to exclude preganancy (1)
FSH, LH and Oestradiol level to exclude premature ovarian failure how? low levels? .
Prolactin level if hyperprolactinaemia is suspected.
Skull-X-ray, CT scan or MRI of the skull for sella turcica.
Pelvic ultrasound scan looking for polycystic ovaries.
Hysterosalphingogram if Asherman syndrome is suspected. you were not asked to list investigations

See excellent answer above. You have sufficient factual knowledge to pass but the examiner will conclude that you cannot be bothered to make the effort and write things down in detail
Posted by PAUL A.
a)
This is a case of secondary amenorrohoea if she has history of unprotected coitus ?? .If this woman use injectable contraceptives Depo-medroxyprogesterone acetate 150mg ,it can cause amenorrhoea (30% after 1st dose, 55% after 4th dose).If she exercise or dieting vigorously .these subpress hypothalamus inhibit ovulation and prouduce amenorrhoea (1) . History of vigorous curettage prior to this amenorrhoea indicates amenorrhoea due to asherman syndrome. Premature ovarian failure may be a cause .In this case she may felt hot flush orother menopausal symptom (1) or family history .Sometimes subclinical thyroid disorder presents with secondary amenorrhea.
b)
I would enquire about her menstrual cycle (1) age at menarche such as the last menstrual period, cycle length, blood flow.
History of symptoms of pregnancy ,feeling of fetal movement should be asked (1) .
The obstetric history should include parity, mode of delivery,any recent history of miscarriage, uterine curratage and if she is currently breast feeding .
Details about her contraception COCP does this cause secondary amenorrhoea? or injection DMPA ,duration of use.
Is she an athlet, or a member of rowing team.History of vigorous exercise or severe dieting should be asked (1) .
Family history of premature ovarian failure ,PCOS should also be enquired is family history the only relevant history with regards to PCOS? .
Has she any previous history of meningitis or head injury?
Clinical examination includes pulse for tachycardia body weight,low BMI,presence of acne, hirsuitism you have written a list – what is the relevance of these findings? .
Thyroid gland( for goiter ,any bruit), ,jerk,tremor , presence of any discharge from breast should be examined.
A careful abdominal examination should be done to look for enlarged uterus (1) .
c)
I will ask for investigation like urine for pregnancy test to exclude pregnancy (1) .
Ultrasound scan to look for pregnancy, poly cystic ovary.
If pregnancy test negative the progesterone challenge test – 10mg oral medroxyprogesterone acetate for 5 days is to be done. If a withdrawal bleed is induced then a diagnosis of anovulation anovulation is not a diagnosis . It is either due to PCOS or due to stress , exercise, weight loss or hypothalamic-pituitary dysfunction so it is not a diagnosis – how do you tell which of these conditions caused it? The progesterone challenge test is not a useful tesst .
Negative progesterone challenge test –indicates lack of oestrogen stimulation to endometrium .This may be due to premature ovarian failure is this how you diagnose premature ovarian failure? .
Base-line serum prolactin, thyroid function tests and gonadotrophin levels isto be done.FSH level around 40 mliu/ml means premature ovarian failure (1) so why do the progesterone challenge test?, LH,FSH ratio 3;1 or more suggests PCOS not a diagnostic criterion .
Karyotyp to find out mosaic turner. see excellent answer above
Posted by PAUL A.
(a) Physicological causes like undiagnosed pregnancy (1) and lactational amenorrhoea with continued lactation.
Hypothalamic causes like excess weight gain (or) weight loss or tumors of brain like craniopharngioma but unlikely with out other neurological symptoms.
Pituitary causes like prolactinoma like microprolactinoma may not have any pressure effects and without other neurological symptoms (1)
pituitary ovarian axis like polycystic ovarian syndrome. ? meaning
ovarian causes like resistant ovarian syndrome or premature ovarian failure.
uterine causes like ashermann syndrome with previous uterine currettings or cervical stenosis with previous cervical trauma you are simply writing lists
Undiagnosed pelvic tuberculosis may also cause uterine synechiae and amenorrhoea
Drug induced causes like depot medoxyprogesterone acetate or levorgesterol intrauterine devises for contraception can cause amenorrhoea.
endocrine causes like thyroid disease, cushings syndrome or late onset congenital adrenal hyperplasia are other possibilities

(b) History of recent pregnancy and breatfeeding to exclude lactational amenorhoea, history of pregnancy and likelyhood should be excluded with a urine pregnancy test you were not asked about investigations here .
History of significant weight gain or loss e.g. h/o excessive exercise.
History of stress may suggest cause for hyperprolactinaemia i is stress-induced amenorrhoea caused by hyperprolactinaemia? nduced amenorrhoea. H/o headache may suggest neurological causes like macroprolactinoma and may be associated with visual field defects like bitemporal hemianopia.
H/O hirsutism, hair loss may suggest PCOS (1) or androgen secreting tumors(rapid onset)
h/o of current contraception to exclude causes with DMPA/ Mirena.
Past h/o uterine/cervical procedures may suggest ashermanns syndrome with uterine synechiae and / cervical trauma. A WOMAN PRESENTS WITH SECONDARY AMENORRHOEA AND YOU DO NOT TAKE A MENSTRUAL HISTORY!!!
Examination findings with raised BP with striae/ moonface etc no marks for this . may suggest cushingoid features. BMI to assess weight gain or loss.
speculum examination to exclude cervical abnormalities
abdomino-pelvic palpation may suggest ovarian or adrenal tumours (1) .
visual field examination as directed by history to exclude optic chiasma compression causing bitemporal hemianopia.

(c)Urine pregnancy test to exclude pregnancy (1) .
Blood investigation for thyroid function test (with history of thyroid disease) and prolactin test to exclude any throid diseases and hyperprolactinaemia (1) .
Testosterone levels , if raised above 5 then exclude androgen secreting tumours.
SHBG along with testosterone with calculated raised free androgen index will help diagnose PCOS (1) .
MRI/ CT of brain if clinical assessment suggestive of brain tumours.
Pelvic and abdominal ultrasound and or CT abdomen and pelvis if clinical assessment suggestive or adrenal or ovarian tumours.
Pelvic ultrasound may also suggest ultrasound features of polycystic ovaries (1) to aid diagnosis.
Hysteroscopy if assessment suggestive of uterine synechaie to confirm diagnosis and treat the same.
Laparoscopy may aid confirmation of pelvic infection with microbiological confirmation e.g. tuberculosis of pelvic organs ? premature ovarian failure
Posted by PAUL A.
A)Differential diagnosis can be pregnancy (1) if sign symptom presented with morning sickness, lactitional amenorrhooea if history of lactation,can be poly cystic ovary ?? 1 in 4 women have polycystic ovaries if presented with acne ,hirsutism &baldness.hyperprolactinaemia if there is milky discharge from nipple,anorexia nervosa if present with eating disorder how does a woman present with an eating disorder? She presented with no periods for 7 months ,hypothyroidism if patient has weight gain,lethergy,cold intolerence.premature ovarian failure if presented with menopausal like symptom.it can be due to use of contraception like long acting medroxy progesterone acetate&LNG-system You have written a single sentence and you are presumably going to repeat all these symptoms and signs below .It can be asherman syndrom if history of vigorous curettage.B)History-of morning sickness,nausea, vomiting&feeling of unwell&tierdness sugest pregnancy (1) you should end your sentence here with a full stop (.) and begin the next sentence with an upper case letter , history of child birth& lactation sugest lactionan amenorrhoea.use of contraception like medroxy progesterone&LNG-system you wrote the same thing earlier – you will not get marks twice for the same facts . history of oligomenorrhoea ?? , sub fertility&use of fertility induction drug previously sugest poly cystic ovary does it? Suggest you look for hirsutism / weight gain .galactorrhoea,headach,visual disturbance sugest hyper prolactinaemia (1) .history of weigt gain,cold intolerence,lethergy can be hypothyroidism.history of radiotherapy&chemotherapy can cause premature ovarian failure&presentedwith menopausal symptom (1) .history of vigorous curettae sugest asherman syndrom,history of postpertum haemorrhage sugest sheehan syndrome.Examination-Height,weight,body mass index(BMI) if low BMI suggestive of anorexia nervosa or excessive exercise related amenorrhoea.presence of high bp sugest cushing synrome,acne,hirsutism&balding sugest polycystic ovary syndrome / disease .visual field defect&galactorrhoea is hyperprolactinaemia.per abdomen exam -palpable abdominal mass sugest pregnancy,per vaginal on ins pection vaginal dryness sugest estrogen deficiency it can be for POF,hyperprolactinaemia (1) .C)Investigation-pregnancy test (1) to confirm pregnancy,hormonal analysis for FSH,LH&estrogen if FSH high&low estrogen it can be POF (1) .Thyroid function test-decrease free t3&t4&increase TSHsugest hypothyroidism.USG-to dx PCO&pregnancy,MRI&CT scan to confirm pituitary micro¯o adenoma will you measure prolactin levels first? .HSG&Hysteroscopy to dx Asherman syn drome. Your punctuation is very poor and it makes your answer difficult to read. See excellent answer above
Posted by PAUL A.
A healthy 30 year old woman with previously normal menstrual cycles has been referred to the gynaecology clinic because she has not had any menstrual periods for 7 months. (a) Discuss the differential diagnoses [5 marks]. (b) Discuss what additional information from the history and examination is helpful in establishing a diagnosis [9 marks]. (c) Justify which further investigations you would perform to establish the diagnosis [6 marks].

(a) The main differential diagnoses for amenorrhea in this patient will include Pregnancy, Polycystic Ovarian Syndrome (PCOS), which is common in this age group, and Premature Menopause (1) where is the discussion? .
Other causes to consider will be - Post Pill (oral contraceptives) THIS CONDITION DOES NOT EXIST or less likely the Depot Provera injection, which is associated with amenorrhea during its use, as well as afterwards.
Stress, Anxiety and extreme weight loss/exercise ? WHAT?? This is not a sentence
Obesity induced amenorrhea
Hyperprolactinaemia from a pituitary adenoma or drug induced, with suppression of gonadotrophins and gonadotrophin releasing hormones.
Rare causes like a testosterone secreting tumour should be thought of. you have sufficient factual knowledge. Look at the excellent answer above to see why it will be unfair to give you marks when others take the time to write things down in full and complete sentences
As this patient has been healthy, causes from chronic illness, other endocrine diseases and iatrogenic ovarian failure are unlikely.

(b) History would include her menarche need a full menstrual history , as late menarche is associated with premature menopause, parity and any prior subfertility, which would point towards PCOS sub-fertility is not a criterion for diagnosing PCOS ; as would a history of acne, male pattern hirsutism (1) .
Her medical and surgical history for any possible causes of iatrogenic ovarian failure, as well as her contraceptive and other drug history should be noted. Galactorrhea, headaches and visual disturbances would point towards a pituitary adenoma (1) .
A family history of premature menopause should be noted ? menopausal symptoms .
Clinical examination would include her body mass index and observation of any hirsutism, abdominal and pelvic examination for any palpable adnexal masses (1) .
Features of other endocrine conditions should be noted, if present eg thyroid eye signs, goitre, cushinoid features etc.

(c) Investigations would include a urine pregnancy test (1) to exclude pregnancy, a pelvic ultrasound to diagnose polycystic ovaries (1) and other adnexal masses. This should be preferably transvaginal as it is associated with a higher sensitivity for ovarian pathology, especially in obese patients.
Blood tests for serum gonadotrophins- LH, FSH, testosterone and a sex hormone binding globulin would be adjuncts to diagnosing polycystic ovarian syndrome according to the Rotterdam Criteria how does the examiner know that you know what these are? .
A high FSH (>30iu/ml), would indicate premature ovarian failure (1) , though this needs to be repeated after six months for confirmation.
Further investigation would be based on clinical suspicion with serum prolactin, thyroid function tests, MRI for pituitary masses and a CT scan for adrenal causes (1) .
Posted by PAUL A.

RnRn

A.
Uterine causes are rare why start with rare causes? Surely you will start with the most common or the most serious cause ; Asherman syndrome following curettage may lead to amenorrhea. Most common ovarian cause is polycystic ovary syndrome (PCOS) (1) , causing amenrrhea through anovulation. Another ovarian cause is premature menopause (1) ovarian failure . On pituitary-hypothalamus level causes include adenoma (most commonly prolactinoma), hypothyroidism, post-pill amenorrhea THIS CONDITION DOES NOT EXIST , weight changes to extremes of both ends or physical exercise (1) . Rare is Sheenan-syndrome causing pan hypopituarism after severe haemorrhage. Late onset CTH is possible. Iatrogenic through medication is possible.

B.
History and examination are aimed at identifying possible causes Not necessary . Detailed cycle history (1) including menarche and use of contraception, in particular COCP post-pill amenorrhoea does not exist . Family history including premature menopause and menopausal symptoms (1) . Previous infertility treatment, pregnancies, deliveries – in particular severe post-partum haemorrhage – miscarriages and uterine instrumentation are asked for. I’ll enquire regarding weight changes, exercise, voice change or hirsutism why? , symptoms of hypothyroidism (fatigue, constipation, hair loss, cold), and presence of visual symptoms. Use of any medication, presence of medical problems such as auto-immune disease, previous chemotherapy or abdominal radiotherapy.
On examination I’ll assess blood pressure & pulse rate, weight & height for BMI, visual field testing, overall inspection for body habitus (obesity, underweight), distribution of hair-pattern (hirsutism) (1) , breast assessment for galactorrhea. I’ll examine the abdomen for palpable masses. Speculum examination to assess cervix, vaginal examination to identify pelvic mass (1) .

C.
Baseline investigations include bloods; LH-FSH, as raised in ovaraian causes like premature menopause (1) and LH:FSH ration increased in PCOS not a criterion for diagnosis . Free testosterone; increased in PCOS (1) , late onset AC. For the latter also 17-alfa-hydroxyprogesterone. TSH & fT4 to identify thyroid disorders and prolactine for prolactinoma (1) . If a pituitary adenoma is suspected, CT brain can be considered, which is also helpful in suspected Sheenan syndrome. Ultrasound examination; may show PCOS-like ovaries (1) , can identify normal anatomy uterus, haematometra, any pelvic mass. If Asherman syndrome is suspected, hysteroscopy can be considered. In premature ovaraian failure, karyotyping can be considered (eg X0-mosaicism), though <10% of premature ovaraian failure caused by abnormal karyotype (1) will you do a pregnancy test????.
Posted by H H.
Is it right to put lactation as a cause, as you know she had previously had normal menstruation and to put lactation mean she had a delivery .
In the quetion what does the word additional information signify in our answer, what does it differ from saying, Discuss what we get from history and examination in helping establishing the diagnosis?
In part C what does the word ,further, in further investigations signify Much obliged
Posted by Shaimaa M.
A
This is a case of secondary amenorrhoea so pregnancy should be excluded. She might be lactating which suppresses ovulation causing amenorrhoea. Galactorrhoea due to elevated prolactin, pituitary tumours. Causes related to stress, strenuous exercise e.g. female athletes, weight loss as in anorexia nervosa. It could be due to drugs as in psychiatric conditions with dopamine antagonist or external radiation. Sever hypo or hyperthyroidism may affect menstruation. Pituitary insufficiency sheehans syndrome may lead to secondary amenorrhoea. Adrenal tumours, ovarian tumours. Asherman\'s syndrome could follow septic abortion, surgical termination of pregnancy, PID. Finally premature ovarian failure.

B
Initially patient mental state may point psychiatric illness. Visual field problems, headaches may point out intracranial lesions. Thorough history with questions directed on recent unprotected intercourse, her previous periods and how regular they were. Previous deliveries outcome, mode of delivery, history of retained placenta and surgical procedure to remove retained products. History of septic abortion, surgical termination of pregnancy might point out to asherman\'s syndrome.
Type and timing of contraception, continuous POPs might lead to amenorrohea with occasional breakthrough bleeding, Mirena coil may cause long period free bleeding.
Recent weight loss or weight gain, eating disorders may point to anorexia nervosa.
Any breast discharge although Hyperprolactinaemia may happen without galactorrohea. Asking about any abnormal hair growth (male pattern of hair growth) could be due to PCO or androgen producing tumour. Menopausal symptoms could point out premature ovarian failure
On examination general examination, BMI < 17 or more than 30 could point out weight change leading to amenorrhoea. Signs of endocrinpathies, Tachycardia, tremors, thyroid swelling may point out hyperthyroidism. Evidence of virilisation male type balding, abnormal hair sites, cliteromegaly may point to virilising adrenal tumours.
Abdominal examination may show masses due to tumours. Pelvic examination may reveal adenxal masses due to ovarian tumours.

C
Investigations should include pregnancy test to exclude pregnancy. Gondotrophic hormones FSH, LH. If FSH/LH is decreased hypothalamic causes like stress, anorexia nervosa, vigorous exercise. If FSH/LH is increased it may indicate premature ovarian failure. Testosterone and Sex hormone binding globulin may be useful in PCO. Elevated prolactin levels as in pituitary micro or macroadenoma. Thyroid function test, TSH, free T4 will help in excluding thyroid dysfunction.
Radiological investigations include, pelvic and abdominal ultrasound for anatomical structures, asherman syndrome, could show endometrial atrophy as in premature ovarian failure. Brain CT, MRI for intracranial tumours or lesions.
Posted by PAUL A.
Is it right to put lactation as a cause, as you know she had previously had normal menstruation and to put lactation mean she had a delivery . You should take the question at face value and not try to read behind the words. If you see a mother of 3 and ask her about her periods, she might say she always has regular periods. She will not say ‘I had regular periods except when I was pregnant
In the quetion what does the word additional information signify in our answer, what does it differ from saying, Discuss what we get from history and examination in helping establishing the diagnosis? The question already gives you a history, and may give you examination and investigation findings. Additional means just that – in addition to what you have been told in the question
In part C what does the word ,further, in further investigations signify see comment above Much obliged
Posted by PAUL A.
A
This is a case of secondary amenorrhoea so pregnancy (1) should be excluded. She might be lactating which suppresses ovulation causing amenorrhoea. Galactorrhoea due to elevated prolactin, pituitary tumours (1) . Causes related to stress, strenuous exercise e.g. female athletes, weight loss as in anorexia nervosa (1) . It could be due to drugs as in psychiatric conditions with dopamine antagonist HEALTHY woman or external radiation. Sever hypo or hyperthyroidism may affect menstruation. Pituitary insufficiency sheehans syndrome may lead to secondary amenorrhoea. Adrenal tumours, ovarian tumours. Asherman\'s syndrome could follow septic abortion, surgical termination of pregnancy, PID. Finally premature ovarian failure ? discuss. What about PCOS? .

B
Initially patient mental state may point psychiatric illness healthy . Visual field problems, headaches may point out intracranial lesions. Thorough history with questions directed on recent unprotected intercourse ? relevance , her previous periods and how regular they were need detailed menstrual Hx . Previous deliveries outcome, mode of delivery, history of retained placenta and surgical procedure to remove retained products. History of septic abortion, surgical termination of pregnancy might point out to asherman\'s syndrome.
Type and timing of contraception, continuous POPs might lead to amenorrohea with occasional breakthrough bleeding, Mirena coil may cause long period free bleeding.
Recent weight loss or weight gain, eating disorders may point to anorexia nervosa (1) .
Any breast discharge although Hyperprolactinaemia may happen without galactorrohea (1) . Asking about any abnormal hair growth (male pattern of hair growth) could be due to PCO ? PCOS or androgen producing tumour. Menopausal symptoms could point out premature ovarian failure (1)
On examination general examination, BMI < 17 or more than 30 could point out weight change leading to amenorrhoea. Signs of endocrinpathies, Tachycardia, tremors, thyroid swelling may point out hyperthyroidism. Evidence of virilisation male type balding, abnormal hair sites, cliteromegaly may point to virilising adrenal tumours (1) .
Abdominal examination may show masses due to tumours. Pelvic examination may reveal adenxal masses due to ovarian tumours (1) .

C
Investigations should include pregnancy test (1) to exclude pregnancy. Gondotrophic hormones FSH, LH. If FSH/LH is decreased hypothalamic causes like stress, anorexia nervosa, vigorous exercise. If FSH/LH is increased it may indicate premature ovarian failure (1) . Testosterone and Sex hormone binding globulin may be useful in PCO NO, PCOS or disease . Elevated prolactin levels (1) as in pituitary micro or macroadenoma. Thyroid function test, TSH, free T4 will help in excluding thyroid dysfunction.
Radiological investigations include, pelvic and abdominal ultrasound for anatomical structures, asherman syndrome, could show endometrial atrophy as in premature ovarian failure. Brain CT, MRI for intracranial tumours or lesions (1) .
Posted by PAUL A.
A good answer should include the following

(a) Discuss the following

• Pregnancy (1 mark)
• Polycystic ovary syndrome / hyperandrogenaemia (1 mark)
• Premature ovarian failure (1 mark)
• Hypothalamic amenorrhoea – eating disorders, excessive weight loss / exercise (1 mark)
• Endocrine causes – hyperprolactinaemia / other undiagnosed endocrine disorder (1 mark)

(b) Discuss the following
History
• Detailed menstrual Hx – age at menarche, cycle length & regularity, menstrual loss (1 mark)
• Contraceptive history and possibility of pregnancy (1 mark)
• Symptoms of hyperandrogenaemia – hirsutism, acne. If present, severity and rate of progression (1 mark)
• Symptoms of endocrine disorders especially galactorrhoea (1 mark)
• Menopausal symptoms suggestive of premature ovarian failure (1 mark)
• Dietary habits, exercise and recent weight changes (1 mark)
• Obstetric Hx including history of severe PPH / post-partum D&C (1 mark)

Examination
• BMI, hirsutism & grading (1 mark)
• Presence of galactorrhoea & visual fields (1 mark)
• Abdominal & pelvic examination (1 mark)

(c) Discuss and justify the following
• Pregnancy test (1 mark)
• Exclude premature ovarian failure – FSH & LH (1 mark)
• Identify hyperandrogenaemia – testosterone, SHBG, DHEA, DHEA-S, 21-OH-progesterone (1 mark)
• Exclude other endocrine disorders – serum prolactin, TSH if symptomatic (1 mark)
• Ultrasound scan of the pelvis – polycystic ovaries (1 mark)
• Further investigations depending on initial results including karyotype, CT abdomen if androgen-secreting tumour suspected or brain if prolactinoma suspected (1 mark)

addad Posted by PAUL A.

adad