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Essay 370: Secondary amenorrhoea

Essay 370: Secondary amenorrhoea Posted by Farrukh G.

A 35 year old mother of 2 children has been referred to the gynaecology clinic because she has not had any menstrual periods for 6 months. Her pregnancy tests have been negative. (a) Discuss your clinical assessment [10 marks]. (b) Justify the investigations that you will undertake given that clinical assessment is unremarkable [5 marks]. (c) She is found to have premature ovarian failure. Discuss your subsequent management [5 marks].

essay 370 Posted by sujata B.


I will ask the woman if the amenorrhoea was preceded by aphase of irregular scanty period. I willalso note if she was on any contraception and whether she is still continuing the same.I will ask if her last delivery was followed by severe bleeding requiring blood transfusions.I will ask her if her children were conceived spontaneously or after treatment. I will ask if she has put on weight in the recent past. I will note if she is on any medications like for a thyroid problem,and for diabetes. I will ask for history of headaches with any blurring of vision. I will ask if she has noted any insrease in facial hair or aalso any signs of secretions from the breasts.. I will ask her if she is experiencing any hot flushes or vaginal dryness which might be influencing her quality of life.I will ask if she is on any medication like steroids which may suggest an autoimmune problem. I will ask for any family history suggestive of premature ovarian failure.I will ask if she has already consulted a doctor for her complaints and whether any tests and treatment has been commenced.
I will take her Ht ,WT and BMI. Iwill check her BP and palpate her abdomen and do a bimanual pelvic examination.
I will do her FBC, FBS TFT, and tests related to her specific complaints like an FSH, Karyotyping, an ultrasound of her abdomen and pelvis and an MRI of the brain to rule out prolactinomas.I will repeat her FSH after 4 weeks if the first value was more than 30IU. I will do a funduscopy to look for bitemporal hemianopia.
I would counsel her in a very sensitive manner, and explain to her the problems she might face ,due to early dysfunction of her ovaries.I will aim to treat her present complaints and also treat her to prevent  her future problems like osteoporosis that she might face. I will explain to her the options non hormonal and hormonal treatment and their risks and benefits.HRT like an estrogen patch with oral progesterone like medroxyprogesterones.  AN androgen patch or gel will be offerd in womwn with decreased libido.The HRT will be offered in a combined form. I will suggest diet modification and life style changes.SSRi.Clonidine patches for menopausal complaints, and biphosphonates -to prevent osteoporosi will be offered forher if she is not keen on hormones.i will give give her numbers of support groups like the DAISY network group.
essay 370 Posted by Gajendran K.

a) From history i would ask her for symptoms of menopause such as vaginal dryness , hot flushes . i would  ask her if she had any massive previous postpartum hemorrhage in her 2 pregnancy's before this. i would ask her if she was having any visual field defect , anosmia or headache. i would also ask her if she was having galactorrhoea . next i would ask her about age of menarche . I would also  ask her for her any history of irregular periods . I would also try to elicit for triggers of  ammenorhoea such as excessive weight loss , emotional stress and symptoms of anorexia nervos. I would also ask regarding any family history of  early menopause . I would also if she was on any method of contraception before this. i would also ask if she had receive any chemotherapy or irradiation before this for any disorders. I would also ask her for any previous uterine surgery such as endometrial curretage . I would also ask her for any comordities such as autoimmune disorders such as thyroid dysfunction . On examination i would measure her bmi , take her blood pressure . i would look for at secondary sexual characteristics such as breast  development and axillary hair presence . i would also look for signs of hyperandrogenism such as hirutism , acne , abdominal striae .signs of hperthyroidsm such as exompthalmos , goitre , tachycardia. breast examination should be done if there is galactorrhoea . visual field should be examined if pituitary lesions are suspected. i would then palpate the abdomen for any masses and do external genitalia and a vaginal examination .

b )i would do a hormonal profile such as FSH , LH whereby  elevated levels which would indicate failure of negative feedback from ovaries i e ovarian failure and low levels would suggest a pituitary or hypothalmic cause .    i would also do a karyotyping looking for turner's mosaicism which can be a cause for secondary amenorrhoea.. measurement of bone mineral density is indicated if the women's estrogen levels are low . Hysteroscopy should also be undertaken if the woman has had history of endometrial curretage and her hormonal profiles are normal to rule out asherman's syndrome. Ultrasound of the pelvis to look at the ovaries for signs of polycystic ovarian syndrome should also be done.  

c)i would first inform her in a sensitive and calm manner regarding the diagnosis and explain the condition to her  .  multidiscipilnary management involving reproductive specialists and psychologist should be considered .  i would consider starting her on hormone replacement therapy with the sequential regime whereby she will still get her periods and alleviate her symptoms of menopause if any. it also has beneficial effects on her cardiovascular status and bone density.  If she is keen to conceive i would also inform her that her chances of conceiving are rather slim at 5 - 10% and hence she may have to consider adoption or oocyte donation . i would give her patient information leaflets and inform her on support groups regarding premature ovarian failure .  

SAQ secondary Amenorrhoea Posted by ALi S.
A) History will include details of menstrual history as age at menarche as early mearche is on of risk factor for premature menopause, regularity of her cycles. Asking about her current contraception and if she is on hormonal contraception as COC or depot progesterone injection duration of her use which can affect her cycles as well as history of other medications like steroids, antipsychotic History of recent change in her weight , hair growth, nipple discharge. Lastely if she had recent chemo or radiotherapy treatment and family history of similar condition. At examination I will check her BMI as obesity will point out to PCOS followed by systemic general examination of neck for any thyroid swelling ,breast for galactorrhoea, any central obesity,skin pigmentation. Pelvic examination to check uterine size and if any adenxal swelling. B) I will check her hormonal profile as FSH >30 will diagnose Premature ovarian failure , I will check LH /FSH if raised ratio in cases of PCOS. Serum prolactin, Thyroid unction tests TVS is the next investigation tool to assess ovaries for cystic changes ,any ovarian swelling and or other pelvic pathology. Other investigations like brain CT/MRI will only be needed if history suggestive of intracranial leison. C) I will senstively explain the diagnosis of Premature ovarian failure and the implictions on her health at short term regarding relief of symptoms like hot flushes ,sweating ,mood swings an long term regarding osteoporosis . So; if her main concern are menopausal symptoms I will offer sequential combined HRT if no contrindications after exlaining the benfits and risks.Althought pregnancy is rare in cases of POF but carries major risks so I will advice her to have contraception for 2 years fron the diagnosis . In case if she wish another pregnancy I will explain that that could only be possible by oocyte donation.Patient will need p[sychological support as well as information leaflet and support group.
correction at previous answer Posted by ALi S.
A) History will include details of menstrual history as age at menarche as early mearche is on of risk factor for premature menopause, regularity of her cycles. Asking about her current contraception and if she is on hormonal contraception as COC or depot progesterone injection duration of her use which can affect her cycles as well as history of other medications like steroids, antipsychotic History of recent change in her weight , hair growth, nipple discharge. Lastely if she had recent chemo or radiotherapy treatment and family history of similar condition. At examination I will check her BMI as obesity will point out to PCOS followed by systemic general examination of neck for any thyroid swelling ,breast for galactorrhoea, any central obesity,skin pigmentation. Pelvic examination to check uterine size and if any adenxal swelling. B) I will check her hormonal profile as FSH >30 will diagnose Premature ovarian failure , I will check LH /FSH if raised ratio in cases of PCOS. Serum prolactin, Thyroid unction tests TVS is the next investigation tool to assess ovaries for cystic changes ,any ovarian swelling and or other pelvic pathology. Other investigations like brain CT/MRI will only be needed if history suggestive of intracranial lesion . C) I will senstively explain the diagnosis of Premature ovarian failure and the implictions on her health at short term regarding relief of symptoms like hot flushes ,sweating ,mood swings an long term regarding osteoporosis . So; if her main concern are menopausal symptoms I will offer sequential combined HRT if no contrindications after exlaining the benfits and risks.Althought pregnancy is rare in cases of POF but carries major risks so I will advice her to have contraception for 2 years fron the diagnosis . In case if she wish another pregnancy I will explain that that could only be possible by oocyte donation.Patient will need p[sychological support as well as information leaflet and support group.
Posted by Lola B.

a) First, I will take a history. I will ask her previous menstrual history -- her menarche and the pattern of menses prior to these 6 months. Ask for symptoms of hyperandrogenism which may point towards PCOS, like hirsutism and acne. Ask about recent drastic weight loss or weight gain. Ask about signs of premature ovarian failure, like vaginal dryness, skin dryness, reduced libido. Ask for symptoms of hyperprolactanaemia, like galactorrheoa, headahces, visual disturbances, nausea and vomitting (the last 4 symptoms will point towards a prolactinoma). Ask about symptomts of hyperthyroidism, like palpitations, anxiety, insomnia, heat intolerance. Ask for any abdominal mass or tenderness. Ask for any family history of premature ovarian failure, or other medical or genetic problems, like fragile X syndrome. Ask for personal history of medical problems -- like thalassaemia or galactossaemia, or genetic abnormalities. Ask for any ingestionover hte counter drugs, if she has sought helpfor this problem and what treatment has been given. Ask for her plans for family planning, if she is using contraception and whether she is on any IUCD. 


The physical examination will be led by the history taken. Look for signs of hyperandrogenism, like acne and hirsutism. Look for signs of metabolic disease like acanthosis nigricans. Palpate the abdomen for any masses or tenderness. Assess visual fields.


b) I will do a random FSH and LH. If raised, to repeat again and if persistently raised, POF is diagnosed. Sometimes, PCOS may manifest with a LH:FSH ratio of >3:1. Do a total and free testosterone level, to look for hyperandrogenism. A low estrogen level will further confirmt he diagnosis of POF. A deranged thyroid function test (raised fT4, depressed TSH) may be the cause of amenorrheoa.  A raised PRL (prolactin) will indicate hyperprolactinaemia. An ultrasound pelvis is performed to assess for any pervic tumours, to look for polycytic ovaries. 


c) I will explain to her with sensitivity the meaning of premature ovairna failure --  that the ovaries have stopped functioning prematurely. A cause will be sought for, for most of the times, it is an idiopathic cause. I will screen her for autoimmune endocrinopathies or thyroid pathologies. 

Advise her on the risk of osteoporosis and the need for hormone replacemnet therapy. She will need a sequential combined preparation. To do a baseline BMD and a BMD every year. Advise her on steps to prevent osteoporosis -- Vit D and CAlcium intake , exercise. 

Testosterone replacement may be considered to improve libido. 

Advise on increased risk of cardiovascular disease -- the need of reguarl lipid screening. 

The options of fertility incude oocyte domation and adoption. 

To provide her with written information, and refer her to appropriate support groups.


Posted by Christa R.



I would enquire about the lady’s general health.   I would specifically note any systemic symptoms such as hot flashes, vaginal dryness, mood changes, decreased libido which are associated with a menopausal state. I would enquire about her appetite and whether her weight is stable. I would ask about any history of galactorrhoea, headaches or visual disturbance which may suggest a pituitary tumour (prolactinoma).  I would enquire about her menstrual cycle prior this episode of amenorrhoea.  Was her cycle regular and of normal length (approximately 28 days) or does she have a long standing  history of oligo-amenorrhoea, which may be associated with PCOS. I would note any previous episodes of amenorrhoea and their duration. I would note any history of eating disorders or excessive exercise which can disrupt the hypothalamic-pituitary-gonadal axis.  I would note any past history of miscarriage and curettage, as rarely Asherman’s syndrome may present with secondary amenorrhoea.  I would enquire regarding her past medical history, specifically that of autoimmune diseases (including thyroid, adrenal).  I would ask about any previous gynaecological surgery, particularly ovarian surgery.  I would enquire about history of infections such as mumps which can occasionally cause oophorits and result in accelerated follicle atresia.  I would ask about any history of malignancy and treatment with chemo-radiation. 

I would note her past obstetric history.  Is she recently postpartum, is she breast feeding?  Could these explain her anmenorrhoea.  I would enquire about contraception.  Progestogenic methods can cause amenorrhoea.

I would then enquire about her family history, including the ages of menopause of female relatives if known.  I would enquire about family history of autoimmune conditions, genetic conditions such as fragile X and history of learning difficulties.

On examination I would check BMI (anorexic or obese), I would note BP.   I would look for signs of hyperandrogenism such as acne or hirsuitism which may occur in PCOS.  I would look for any stigmata of Turners syndrome (short stature, short neck, low hairline).   If any history of visual disturbance I would check visual fields.  I would check for any stigmata of autoimmune conditions such ask skin changes of vitiligo, joint effusions etc.  I would examine the abdomen and pelvis for the presence of organomegaly or masses.  I would note any evidence of oestrogen deficiency such as atrophic vaginal mucosa.



I would perform a baseline endocrine profile including LH, FSH, oetradiol.  Raised FSH levels and low oestradiol levels may indicate ovarian failure. A persistently elevated FSH in absence of all other abnormalities may indicate resistant ovarian syndrome.

 In addition I would check prolactin levels to rule out a prolactinoma.  I would check serum androgen levels which may be elevated in PCOS.  I would check DHEA and DHEA-sulphate levels and also  21-hydroxy progesterone levels to exclude late onset congenital adrenal hyperplasia.  I would consider performing thyroid antibody testing ( thyroid peroxidise, anti-throglobulin), especially if thyroid symptoms.  I would also discuss peforming a karyotype to identify/rule out any karyotypical abnormality such as translocation deletion of X chromosome.  I would arrange an TVS +/- renal tract USS to assess ovarian morphology (exclude PCOS) and exclude Mullerian abnormalities.  Finally I would arrange for bone densitometry.



I would sensitively inform of the diagnosis and provide information on the condition with contacts of support groups.  I would discuss the fact that despite her current diagnosis spontaneous ovulation may occur and therefore contraception is still necessary.   I would enquire about her fertility wishes.  If she wishes to extend her family, this would need to be via egg donation and IVF.  If pregnancy is not desired, I would recommend HRT and this can be via the COCP, although she may need additional  contraception as the COCP may be ineffective due to elevated gonadotrophins.  An IUCD may be an option for contraception.  I would ensure adequate oestrogen replacement for osteo-protection.  I would follow up results of bone densitometry and auto-immune screening with treatment are referral to additional specialties (medical) as necessary.  I would discuss healthy eating and exercise in view of increased risks of CVS disease.  If overweight I would encourage weight loss with referral to a dietician if necessary.

essay 370 ans Posted by Liza S.


Essay 370 
Clinical assessment
A detailed history regarding her age of menarche, previous menstrual history, and regularity of cycle, length of cycle and duration of bleeding should be asked. I will ask whether the last menses were spontaneous bleeding or hormonally induced. Enquire the H/O of contraceptive use of progesterone method of contraception like depot medoxyprogesterone acetate injection, levonorgesteral intrauterine system can cause the secondary amenorrhoea. Regarding her obstetric history enquire the age of last baby in view that may be she has a lactational amenorrhoea, or any H/o severe PPH, also ask any H/O postpartum endometrium curettage .Enquire about the hot flushes and vaginal dryness suggesting the premature ovarian failure. I will enquire about any weight loss for eating disorder. Any stress or depression H/o should be asked .Enquire strenuous exercise level .History of headache, visual field changes and galactorrhoea will be suggestive of pituitary causes like prolactinoma .Enquire about acne and hirsutism and weight gain-if present I will ask the severity and progression which will point towards PCOS / hyperandrogenamia. Enquire about the drug H/o such as antipsychotic and illicit drug use in particular cocaine and opiates. Enquire the family history of cessation of menses before 40 years of age for premature ovarian failure, and diabetes. Enquire the medical history including: chemotherapy, pelvic radiation which can cause the premature ovarian failure, and head injury which can cause hypopituitarism. Enquire also any H/o of hypothyroidism or hyperthyroidism which is rare causes of secondary amenorrhoea.
Measure height and body weight and calculate body mass index .Perform fundoscopy and assess visual fields if a pituitary tumour is suspected, the presence of galactorrhoea and visual field defect (temporal hemianopia) will point towards hyperprolectinemia .If hirsutism present perform  Ferriman Gallwey scoring system. Perform abdominal examination looking for any abdominal masses .On pelvic examination look for vaginal dryness, clitoromegaly, and the presence of any adnexal mass may show enlarged ovaries in ovarian tumour.
Obtain the following measurements: FSH, LH, prolactin, total testosterone and sex hormone-binding globulin, TSH. *follicle-stimulating hormone and luteinizing hormone-high FSH and LH levels on two occasions suggest premature ovarian failure in this younger women age < 40 years. Normal or low FSH levels and normal or low LH levels suggests hypothalamic causes of secondary amenorrhoea most commonly weight loss, excessive exercise, or stress, or rarely, a hypothalamic or pituitary tumour. Normal FSH levels and normal or moderately increased LH levels may be found in polycystic ovary syndrome. *Prolactin levels: greater than 1000 mIU/L need further investigation by an endocrinologist usually MRI of the pituitary fossa is required and the causes include pituitary adenoma and hypothyroidism .if levels are 500-1000mIU/L repeat the measurement and if these levels persist, pituitary adenoma may be the cause need imaging and other causes are recent breast examination, venepuncture medications like antipsychotic, antidepressants, and polycystic ovary syndrome. *total testosterone if normal or moderately increased and free androgen index greater than 5 is seen in polycystic ovary syndrome. High levels of testosterone warrant investigation to exclude other causes, such as Cushing syndrome, late –onset congenital adrenal hyperplasia, or an androgen-secreting tumour. *Ultrasound scan for polycystic ovary shows the presence of 12 or more follicles in at least in one ovary, measuring 2-9mm diameter, or increased ovarian volume greater than 10 mL. *further investigation depending on initial result including karyotype, 24 hour urinary free cortisol levels if suspecting Cushing syndrome .TSH if suspecting thyroid disease.
The main stay of treatment is appropriate counselling and support, discussion about hormone replacement therapy and reproductive health care, including contraception and fertility treatment. Multidisciplinary management involving reproductive subspecialists, endocrinologists, and psychologist should be involved.
Psychological support. The first aim of management is to help the women deal with the diagnosis by giving her information about cause and treatment options available. This information I will give her in a sensitive and timely manner, as this diagnosis of premature ovarian failure can have a significant impact on her psyche as she find herself menopausal and infertile. This woman if very anxious and depressed I will refer her to the professional counsellor and psychologist. If aetiology identified I will involve the endocrinologist or geneticist. Advise her to connect the Support groups such International Premature Ovarian Failure Association and Daisy Network Premature Menopause Support Group are valuable adjuncts in helping this woman come to terms with the diagnosis. Hormonal replacement therapy (HRT). In this young woman HRT should be used, to prevent osteoporosis and menopausal symptoms, unless contraindicated, HRT should be use until the age of menopause and then reviewed. Her treatment should be individualised according to choice and risk factors .Besides HRT, general measures to avoid bone loss such as physical activity, a calcium-rich diet, Vitamin D supplementation and avoidance of smoking and alcohol should be discussed .Non hormonal treatment of menopausal symptoms can be considered if there is contraindication of oestrogen and HRT, or she refuses HRT. Like for Hot flushes and night sweats she can have the life style changes by doing regular exercise, reduce stress, and maintain regular bedtime. Reproductive health and contraception, 5-10 % women with Premature ovarian failure (POF) have spontaneous resolution leading to pregnancy and if she wants to avoid pregnancy contraception like barrier method or intrauterine contraceptive devices are preferred options for her as oral contraception fails to suppress the high FSH levels characteristic of POF .But if she desire pregnancy, her options are achieving a pregnancy by oocyte or embryo donation or either adoption.
sec amenorrhea Posted by shraddha G.


A)     History has to be taken regarding her previous menstrual pattern whether oligomenorrhoea and decreased flow in the menstrual cycles preceded the secondary amenorrhea or it was menorrhagia and polymenorrhoea. If she had gained weight recently, following which she may have anovulatory cycles and so amenorrhoea. Ask detailed obstetric history, what is the duration since last delivery, if she is breast feeding her baby and had lactational amenorrhea. If she had excessive bleeding following last delivery which may result in Pan-hypopituitarism, Sheehan syndrome and as a result secondary amenorrhoea. If she had post-partum endometritis. If she had curettage done following any miscarriage, after PPH or any surgical termination of pregnancy which had resulted in Asherman’s syndrome. Ask contraceptive history and any treatment history for menstrual disorders. COCP may result in post-pill secondary amenorrhea in 1% cases. LNG-IUS (Mirena) used for AUB may also result in amenorrhea in 37% cases by 1 year. Ask for rapid growth of facial hair, deepening of voice as adrenal or virilising ovarian tumour may present thus. Ask if she had menopausal features of hot flushes, vaginal dryness , which suggests premature ovarian failure. Ask if she had chronic disorder of thyroid, diabetes, tuberculosis. Ask for the symptoms of headache, visual symptoms or discharge from breast as hyper-prolactinaemia may be the cause. Past history of mumps needs to be excluded. Ask about any chemotherapy or radiotherapy in the past. Family history of premature menopause and autoimmune disorders need to be excluded.    

General examination should include thyroid swelling(thyroid disorder), galactorrhoea(hyper-prolactinaemia), hirsuitism, acanthosis nigricans and vitiligo( auto-immune disorder).Calculate BMI as obese females are likely to have anovulatory cycles.

B)      Investigation should include serum hormone measurement –LH, FSH, Prolactin so to exclude premature ovarian failure, hypo-pituitarism and hyper-prolactinaemia respectively. Thyroid panel including TSH with free T3 ,T4 and antithyroid peroxidise antibody to rule out any autoimmune thyroid disorder. Measure Serum androgen, DHEA,DHEA-S, 21(OH) progesterone to exclude rapid virilising adrenal and ovarian tumour and late onset congenital adrenal hyperplasia. Also measure serum electrolytes, Na+/K+ as these are disturbed in CAH. Perform TVS to assess uterine size, endometrial thickness and ovaries for presence of follicles, ovarian tumour. Test for fragile X syndrome by karyotyping. CT/MRI to exclude any asymptomatic micro prolactinoma.

C)      Treatment has to be offered based on patient’s symptoms and wishes. Explain her about the nature of disease and diagnosis and outcome. Spontaneous ovulation and pregnancy may occur. Provide written information leaflets. If she had menopausal symptoms start HRT in form of COCP. Explain her due to elevated FSH levels, COCP may not eliminate the chances of pregnancy. Ensure osteo-protective dose of HRT. Explain about the close follow-up required to ensure adequacy of HRT, bone densitometry and screening for autoimmune disorders.  Explain about the long term risks of osteoporosis and cardiovascular risks. If she wishes for further fertility, explain about egg donation and provide appropriate counselling. Provide information and contacts of social support groups.

Posted by Nabila A.

(a)History  is taken  about the last childbirth and lactation. History of severe post partum haemorrage may indicate pituitary cause.Enquire about contraceptive use of COCs ,progestogen only pills ,injectables ,implants or IUS which can cause amenorrohea.Irregularity of menstrual cycle (oligomennorrhea) before cessation is asked. Enquire about acne and  hirsutism.Symptoms of estrogen deficiency in the form of hot flushes,night sweats and loss of libido should be asked.History of any eating disorder ,exercise ,stress and weight loss is taken.Symptoms of headaches and galactorrhea  are asked..History of chemotherapy ,radiotherapy or pelvic surgery in the past should be taken.History of cervical surgery ,dilatation and curettegema y indicate cervical  cause   or ashermannn s syndrome.History  pertinent to autoimmune disorders including diabetes mellitus ,hypothyroidism  is elicited .A family history of premature menopause is asked.

A physical examination including height  weight and body mass index is essential.Breast examination is indicated to detect galactorrohea.Skin should be examined  for acne,hirsutism,striae,acanthosis nigricans and vitiligo indicating autoimmune disease.Abdominopelvic examination done to detect any palpable mass .Visual field examination indicate dif history suggests.

(b)After ruling out the possibility of pregnancy,Serum prolactin and thyroxine levels should be done to exclde hyperprolactenemia  and  thyroid dysfunction.Serum FSH ,LH,estradiol levels   are essential for  the diagnosis of premature ovarian failure .If there are signs of hyperandrogenism ,serum dehydroepiandrosterone and testosterone  should be measured.

Follow up tests are arranged  according to the clinical history and results of initial tests.If initial gonadotrophin level are increased,these should be repeated afte r 3-4 weeks….2 FSH levels >or equal to 30 i.u/l at an interval of atleast one month are diagnostic of Adrenal,anti thyroid peroxidase antibodiespremature failure.

Ultrsound examination is done for endometrial thickness (to detect estrogen deficiency),ovarian volume and antra lcount  is  done .After the diagnosis of premature ovarian failure is made( which is idiopathic in most of the cases) further investigations can be considered depending on woman s wishes to know the exact diagnosis.Karyotyping and FMR 1 mutation analysis can be useful.Screening for autoimmune disease (antiadrenal ,anti thyroid peroxidase antibodies,anti thyroglobulin antibodies).AMH estimation is done for ovarian reserve.DEXA can be considered for baseline assessment as woman is at risk of osteopenia.

(c)Multidisciplinary approach should be adopted for the management .The diagnosis of premature ovarian failure has a significant psychological impact on the woman so  the information should be given in a sensitive manner.Clinical psychologist and professional counsellors can be particularly helpful. Endocrinologist or clinical geneticists  help shoud be sought depending on the aetiology of the POF.Support groups are valuable helping woman to accept the diagnosis and self management.

HRT  is indicated to reduce the effects of estrogen deficiency.Starting treatment early has more long term benefits on the long term health of the woman.It decreases th risk of coronary artery disease and has beneficial effects on osteoporosis.HRT should be use d in young women till the age of menopause unless contraindicated and then reviewed,Better cardiovascular results are obtained with transdermal estradiol with vaginal progesterone as compared with oral.It can be sequential or continuous..sequential HRT will have the advantage of monthly cycles.

ANDRGEN REPLACEMENT can be considered in case of hypoactive sexual desire.General measures to avoid bone loss  sch as physical activity calcium rich diet ,vitamin D replacement should be discussed.Aoidance of smoking and alcohol is advised.Non hormonal treatment of menopausal symptoms  can be considered if ther are contraindications to HRT

If the woman desires pregnancy , adoption  or achieving pregnancy with oocyte or embryo donation  is discussed .In case woman does  desire pregnancy ,contraception needs to be practiced as pregnancy is reported in 5- 10% of the women withPOF.Barrier methods  and intrauterine  contraceptive devices are preferable 

ans Posted by Yingjian C.


I will ask her regarding symptoms which may point to a cause of secondary amenorrhea: hot flushes or vaginal dryness(suggest premature ovarian failure), galactorrhea or visual changes or headache (suggest hyperprolactinemia), any recent weight loss or vigorous exercise (suggest hypothalamic cause), any signs of virilism such as deepening of voice or breast atrophy or baldness, increased acne, increased body hair. I will ask any symptoms such as heat intolerance or changes in appetite which may suggest endocrine cause such as thyroid disorder.  I will ask if she has chronic medical problems such as thyroid disorder,renal disease or any autoimmune disorder such as type 1 diabetes. I will ask on previous uterine surgeries such as curettage which may suggest Asherman’s syndrome or hysterectomy (predispose to premature ovarian failure). I will ask on recent obstetric history of massive postpartum haemorrhage (suggest Sheehan’s syndrome). I will ask if she is on contraceptives such as intramuscular depot progestogens, Mirena (cause amenorrhea) or stopped combined oral contraceptive pills (postpill amenorrhea). Drugs such as phenothiazines can cause hyperprolactinemia. I will on family history of premature menopause or hirsutism. I will ask if she has any cancer which was treated with chemotherapy/radiotherapy. I will ask on recent abdominal distension or pain.

On examination, I will assess her body habitus for any cushingoid features such as buffalo hump or moon facies. I will check her body mass index. If she has symptoms suggesting hyperprolactinemia or visual problems, I will check visual fields for bitemporal hemianopia. Check her breasts for galactorrhea. I will check thyroid for goitre. I will check for acanthosis nigricans. I will look for virilsim such as male pattern baldness, breast atrophy, clitoromegaly. I will check for any abdominal or pelvic masses. I will check her blood pressure.


I will check her serum FSH, LH and estrogen levels: elevated FSH levels need to be repeated and if consistently elevated >30 then may suggest premature ovarian failure. I will check her serum testosterone, DHEAS, androstedione, serum hormone binding globulin and free androgen index: elevated DHEAS suggests adrenal cause of high androgens; high testosterone levels>5n/l suggest adrenal tumors. I will check her serum prolactin levels : elevated prolactin may cause secondary amenorrhea , if levels are very high and she has symptoms such as headache or visual field changes then MRI of her pituitary will be done to rule out prolactinomas.  I will do a serum 17 hydroxyprogesterone (elevated levels suggest late onset congenital adrenal hyperplasia). I will do a 24h urinary cortisol (elevated levels suggest Cushing’s syndrome). I will do an ultrasound of the pelvis to look for polycystic ovaries. I will do a CT of abdomen for any adrenal tumours depending on serum androgen levels and any abdominal/pelvic masses felt on examination. I will consider a karyotype if premature ovarian failure is suspected.


c) A sensitive approach is needed.  I will explain diagnosis to patient: premature ovarian failure means she will not have any more menstruation or childbearing. Most cases are idiopathic, I will discuss her investigation results if there are any causes. I will offer her written information, support groups and counselling. I will discuss regarding hormone replacement therapy: for osteoprotection and relieve any menopausal symptoms. HRT in premature menopause is not associated  with increased breast cancer/stroke/heart disease. She will need bone density scan regularly and regular follow-up. I will discuss her fertility intentions: if she does not want children then barrier contraception is needed as there is a 10% chance she can still spontaneously conceive. If she wants children, then she may consider ovum or oocyte donation/adoption or surrogacy, multidisciplinary management with fertility specialists may be needed . I will counsel on healthy lifestyle such as stopping smoking or alcohol and taking calcium supplements if she does not take milk and do regular exercise.   

Posted by uzma sultana M.

  A] Take detail history and examination .  Menstrual history of attainment of menopause,  LMP ,cycles, regularity, flow and any associated complications .  Obstretic history of last child birth, parity, any previous miscarriages which might have been curetted extensively resulting in ashermans syndrome .  any history of previous severe PPH which could have resulted in pitutary necrosis and sheehans syndrome .  any history of chromosomal anamoly such as Turners syndrome  . Contraception history of previously used or presently on depot medroxy progesterone and associated complications.  any history of drug ingestion such as methyldopa, chlorpromazine.  Family history of Turners, late onset CAH, Premature menopause . Any history of headache, visual disturbances and galactorrhoea to rule out prolactinoma .  any trauma to the skull , radiation exposure before , and chemotheraphy before .  any previous abdominal surgeries and trauma to the ovaries or  abdominal adhesions resulting in ovaries been burried .  any ovarian or adrenal tumors and symptoms associated with them .  any history of exessive weight loss, sternous exercise ,or anorexia resulting in hypothalamic cause of amenorrhoea .  any hot flushes and vaginal dryness for premature menopause .  any symptoms of PCOS resulting in anovulation and amenorrhoea .  any sudden increase in weight and excessive growth of body hair especially fascial hair ,masculinization , breast atrophy resulting in hirsutism .  any galactorrhoea secondary to hyperprolactinoma .  any history of hypothyroidism .

Examination - weight of the patient and BMI  . external appearance for excessive fascial hair and increase muscle mass , and breast atrophy  for hirsutism .  Breast for galactorrhoea .  abdomen for palpable  adrenal or ovarian masses .  external genitalia for clitoromegaly .  vaginal examination for uterus size, mobility, adnexal masses or ovarian mass .

B] Pregnancy is ruled out  . blood for base line  hormonal assay such as FSH , LH , DHEA , DHEAS, SHBG ,Testosterone , Free androgen index ,  prolactin level , 17 hydroxy progesterone , TSH, T3 , T4, for Hypothalamic, pi tutary and ovarian  causes .  thyroid causes , and Late onset CAH .  Karyotyping should be done . bone mineral density for osteoprosis  . Abdominal USG for ovarian and adrenal tumor  . X ray of skull , CT , MRI of brain . CT of abdomen .

C] The diagnosis of premature ovarian failure  should be told very sensitively .  it might be difficult for the patient to accept .  multidisciplanary aproach is needed involving psychologist  .  Tell the patient that her ovaries are not functioning like before .  she has attained premature menopause .  despite of this she can ovulate spontaneously and concieve .  ask her if she has completed her family or need more children .  Tell her that her  sexual life will not be effected . She needs sequential  HRT  .  This is in the form of oral, Patch  or vaginal ring of low dose oestrogen of .625mg CEE and oral medroxy progesterone acetate of 2.5 mg daily .  By this the patient might menstruate once in month or once in three month .   if she needs contraception she can insert LNG iud along with  oral oestrogen or patch .   patient has feeling of well being  .  Discuss about the risk and benefits .  HRT has increased incidence of coronary artery disease, stroke ,VTE in first year of use .  risk of cancers such as ovarian , endometrium , and breast .  There is decreased risk of osteoporosis for 2 yrs  , but for long term effect alternate treatment must be used .  she can do exercises and diet  to prevent osteoporosis  . risk of colorectal cancer, alzhmieres disease is reduced  .  Hot flushes are improved   . vaginal dryness can be prevented by local application of oestrogen creams .   The chances of conception are very less if she wants child she can go for Ovum donation and  IVF  or adoption .   Provide counselling and information leaflet  and contact of support group .

essay secondary amenorrhea Posted by MONA V.


a)        After pregnancy is ruled out,  ask about  previous menstrual history , cycle length Previous irregular cycles ,weight gain, acne hirsutism point to  poly cystic ovarian syndrome(PCOS).  History of  strenuous  exercise,  stress,  anorexia  denotes hypothalamic  cause for  amenorrhea .     She is asked about recent headache, visual field changes , galactorrhea  which is seen in  hyperprolactinemia  secondary to pituitary tumour.        Symptoms of estrogen deficiency like loss of libido, vaginal dryness, hot flushes would suggest premature ovarian failure.

 History of cold intolerance  weight gain dry skin points to endocrine dysfunction like hypothyroidism .   

  Previous obstetric history of massive post partum bleeding   would suggest possibility of Sheehan syndrome. Ask for  use of contraceptives   like levonoregestrel system (LNGIUS), depot progesterone injection which cause amenorrhea.

Previous uterine curettage could lead to asherman syndrome adhesions and amenorrhea.

History  of previous surgery like cvarian  cystectomy,  previous chemotherapy radiotherapy for malignancy is elicited. Family history of premature cvarian failure asked.

Examination done for height weight BMI . Look for acne hirsutism, acanthosis nigrans suggesting PCOS. If galactorrhea present do breast examination. Abdominal and pelvic examination done for  any mass .


b)    FSH (follicle stimulating hormone)  LH, serum estradiol are indicated to assess    hypothalamic pituitary axis . If FSH is > 30 u/L repeat test after 4-6  weeks needed to diagnose premature ovarian failure. Low levels indicate   hypofunction of hypothalamus.

  Free T4 and TSH done for hypothyroidism . Serum prolactin done to assess hyperprolactinemia.  Serum testosterone SHBG (sex hormone binding levels ) for free androgen index may be done in PCOS. As no clinical evidence of hyper androgenism DHEAS, 17 OH progesterone not indicated .  Ultrasound pelvis(TVS) indicated to assess  endometrial thickness , ovarian volume which is increased in PCOS.

If premature ovarian failure diagnosed second line tests like karyotype, dexa scan for bone density done. Anti mullerian hormone done to assess ovarian reserve


c) Once a diagnosis of  Premature ovarian failure is made sensitive approach and pscychological couselling is imperative . She should be seen by multidisciplinary team comprising gymecologist, endocrinologist,  pscychological counselor. As there is increased risk of osteoporosis , coronary heart disease HRT (hormone replacement ) is needed . DEXA scan is done for osteoporosis.

She can be given combined sequential HRT, in the form of patch ,gel tablets, with progesterone component as implant ,LNGIUS if no contraindication.  Androgen replacement by testosterone patch can be given as loss of libido due to ovarian failure.    General advice on exercise healthy diet, vitamin D calcium supplement given as chance of osteoporosis.

Future contraception advice is important  as 5-10% chance of spontaneous ovulation is present . Combined pills are not useful as FSH not suppressed,  so  barrier methods or intrauterine device is recommended.If future pregnancy desired ovum donation IVF or adoption suggested.

Written information given . She is told about  support groups like daisy network, POF international 

Posted by gouthaman S.


Menstrual  history LMP,regularity  of  cycles  is  enquired. History  of  exercise,recent weight loss,eating disorder  is  asked  which  would  suggest  hypothalamic  cause . H/O  headache,visual disturbances,galactorrhoea  would  suggest  prolactinoma. H/O  excessive  blood  loss ,blood  transfusions,during  prior  deliveries ,irregular cycles  would  suggest  Sheehans  syndrome.She  is  asked  about  weight gain,intolerance  to  cold  suggestive  of  hypothyroidism.H/o  of  curettage  suggests Ashermans  syndrome. She  is  asked  about  contraceptive  use DMPA as  it  can cause  amennorrhoea.Loss of libido, vaginal dryness,hotflushes,dyspareunia  suggestive  of  premature  ovarian  failure  is  asked.History  of  ovarian  surgery,prior  chemotherapy, radiotherapy ,autoimmune disorders  which  can  lead  to  POF is enquired..Family  history  of  POF is  asked. H/O  of  weightgain,acne ,hirsuitism   suggestive  of PCOS.Rapid  hirsuitism,voice change  would  point to  androgen  secreting  ovarian tumouror adrenal tumour.  BMI is  checked.  Presence  of  acne, acanthosis nigricans,hirsuitism  by  Ferriman Gallway  scoring  are  noted.Visual fields  is  checked. Breast  examination is  done if H/O  galactorrhoea  . Presence of central obesity,stria ,moon facies noted  suggestive of Cushings syndrome. Perabdominal examination  is done for presence of   mass.Pelvic examination is done  for assessing presence  of pelvic mass.

b)  Serum  FSH,LH levels are done.FSH  more  than  30u/ml suggests premature ovarian failure.POF  is  confirmed  by  repeating  FSH  after  4  weeks  for  persistant elevation above 30u/ml.IF  POF  diagnosed  other  tests  include  karyotyping  for turners mosaic,.Screening  for  other  autoimmune  disorders   like antithyroid antibodies .Due to 50% association of osteopenia  with POF DEXA scanning  is done. If  patient has  fertility  wishes serum AMH is done for  ovarian  reserve.  Low  FSH  ,LHlevels  would  suggest hypothalamic cause. Serum prolactin is checked for prolactinoma.,Thyroid profile  done for  hypothyroidism.. If  prolactin >1000 iu/ml ,further brain imaging with CT warranted.  Free  androgen index,  serum testosterone, SHBG  done for  PCOS.   Ultrasound pelvis  is  done  for  assessing endometrial thickness, polycystic ovaries in PCOS. 17 alpha hydroxy progesterone  if raised would suggest late onset  congenitaladrenal hyperplasia.

c)POF  should  be  dealt  in a  sensitive  and  supportive  approach.Her  fertility  wishes  enquired. Multidisciplinary  care  involving  gynecologist,endocrinologist,fertility specialist,counsellor  is  provided. Due  to  increased  cardiovascular risk,osteoporosis   due to estrogen deficiency  combined  or sequential HRT  with  estrogen and  progesterone  is given to her. Androgen replacement  in the form of patch INTRINSA  is  offered  for  sexual dysfunction  due to androgen deficiency. Lifestyle modification,exercise  advice,vitaminD ,calcium supplementation given due to risk of osteopenia. Due to  spontaneous ovulation in 5- 10%  of  cases contraception  advice is given.  Barrier  and  IUCD are the preferred methods as OCP cannot  suppress high  FSH  levels.If  fertility wishes are present op tions  of adoption and oocyte donation discussed.Written information leaflets provided .Contacts of support group DAISY  N etwork  is provided to her.

assay 370 Posted by huaida A.


I would  take a history about the parity  and the age of the last kid,  and whether she is lactating or not ,  as lactation is a possible cause of secondary amenorrheoa .

would  inquire about drugs that may induce amenorrhoea  such as depo provera injection  or subdermal implanon contraceptives .

Also would inquire about history of postpartum heamorrhage  that followed by failture of lactation , such senario may point to the development of sheehans syndrome  that results in pan hypopituitarism .

would inquire about history of uterine curretage  , as excessive curretage  would result  in asherman syndrom.

Also would ask about symptoms of hypo oestrogenemia such as hot flush , dry vagina and loss of libido  , because premature ovarian failure is a possibility .

would ask about over exercise  which may cause hypothalamic amenorrhoea  .

Eating disorder is another differential diagnosis so would ask about it  in spite it is uncommon in such as age group .

Then would examine the woman . BMI  would detects under weight  as in eating disorder.

Also it would detect obesity which may presents in some cases of polycystic ovarian syndrome   as a cause of secondary amenorrhoea .

would observe abnormal hair distributiton pattern  that may presents in cases of PCOS or in androgen secreting tumour. would ask the lady to squeeze her nipples to exceclude galactorrhoea . would examin the abdomen for pelvic abdominal mass .

B /

Random FSH would help to diagnose or refute the diagnosis of premature ovarian failure .Transvaginal ultrasound would diagnose PCOS and may detect  an ovarian mass.Serum prolactin  may be elevated even in absence of galactorrhoea .TSH ,LH FSH ,ACTH   , Would be low in cases of sheehans syndrome.

Endometrial biopsy will be taken if endometrial tuberculosis is suspected.

uterine hystrescopy would be  good  option of invistigation if there is normal level of FSH, and there is failure of withdrowal bleeding  after short coarse of progestogens.


Premature ovarian failure is a risk factor for osteoporosis  and cardiac disease.Also skin texture would be affected  as well as libido .Hot flush and sweating may be sever enough to disturb the woman life.

The woman may still be at risk of pregnancy as FSH level would not predict  ovarian ovulation accurately .

So if the woman need contraception   ,low dose combine oral contraceptive pill,  would prevent pregnancy and relieve the other menopausal symptoms (in absence of contraindication ).Continous combined HRT is another option ,if no contra indication ,such as ,high risk for thromboembolism .

Subdermal oestrogen patch or implant is also good option  but should be combined with progestogen arm either orally or in form of mirena loop .

The woman should be counselled that HRT in premature ovarian failure is not associated with increase risk of breast cancer as in menopausal women , and the benefit outweigh the risk in absence of contra indication of their use .



If there is no contra indication forHRT she can use the continous combined oral one or subdermal oestrogen implant wi


Answer Essay 370 Posted by preetiba rani V.

a)  I will start with taking her menstrual history.  History of irregular menses with oligomenorrhoea and also subfertility needing ovulation induction agents may point towards PCOS.  Other features suggesting PCOS such as weight gain, acne and hirsutism need to be ascertained.  Past catastrophic obstetric history of massive post partum heamorrhage may point towards Sheehan's syndome. A previous history of dilation and curretage and infection may cause Asherman syndrome which also may lead to amenorrhoea.  Causes of hypothalamic amenorrhoea can be elicited from the history by asking regarding stress, excessive exercise and weight loss.  Symptoms such as galactorrhoea, headaches and visual disturbance may point towards prolactinoma.  I will also ask regarding sudden onset of virilisation symptoms such as deepening of voice, enlargement of the clitoris and breast atrophy which is suggestive of an adrogen secreting ovarian tumour or an adrenal tumour.  Underlying chronic diseases such as diabetes or renal disease need to be ascertained. Previous history of pelvic surgery, chemotherapy or radiotherapy also need to be elicited. Endocrine causes such as thryoid disorders can be elicited by enquiring regarding symptoms of hypo and hyperthyroidism.  Other symptoms of auto immune diseases should be elicited.  I will also ask regarding symptoms os hypoestrogenism such as hot flushes, irritability and insomnia as there is a possibility of premature ovarian failure.

A physical examination will include measurement of height, weight and BMI.  It is also important to recognize any dysmorphic features suggesting a genetic cause.  Examination of the neck may reveal an enlarged thyroid gland.  Breast examination is indicated if there is evidence of amenorrhoea.  This is followed by a visual field examination to look for bilateral hemianopia.  Cutaneous evidence of hyperandrogenism such as acne, hirsutism, clitoromegaly and breast atrophy must be looked for.  Sign such as acanthosis nigricans is suggestive of underlying autoimmune disorder or insulin resistance.


b)  Serum prolactin and thyroid function test needs to be done to exclude hyperprolactinaemia and thyroid disorders respectively.  If the serum prolactin is suggestive of prolactinoma MRI brain will be helpful.  Serum FSH, LH and oestradiol levels are equally important as high levels of FSH and LH in the postmenopausal range may indicate premature ovarian failure.  Serum DHEAS and testosterone may be indicated.  An ultrasound examination of the pelvis must be done to assess endometrial thickness (this may reflect the estrogen status of the woman), ovarian volume and antral follicular count.  I will also look for any ovarian mass that may be an androgen secreting tumour

c)  The diagnosis of premature ovarian failure should be disclosed to her in a sensitive way.  I will explain that it occurs in around 1% of woman and most of the time the cause is unknown.  Second line investigations such as karyotyping and screening for autoimmune diseases may be helpful to provide clear explanation to the patient.  Besides that it may help to identify those woman who are at risk of autoimmune disease.  Ovarian biopsy is not necessary.  A DEXA scan should be considered as a baseline assessment as women with premature ovarian failure have risk of osteoporosis.  The first aim of management is to help the woman to deal with the diagnosis.  Threfore contact numbers of support groups and information leaflets should be provided to the patient.  This woman will also benefit from HRT as she is at risk of having osteoporosis, depression, urogenital symptoms, derangement of lipid profiles and cardiovascular disease.  It is also important to counsel the patient regarding the risk HRT such as thromboembolic events.  Other general measures to reduce bone loss such as weight bearing exercise, cessation of smoking and alcohol must be emphasized.  Counselling regarding her reproductive health is also important.  I will inform her that 10% of women with premature ovarian failure may experience spontaneous resolution which leads to pregnancy.  Thus contraception is still needed to avoid unplanned pregnancies.  If the woman has a desire for more children the options may include ovum or embryo donation and adoption.

Posted by shazard S.

essay 370 secondary amenorrhea/POF


Take a menstrual history. Ask about her LMP, cycle length, regularity and menstual flow. Ask about contraceptives used. Combined oral contraceptives, depot progestogens or levonorgestrel-intra-uterine system use may cause amenorrhea. Ask whether she has future reproductive ambition. In her obstetric history ask the date of her last delivery and outcomes. Ask about post-partum haemorrhage. This predisposes to Sheehan's syndrome. ASk if she is breast feeding to rule out lactational amenorrhea. Ask about oligomenorrhea, weight gain and hirsuitism. These suggest Polycystic ovary syndrome. Regarding Premature Ovarian Failure (POF), ask about cigarette smoking, auto-immune conditions (pernicious anaemia, type 1 diabetes), climacteric symptoms (hot flushes, vaginal dryness) and a family history of early menopause. These increase the risk of POF. Ask about weight loss and altered eating habbits. These suggest anorexia nervosa. Enquire about strenuous exercise and stress. Enquire about headaches, visual disurbances and galactorrhea. These indicate a pituitary tumor. Regarding hyperthyroidism, ask about a history of hyper thyroidism or its symptoms(palpitations, weight loss and heat intolerance). Ask about rapid onset hirsuitism. This suggests an adrenal cause. Regarding surgical history, ask about ovarian surgery, endometrial curettage and endometrial ablation. Ask about a personal or family histoy of abnormal karyotype. Mosaic forms may cause secondary amenorrhea. Ask about prior chemotherapy or radiotherapy that may have been gonadotoxic. On examination measure her weight and calculate her BMI. Inspect for vertilligo and hirsuitism. Grade hirsuitism by the Ferriman-Galleyway system. Examine her visual field. Palpate and auscultate her thyroid. Goitre with a thyroid bruit suggest hyperthyroidism. Palpate her abdomen for ovarian masses. Perform a breast exam looking for galactorrhea. Perform a speculum vaginal exam looking for vaginal atrophy.


Blood investigations include serum FSH, estradiol, prolactin, androgens, and thyroid function tests. Increased FSH indicates POF. Low estradiol supports POF. Do not offer ovarian biopsy to distinguish resistant ovary syndrome as it is of no clinical significance. Offer genetic screening for karyotype abnormality if raised FSH. Mosaic Turner's syndrome may cause gonadal dysgenesis. If FSH decreased offer CT or MRI imaging to demonstrate a hypothalamic or pituitary tumor. Elevated prolactin supports a pituitary prolactinoma. Elevated T3 or T4 with low TSH demonstrates hyperthyoidism. Raised androgen levels suggests an adrenal cause. Perform serum 21 hydroxy-progesterone levels. If elevated suggests adult onset congenital adrenal hyperplasia. Transvaginal ultrasound to rule out PCOS. Contrast sonography may demonstrate intra uterine synechiae. This is confirmed with hysteroscopy.


Explain to her the nature of the diagnosis. Explain that with a normal karyotype menstral flow and ovulation resumes spontaneously in 20% of cases and pregnancy may occur in this situation. Detirmine her concerns regarding fertility and climacteric symptoms. If fertility is not desired advise contraception. Advise that the COCP may not offer effective contraception and advise intra uterine devices. If she has further reproductive ambition counsel her regarding egg donation, embryo transfer or adoption and refer to a fertility specialist. Explain that menopause increases her risk of cardiovascular disease (CVD), osteoporosis, alzheimer's diseaese, macular degeneration and tooth loss. Offer Hormone Replacement Therapy(HRT) at doses that prevent osteoporosis. Advise lubricant or vaginal estrogen cream for vaginal dryness. Offer Raloxifene and advise weight bearing exercise to reduce bone loss. Explain that HRT increases the risk of CVD, VTE and Breast cancer. Assess her risk for these conditions. Offer written information and contact information for support groups such as the daisy network and the international premature ovarian failure association.

Posted by Anagha W.

I would ask in detail about her menstrual cycle pattern, age of menarche and confirm the date of her last menstrual period. Presence of hot flushes, night sweats, decreased libido, dryness of vagina and mood swings may point towards premature ovarian failure. I would ask when was her last baby born and is she still breastfeeding as it may be associated lactation amenorrhoea. Previous catastrophic obstetric haemorrhage at the time of delivery can cause Sheehan’s syndrome (pituitary necrosis) leading to amenorrhoea. Previous dilatation and curettage leading to Asherman’s syndrome should be ruled out. I will ask her about type of contraception she uses; Depot medroxy progesterone acetate, progesterone only implants and Levonorgestrel containing intrauterine devices may cause amenorrhoea in some. There can be delay of return of periods for upto 6 months after stopping combined hormonal pills. I will inquire about presence of headaches, visual disturbances and galactorrhoea as it may point towards hyperprolactinaemia. Medications like phenothiazines, metoclopramide and alpha methyldopa can also cause hyperprolactinaemia. Medical history of Diabetes, thyroid dysfunction, and adrenal insufficiency should be ruled out. Acne, hirsutism, weight gain and subfertility may be present if she suffers from polycystic ovarian disease. I would ask her about previous pelvic surgery, radiotherapy or chemotherapy.  I would ask her about family history of early menopause especially in her mother or sisters. I will make an enquiry into her eating habits as severe weight loss and anorexia can lead to amenorrhoea. I will ask her about her occupation as a one involving intense exercise like athletes or ballerina can be associated with amenorrhoea. I will also make a sensitive inquiry to find out if she is intensely stressed psychologically or emotionally as it can cause menstrual irregularities including amenorrhoea.

On examination I will check her weight and height to calculate her body mass index (BMI). Extremes of BMI; less than 18kg/m2 like in anorexic individuals or more than 30kg/m2 in obese patients can be associated with amenrrhoea. I will check her blood pressure. I will examine her breast to look for galactorrhoea and her visual fields if she has visual disturbances. Stigmata of autoimmune diseases like acanthosis nigrans in diabetes and hyperpigmented striae in adrenal insufficiency may be seen. Goitre may be present in thyroid dysfunction. I will check for signs of hyperandrogenism like acne and presence and extent of hirsutism, if polycystic ovarian disease is suspected. I will palpate the abdomen for any obvious ovarian masses or cysts. I will perform a pelvic examination to rule out pelvic masses. Atrophic vaginitis may be present in case of dryness of vagina in premature ovarian failure which causes hypooestrogenaemia.


I will check her serum follicle stimulating hormone (FSH), luteinizing hormone (LH) and serum oestradiol (E2) levels. High FSH and LH with low E2 is seen in premature ovarian failure (POF). If serum FSH is more than 30IU/L it should be rechecked after a month. If it is still more than 30IU/L, the likely diagnosis is premature ovarian failure. Normal FSH with normal or high LH and normal or high E2 suggests polycystic ovarian syndrome. Low FSH, LH, E2 is present in anorexia, excessive weight loss and Sheehan’s syndrome. Serum prolactin should be checked to rule out hyperprolactinaemia. Thyroid function tests should be checked if thyroid dysfunction is suspected. Dihydroandrostenedione sulphate and serum testosterone will be raised in hyperandrogenism and adrenal dysfunction. If history is suggestive of diabetes, fasting blood glucose and glycosylated haemoglobin should be checked. Pelvic ultrasound will aid the diagnosis of polycystic ovarian syndrome and help measure endometrial thickness and detect any ovarian cysts.


I will explain the diagnosis to the woman in a sensitive and empathetic manner as it can cause severe psychological and emotional impact on her. I will involve multidisciplinary support from psychological counselors, clinical psychologists, endocrinologists and geneticists (if aetiology of POF suggests a genetic cause). I will explain to her the need for long term hormone replacement treatment- HRT with the risks like small increase in breast cancer and venous thromboembolism and benefits like protection against osteoporosis and for symptomatic treatment of menopausal symptoms like hot flushes, night sweats, mood swings and decreased libido. It contains oestrogen taken either orally, transdermally or vaginally with progestogen which could be oral , transdermal or intrauterine. She may require testosterone containing implant or patch (Intrinsa) for general and sexual wellbeing. I will explain to her that spontaneous ovulation can occur in 5-10 % women suffering from POF and contraception will be required if her family is complete. This can be in the form of barrier or intrauterine devices. HRT is not a contraceptive. If she is desirous of having children, this can be achieved by oocyte donation with invitro fertilization or embryo donation or adoption.


Posted by gouthaman S.

sir you have not corrected my essay the name displaced under my name is not mine my essay  is  above huaida. huaidas answer is corrected under my name .please correct  sir.SORRY FOR THE INCONVENIENCE.

                                                                                                                                  GOUTHAMAN .S

assay 370 Posted by huaida A.




Posted by gouthaman S.

HUAIDA  your answer  has been corrected  but  under  my  name.just check it out.Mine  only  is  not corrected.

                                                                                                                                     GOUTHAMAN .S

Posted by Farrukh G.


Posted by gouthaman S.
Sat Aug 18, 2012 10:32 am

sir you have not corrected my essay the name displaced under my name is not mine my essay  is  above huaida. huaidas answer is corrected under my name .please correct  sir.SORRY FOR THE INCONVENIENCE.

                                                                                                                                  GOUTHAMAN .S

Thanks for pointing this out & sorry for the error. This has been corrected and your answer will be marked and posted below.