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MRCOG PART 2 SBAs and EMQs

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Essay 273 - Sec amenorrhoea

Posted by Shachi M.
(a)Justify the information you would obtain from the history [8 marks].

This is a case of secondary amenorrhea. Progressively increasing generalised swelling of abdomen, heat intolerance,swollen breasts, in a sexually active woman might indicate pregnancy. One should enquire if the periods before 9 months were regular. A history of irregular periods followed by amenorrhea, associated with hirsuitism and acne could be due to polycystic ovarian syndrome. Menopausal symptoms (hot flushes and night sweats) could indicate premature ovarian failure. A history of severe systemic illness or infection (chronic renal failure, liver failure , tuberculosis) or radiotherapy or chemotherapy for cancer, points to a diagnosis of secondary ovarian failure. Symptoms of visual disturbance and headaches could be due to prolactinoma. A history of weight loss, loss of appetite associated with stress could be due to anorexia nervosa. One should enquire about patient’s current method of contraception, as depot provera and mirena coil can give rise to irregular periods or amenorrhea. A history of progressive weight gain, especially truncal obesity and abdominal srtiae could be due to cushing’s syndrome. One should also enquire about recent surgery (oopherectomy for ovarian cyst or severe premenstrual syndrome), current medication (Gonadotrophin hormone releasing hormones for severe endometriosis will cause amenorrhea) and drug and alcohol abuse.

b) Logically outline your investigations, given that clinical assessment is unremarkable [7 marks].

If clinically suspected, a urine pergnancy test should be done. Leutinising Hormone (LH), Follicle Stimulating hormone(FSH), and serum estradiol should be performed. A raised FSH with low estradiol indicates ovarian failure. A raised LH/FSH ratio, high testosterone to sex hormone binding globulin(ASHBG) ratio, and raised testoesterone indicates polycystic ovarian syndrome, in absence of any other cause of hyperandrogenism. A low LH &FSH indicates a disorder of hypothalamic pituitary axis, as seen in anorexia nervosa. Raised prolactin levels can be seen in prolactinoma and polycystic ovarian syndrome. A full blood count, liver function tests, thyroid finction tests and renal function tests should be done only if clinically indicated, to rule out systemic disease. A pelvic ultrasound should be performed to rule out structural abnormalities of uterus and ovaries. Multiple peripheral ovarian follicles (more than 10 follicles, less than 10mm size) or increased ovarian volume could be seen in polycystic ovarian syndrome



(c) She is found to have the polycystic ovary syndrome. Evaluate the non-surgical treatment options to enable her have regular menstrual cycles [5 marks].
It is important that women with polycystic ovarian syndrome have periods at least once every 3-4 months for endometrial protection as they are at increased risk of endometrial cancer.
Women who are not planning to conceive in the near future can have oral contraceptive pills(OCPs) or Mirena coil.
OCPs help regulate periods, provide effective contraception, decrease risk of endometrial and cervical cancer, and are easy to use (once daily oral adiministraion). If dianette is used, it contains cyproterone acetate which reduces hirsuitism. OCP’s are associated with increase risk of thromboembolic episodes and this risk is higher with Dianette. OCPs cannot be used in women at high risk of thromboembolism, migaraines with aura, liver disorders or breast cancer.
Mirena coil provides effectve contraception and endometrial protection (thins the endometrium). It needs to be changed once every 5 years and has minimal systemic side effects. Insertion can be uncomfortable especially in a nulliparous woman andit can cause irregular vaginal bleeding.
Women who are planning for a family in the near future can use cyclical progesterone (eg Medroxyprogesterone acetate 5mg 2-3 times a day). This can be used either once a month or once every 3 months. A pregnancy test should be performed at each cycle before starting progesterone. Oral progestogens acn give rise to systemic side effects like abdominal bloating, headaches and weight. The final decision about the choice of medication should made in consultation with the patient in context with her clinical background and preferance .
Posted by Manoj M.
A healthy 30 year old nulliparous woman is referred to the gynaecology clinic because she has not had a menstrual period for 9 months. (a) Justify the information you would obtain from the history [8 marks]. (b) Logically outline your investigations, given that clinical assessment is unremarkable [7 marks].(c) She is found to have the polycystic ovary syndrome. Evaluate the non-surgical treatment options to enable her have regular menstrual cycles [5 marks].

A) Secondary amenorrhea is a condition that can create anxiety to the patient, therefore a sensitive history should be taken. Pregnancy could be one of the causes, therefore a possibility of this should be enquired. Previous regularity of the menstrual cycles should be enquired. History of increase in weight must be enquired. History of abnormal facial hair groth, acne should be enquired as this along with her amenorrhea could suggest polycystic ovarian syndrome(PCO). History of stress, double vision, headache or galactorrhea may point towards hyperprolactinemia. A recent history of diet or exercise, history suggesting anorexia leading to weight loss should be enquired as this could suggest hypogonadotrophic hypogonadism. History regarding life style, active involvement in athletics or could point towards hypogonadotrophic hypogonadism. Previous history of uterine procedures like dilatation and curettage can suggest uterine synechiae- Ashermann\'s syndrome. History of hot flushes, night sweats and vaginal dryness could point towards premature ovarian failure. A family history for the same should be enquired to rule out karyotypic abnormalities. Any current or previous use of contraception should be enquired- as implanon can cause amenorrhea and DEPO provera can cause amenorrhea upto 2 years of discontinuing it. Any associated medical disorders like thalassemia, renal problems must be asked as this could be one of the causes. Any previous treatments like chemotherapy or raditherapy must be asked for.

B)A pregnancy test should be done to rule out pregnancy. A full blood count should be done to rule out anaemia. Baseline follicular stimulating hormone (FSH), luteinising hormone (LH), oestradiol levels will differentialte between premature ovarian failure( with high FSH >40 and low oestradiol levels) and hyprogonadotrophic hypogonadism( low FSH, LH and oestradiol). An ultrasound of the pelvis will reveal any space occupying lesion like an ovarian tumor. It can be useful in detecting polycystic ovarian appearance and together with mild elevated LH and normal oestradiol levels could suggest PCO. Testosterone and Sex hormone binding globulin levels acn be checked in case of PCO. An abnormally elevated Testosterone level >5nmol/l cpould suggest adrenal tumor. Synacthen test CTscan can be done for the same. Prolactin levels can be checked, if raised MRI of the Brain is mandatory to rule out prolactinoma. Karyotyping can be done to rule out Turner\'s or 47XXX. A hysteroscopy can be done as inpatient or outpatient to rule out uterine synechiae. Additionally urea and electrolytes can be checked to ensure normal renal function.

C) The patient should be reassured and counselled sensitively. A multidisciplinary approach with Gynaecologist, endocrinologist may be more useful. Life style changes should be suggested. If overweight, weight reduction should be suggested. A 5 to 10 % weight loss can improve her chances of ovulation and menstruation. Regular exercise and diet modification may be helpful. The role of dietician must be emphasised to help her in the weight loss. The role of Metformin for ovulation and thus menstruation is controversial. Low dose combined contraceptive pills may be useful in allowing regular cycles. In the long run this would protect the endometrium against unopposed oestrogen action. Progesterones like medroxyprogesterone acetate may be given cyclically to induce withdrawal bleed. It may be mentally very trying for the patient, therfore regular follow up is necessary. Support group information and written information should be provided.
Posted by Srivas  P.
(a) I will enquire about her menarche, previous menstrual history, regularity, cycle length, and amount of bleeding and whether they were spontaneous bleeds or following hormonal treatments. This will help differentiate from a per se primary amenorrhea.

Her contraceptive history about use of DMPA, POPs, Implants or COCs- as all of these may cause amenohhoea. The possibility of pregnancy itself should be kept in mind-history of nausea and vomiting should be taken, also fetal movement if in mid trimester pregnancy.

Recent weight loss of 10-15%, present body mass index less than 19Kg/m2, excessive exercises can cause hypothalamic ammenorrhoea with impaired gonadotrophin secretion. Sudden and extreme emotional upsets may rarely have similar effects but is usually not so prolonged.

I will enquire about hirsutism, acne, weight gain which may point to PCOS but sudden and rapid hirsutism, signs of virilism like voice change, cliteromegaly may suggest Ovarian/ adrenal androgen secreting tumors, or late onset CAH. History of galactorrhoea should be taken along with any visual field changes, head ache that may suggest pituitary prolactinomas.

History of hot flushes and vaginal dryness may suggest premature Ovarian failure. Family history is important. Premature ovarian failure may run in families which could be due to autoimmune conditions, chromosomal disorders. Turner’s syndrome and fragile X syndrome may present with secondary amenorrhea. CAH may also run in families as also PCOS.

Her obstetric history including prior terminations of pregnancy or miscarriages involving uterine curettage can help rule out either Ashermann’s syndrome or cervical stenosis as cause for amenorrhea.

(b) Testing for pregnancy is important to rule out pregnancy. FSH, LH, prolactin levels, and testosterone should be done. High FSH and LH may suggest Premature ovaian failure and this should be confirmed by repeat testing. Low FSH and LH may suggest hypothalamic cause . Prolactin may be moderately elevated in response to stress, breast examination but in these cases it returns to usual levels within 48 hours. Prolactin may be elevated in some cases of PCOS and hypothyroidism, but levels 1500-4000 may suggest pituitary microadenoma and requires further investigation, such as computed tomography or a magnetic resonance imaging of the pituitary fossa to rule out pituitary tumor. A level 5000-8000 mIU/l is usually associated with pituitary Macroadenoma. Measurement of visual field defects should be done for suspected hypothalamic or pituitary tumours.

Testosterone/androgen levels may be mildly elevated in PCOS but levels above 4.8 mmol/l requires investigation to exclude other causes such as late-onset congenital adrenal hyperplasia, Cushing\'s syndrome, or an adrenal or ovarian tumour. In CAH, 17-Alpha hydroxyl progesterones are increased.

Pelvic ultrasound may show polycystic ovaries, with increased stroma and multiple, small, peripherally situated follicles. It is also useful to demonstrate endometrial thickness as evidence of oestrogenization which is seen in PCOS whereas it is not seen in hyperprolactinemia due to other causes. USG may also detect adrenal hyperplasia, ovarian and adrenal tumors.
Hysteroscopy may be indicated if history suggestive of Asherman\'s syndrome.
24-hour urine cortisol measurement if historyand body habitus suggests Cushing\'s syndrome. Woman with possibility of premature ovarian failure at this age should also have karyotyping done.

C) In PCOs, period are likely to remain irregular without treatment but she should have withdrawal bleed every 3-4 months atleast to prevent future development of endometrial carcinoma. Her periods may get spontaneously regular if she loses weight in case she is obese. If the woman also has hyper insulinemia control of her weight and metformin treatment may regularize her periods and also induce ovulation.

If she aims to get regular monthly periods she can take COCs if she is not keen on fertility as yet. If she wants to get pregnant clomiphene treatment induces ovulation and thereby regularizes her periods and helps her achieve pregnancy.
Posted by Manoj M.
A healthy 30 year old nulliparous woman is referred to the gynaecology clinic because she has not had a menstrual period for 9 months. (a) Justify the information you would obtain from the history [8 marks]. (b) Logically outline your investigations, given that clinical assessment is unremarkable [7 marks].(c) She is found to have the polycystic ovary syndrome. Evaluate the non-surgical treatment options to enable her have regular menstrual cycles [5 marks]

(a) A history of regularity of periods prior to 9 months will suggest this is secondary amennorrhoea. Exclude pregnancy from history if she was planning for pregnancy, morning sickness, weight gain, breast changes etc.
History of any current contraceptives use like depot medoxy progestrone acetate, Implanon could explain complete anovulation leading to amennorhoea or a Mirena coil use may suggest thinned endometrium as the cause.
Menopausal symptoms like hot flushes, night sweats, mood swings may suggest premature ovarian failure.
Symptoms suggestive of hyperandrogenism like hirsutism, acne, voice changes may suggest polycystic ovarian syndrome (PCOS).
History of headache, visual symptoms, galactorrhoea may suggest pituitary diseases like prolactin secreting adenoma.
History of stress, weight loss, exercise may suggest hypothalamic dysfunction.
History of pelvic tuberculosis / mumps may cause endometrial fibrosis so does history of traumatic endometrial currettings causing Asherman\'s syndrome.
Any recent treatment with chemotherapy /radiotherapy should also be excluded which may cause ovarian failure/endometrial fibrosis.
Muscle weakness, fatiguability may suggest auto immune causes like myasthenia gavis.
Heat intolerance, weight gain may suggest endocrine causes like hypothyrodism.
Rare causes like surgical trauma to cervix should also be excluded from history as may causes obstructive amenorrhoea.

(b) Pregnancy should be excluded with a urine pregnancy test.
Serum follicle stimulating hormone (FSH), Luteinising hormone (LH) and a free androgen index (FAI) should be done and interepretted as below.
An elevated FSH and LH suggests Premature ovarian failure in a woman of age 30. This could be due to intrinsic ovarian defect or genetic mosaicism for which a Karyotype is helpful.
Elevated LH and FAI may suggest PCOS and a progestrone challenge test will suggest circulating oestrogens are adequate and favours PCOS. An ultrasound scan of pelvis may show polycystic appearance of the ovaries and helpful in diagnosis of PCOS. An ultrasound scan of pelvis and abdomen can also look for androgen secreting tumours.
A thyroid function test can exclude hypothyrodism.
An MRI of brain may be helpful to exclude pituitary tumors/ craniopharyngiomas but these are unlike to present as unremarkable on assessment.

(c) Women with obesity and PCOS will benefit from weight loss making cycles ovulatory.
Dietary advices and dietician input is helpful with targetted weight loss to correct menstrual cycles.
Weight reduction with medications like orlistat may also be helpful in achieving weight loss to regularise menstrual cycle.
Regular exercise is helpful to regularise menstrual cycle
Cyclical progestogens or combined oestrogen and progestogen pills is helpful to regularise menstrual cycle.
Role of metformin in PCOS group to correct insulin insensitivity and in turn correcting ovulation to regularise menstrual cycle is controversial.
Posted by San S.
(a) Justify the information you would obtain from the history [8 marks]
It is useful to enquire about her age of menarche and previous menstrual cycle pattern. Her previous usage of contraception is useful as certain type of contraception e.g.depo-provera may delay return of menstruation up to a year. Previous abnormal smear or treatment may cause cervical stenosis.
Past medical history of miscarriage requiring surgical evacuation may cause Asherman\'s syndrome.Previous meningitis and head trauma can also cause secondary amenorrhoea. Family history is useful for genetic causes of this condition.
Other associated symptoms e.g.hot flushes, night sweats with positive family history may suggest premature menopause. Symptoms of intolerance to heat, sweaty, tiredness and thinning of hair may suggest thyroid diseases. History of recent dramatic weight loss and excessive exercise may suggest hypothalamic cause of secondary amenorrhoea whereas a history of weight gain, acne and hirsutism may indicate polycystic ovarian syndrome.

(b) Logically outline your investigations, given that clinical assessment is unremarkable [7 marks]
I would perform a pregnancy test to rule out pregnancy. Biochemistry investigations would include LH, FSH, testosterone, SHBG, TSH and prolactin levels. In PCOS, there may be increase in LH/FSH ratio, raised serum testosterone levels and decreased SHBG. In premature menopause, FSH and LH may be elevated. TSH and prolactin levels are useful to rule out thyroid diseases and prolactinoma.
An ultrasound scan can be perform to look for features of PCOS and occasional may image features suggestive of ashermans syndrome.

(c) She is found to have the polycystic ovary syndrome. Evaluate the non-surgical treatment options to enable her have regular menstrual cycles [5 marks].
Non-surgical treatment options would depend on the associated symptoms with this condition and her desire for fertility. In any cases, she should be advised on weight loss if she has a BMI>30 as this would help to correct abnormal serum biochemistry changes and result in regular menstual cycle. This would also improve her general health and prevent future morbidity caused by cardiovascular disease and type 2 diabetes. It may be useful to refer her to a dietician.
If she is not planning for pregnancy, she could have combined oral contraceptive pills to regulate her cycles. Dianette may be useful if she has associated symptoms of hirsutism. Medroxyprogesterone acetate for 5 days may be used to induce withdrawal bleed on a monthly to 3 monthly intervals if she wishes. She should be fully informed of the potential side effects of each treatment.
If she is planning for pregnancy, metformin has proved to decrease LH levels, help with weight loss, regulating mentrual cycles and improve fertility.
Posted by Sam M.
She will be asked about her age of menarchae . Regularity of menstraul cycles since menarchae ,length of the cycle ,amount of blood loss, and history of dysmenorrhea will be asked. I will ask her about her last menstrual period ,its duration and amount of loss. I w ill ask her that if she is sexually active and was she planning to get pregnant ? Has she done her pregnancy test?. History of contraception ,its type like hormonal or IUCD , how long she is doing this contraception is important. I will ask her about her current contraceptive methods if any. History of weight gain ,hirsutism ,acne and galactorrhoea will be asked.I will ask her for symptoms of virilization for example deepening of voice ,clitoral enlargement and male pattern of baldness. History of mass abdomen ,pain ,vaginal discharge will also be taken.I will ask her about past medical illnesses ,auto immune disorders and her general health .History of anorexia or execessive exercise for weight reduction is important. History of chemotherapy and radiotherapy or surgical removal of ovaries will be taken. I will ask her about hot flushes ,increasing irritability and discomfort in sexual intercourse because of vaginal dryness.


Part b. I will ask for ,serum FSH ,LH ,testosterone index and prolactin levels. In polcystic syndrome LH will be remarkably raised.LH to FSH ratio is not used as diagnostic criteria for polycystic syndrome.Testosterone >5 nmol/l suggest do 17 hydroxy progesterone level.Prolactin levels are raised in around 20% of polycystic syndrome cases.Raised FSH and LH levels above the normal values (according to menstrual cycle) variation are significant .They indicate that ovary is not functioning (premature ovarian failure secondary to autoimmune disorder ,radiotherapy ,chemotherapy or surgical ablation) and negative feed back is no more there to control execessive FSH and LH productions. Lower than normal values of FSH AND LH indicate hypogonadotrophic hypogonadism which resulted from excessive exercise and anorexia nervosa, tumors and trauma of central nervous system. Pelvic ultrasonography for ovarian morphology (,peripherally arranged follicles > 12 indicate polycystic ovarian morphology),other pelvic pathologies. Progesterone challenge test can be done for assessing that endometrium is primed or not.

].(c) She is found to have the polycystic ovary syndrome. Evaluate the non-surgical treatment options to enable her have regular menstrual cycles [5 marks].

Different types of hormonal preparations are available for regularising menstrual cycle and symptoms control. As there are no signicant risk factors in her history so Combined oral contraceptive pills are suitable ,easily available ,cheap and being oral preparation easy to take.OCP regularizes cycle ,control excessive menstrual loss,dysmenorrhea and PMS .Drawbacks are compliance and breakthrough bleeding in initial phases .These are available in contraceptive doses so if she wants pregnancy then 3 months time period is required for return of fertility after stopping the pill .Progestogen only pills has risk of more breakthrough bleeding and less efficient can only induce withdrawl bleeding. Weight reductions of 10% of body weight regularizes menstrual cycle and ovulation.
Posted by J P.
a.This is the case of secondary amenorrhea in which pregnancy should be ruled out first by eliciting history of any pregnancy symptoms.History of any previous episodes of amenorrhea and the treatments taken will be enquired.History of weight gain ,increase in hair in unusual places which suggest polycystic ovarian syndrome will be asked. History of any mass or sweling in abdomen with deepening of voice[virilisation] suggestive of ovarian or adrenal tumour should be enquired. History suggestive of thyroid dysfunction like weight loss or gain inspite of good appetite and intolearance to heat will be enquired.History of head ache ,vomiting ,milky discharge from nipple suggestive of prolactinomas will be enquired. History of rapid gain in weight with trunkal obesity and abdominal striae suggestive of cushings disease will be enquired.History of recent loss of weight of more than 15 %with more concern over body weight may suggest hypothalamic amenorrhea like anorexia.History of repeated curettage suggestive of ashermann syndrome will be emquired.History regarding contraceptive usewhich may cause amenorrhea like MDPA and her desire for fertility will be carefully enquired since this affects management.

b.Investigations will be based on to rule out the causes for amenorrhea. If early pregnancy is suspected urine pregnancy test to be done.Blood investigations like FSH,LH will be done since LH/FSH ratio more than 2 in PCOSand gonadotrophins level will be normal or low in hypothalamic amenorrhea like anorexia.Dehydro epiandrosterone sulphate and testosterone levels if markedly elevated may indicate adrenal or ovarian tumor.Serum testosterone levels more than 4 nmol/l suggestive of ovarian or adrenal tumors which may need to be confirmed by USG abdomen and CT abdomen in some cases. Thyroid profile and prolactin levels will be done since they may be elevated in asymptomaic patients.CT of brainmay be done in caes of markedly elevated of prolactin to rule out miro prolactinomas which may even present without symptoms.

c.Non surgical treatment will be simple life style changes and pharmacological management.. Her desire for fertility should also be enquired Life style chnges like simple weight reduction of 10 % with the help of dietician will restore menstruration in most of obese PCOS patients.Low dose oral contraceptive pills will restore menstruation and effective contraception with the side effects like mood changes ,retention of fluid and breast tenderness.Alternatively progestogens may be used in luteal phase to cause withdrawal bleeding which is essential to prevent endometrial hyperplasia in PCOS.But this does not provide effective contraception ,hence if the patient does not intend pregnancy it should be combined with IUCD or mirena coil to relieve anxiety of pregnancy.Information leaflets and support groups addresses will be given andultimately patient choice of drug will be taken into account for treatment.
Posted by Asma kamal K.
(a)History will be directed towards finding the cause for secondary amenorrhoea. I will ask her about the LMP, sexual history and morning sickness to exclude pregnancy. I will ask in detail about contraception,(if any) what method she is using(IUCD,Depo form progestogens) . I will ask her about any gain in weight, hirsutism , irregularity of cycles preceding amenorrhea to exclude polycystic ovarian disease. I will ask about irritability and mood changes , hot flushes to exclude premature ovarian failure. To exclude any endocrine cause I will ask her about increase/decrease in appetite, heat intolerance /cold intolerance ( hypo or hyperthyroidism). Frontal alopecia, change in body habitus, change in voice(late onset adrenal hyperplasia). Straiae , pigmentation , proximal muscle wasting (cushing syndrome).
I will ask her about any early pregnancy loss, evacuation of product of conception, pelvic inflammatory disease, IUCD insertion to rule out asherman syndrome. I will ask about any visual problems, headache , galactorrhoea to exclude hyperprolactinemia. To exclude anorexia nervosa and exercise related cause, I will ask about excessive exercise, vomiting ,change in appetite and weight loss.
I will ask her about family history of PCOS, CAH or endocrine problems or difficulty in conception. I will inquire about her desire for future pregnancies and contraception.


(b) I will do Beta hcG to exclude pregnancy, TFT to rule out thyroid abnormalities because such abnormalities may manifest for the first time in the form of menstrual irregularities and they are easy to correct. On clinical assessment ovarian, hypothalamic, pituitary causes may not be evident so I will do prolactin and gonadotrophin levels(FSH,LH). I will repeat these if they are not with in the normal range in four to eight weeks time to ascertain consistency. I will give her progestrone challenge test to have an idea about the oestrogen status and rule outflow tract obstruction. A positive test would be in the form of withdrawal bleed. PCOS thyroid abnormality and mild exercise related causes will give positive results while ovarian failure pituitary tumor and anorexia nervosa will give negative results. In negative test I will stimulate the endometrium with oestrogen first and then give progestrone , the absence of withdrawal bleed will be highly suggestive of Asherman syndrome which will be confirmed on hysteroscopy. I will ask for ultrasound pelvis exclude PCOS and pregnancy.

(c)if the patients BMI > 27kg/m2 weight reduction will improve ovulation and culminate in regular cycles. Exercise and diet controll in consultation with a dietician will help.Regular cycles can be achieved with lipid friendly low dose combine oral contraceptive pills, provided there are no contraindication to there use which seems unlikely in this young healty woman. Alternative is medroxy progesterone acetate/dydrogesterone for 10-12 days every one to three months to cause withdrawal bleed and shedding of endometrium. The advantage of regular shedding of endometrium(prevents from endometrial hyperplasia and neoplasia) and side effect of the COCP(nausea ,vomiting ,VTE), Progestterone(weight gain ,bloating,mood changes) exlpained to the patient . The patient will be allowed to have informed choice and all the information will be supported with written information.
Posted by Farkhanda A.
A----Justify the information you would obtain from history.
This is a case of secondry amenorrhea which may be physiological or pathological. To obtain the correct diagnosis and treatment, detail history is of paramount importance.
I will ask that it happened first time or there is already existing problem of scanty or irregular periods to get some idea about polycystic ovaries (PCOS). PCOS is the most common cause of anovulatory scanty menses in this age group after pregnancy. At the same time, I will explore any abnormal growth and pattern of hair growth. I also ask about her last menstrual periods date to exclude pregnancy or if she is breast feeding her child to confirm or rule out lactational amenorrhea. I will enquire about any headache or visual disturbance to exclude any cause related with pituitary either hyperprolactinaemia due to pituitary adenoma or necrosis of it due to previous history of severe post partum haemorrhage and oligovolumaemia.
I will also ask about any treatment including chemotherapy and radiotherapy. I will enquire about loss of weight and any social or occupational activity which cause her to do sterinous exrercise or if her appetite is lost such as in anorexia nervosa.I will take her contraceptive history, if she is using progestogen only contraceptive pills or intra uterine system which only release progesterone.
I will also ask about heat or cold intolerance and acne or skin changes to see if thyroid is involved or not and finally about any menopausal symptoms , to rule out premature ovarian failure.
B----Investigations will include , first of all pregnancy test to exclude pregnancy. To rule out pituitary cause serum prolactin level . Then hormone profile such as Follicle stimulating hormone (FSH), Latinising hormone(LH) which may be normal (as in anorexia nervosa) or high in premature ovarian failure particularly FSH . The LH may be double or triple than the level of FSH in (PCOS). The androgens level including androgens free index (AFI)., Testosterone level. Androstenedion level and sex hormone binding globulin level (SHBG) which is usually high in PCOS. If there is some doubt about thyroid, then thyroid function tests including thyroid stimulating hormone (TSH) T3 and T4 levels.Ultra sound scan of pelvis for any pathology such as PCOS confirmation. Computerised Tomography(CT) only indicated if suspicion of pituitary cause is in mind.
C----Inform the lady about the diagnosis and reassure her that it is not a malignant condition and about 20% of women in their reproductive age suffer with this condition. If her body mass index(BMI) is more than normal, explain her that only by reducing 10 % of body weight will resume her spontaneous ovulation and ultimately her periods.
If she needs contraception at the same time, then combine oral contraceptive pills or patches will give her withdrawl bleedind after every 3 weeks. She will feel relief that at least her periods are regular.If her skin is also with acne and she is worried, then she can be given cyproterone acetate ( anti androgen activity) + oestradiol = Dianette for 21 days and 1 week pill free for withdraw bleeding.
In PCOS, there is resistant hyperinsulinaemia which had a significant contribution in hormone imbalance and in significant number of women if we give metformin starting 500mg per day and increase gradually it will resume periods and help her to reduce weight.
Posted by H P.

H
(a)I will take a detailed menstrual history regarding cycle length, duration, amount and dysmenorrhea. I would inquire about sexual activity and symptoms suggestive of pregnancy like nausea, vomiting, weight gain, breast changes and quickening. I will ask if there is a prior history of similar episode of amenorrhoea and whether any treatment taken for it. Painless periods may suggest anovulation. A history of preceding oligo- hypoamnenorrhoea may suggest premature ovarian failure or PCOS. I will ask about recent weight changes. Weight gain may be associated with polycystic ovarian disease or hypothyroidism. Recent weight loss more than 15% may point to anorexia nervosa. A history of change in diet and increase in exercise is elicited.
Present or past contraceptive history regarding usage of depot preparation like medroxy progesterone acetate (DMPA) or Implanon is important as it can cause prolonged amenorrhoea. A previous miscarriage or termination of pregnancy with surgical evacuation may cause uterine synechiae (Ashermann’s syndrome). Hot flushes, irritability, night sweats and vaginal dryness suggest ovarian failure. I will ask her about any stressful events which may lead to hypothalamic cause. A history of breast secretions with symptoms of headache and visual disturbances may suggest hyperprolactinaemia. Thyroid dysfunction should be ruled out. Cold intolerance, pedal edema, lethargy and sleepiness suggest hypothyroidism while heat intolerance, irritability, palpitations and insomnia are suggestive of hyperthyroidism. I will ask her if she has noticed any abnormal growth of body/ facial hair and acne which may be due to PCOS or androgen secreting tumour. I will ask her if she has noticed any skin hyperpigmentation or abdominal striae which can be due to Cushing’s syndrome. I will inquire about family history of similar complaint in mother or sisters as congenital adrenal hyperplasia (CAH), premature ovarian failure and PCOS may be inherited. Abdominal mass or pain may be due to ovarian tumour.
(b) I will do a urine pregnancy test if symptoms are suggestive. I will send a blood for complete blood count to rule out anemia, baseline FSH, LH, and serum free and total testosterone level.
After ruling out pregnancy, for estrogen status, a progesterone challenge test (PCT) with 10mg of medroxy progesterone acetate for 5 days is done. Withdrawal bleeding will suggest anovulatory cause like PCOS, hypothalamic-pituitary dysfunction except when there is decidualised endometrium due to high androgen levels or high progesterone like DMPA. PCT is negative in cases of ovarian failure, anorexia nervosa, severe stress and pituitary causes. If PCT is negative, estrogen should be given prior to progesterone and if still no withdrawal bleed will suggest obstruction of outflow tract or uterine cause like synechiae. FSH, LH levels are repeated on second day of withdrawal bleed.
I will arrange for a pelvic ultrasound to rule out any ovarian mass or polycystic ovaries.
Low FSH, LH levels are suggestive of a pituitary or hypothalamic cause. Normal levels may be present in hypothalamic causes like stress/ anorexia.
High FSH, LH level suggest premature ovarian failure or resistant ovary syndrome .A karyotype is needed to rule out mosaic Turner’s or dysgenetic gonads.
Altered LH/ FSH ratio of >2 may be seen with PCOS.
Slightly high prolactin levels may be seen in PCOS, stress or hypothyroidism but levels more than 1000mIU/L needs visual field tests and MRI of brain to rule out pituitary adenoma.
Serum testosterone may be raised in PCOS but level >5 nmol/l, need ultrasound for androgen secreting ovarian tumour. Serum 17 alpha hydroxy progesterone levels may be needed in presence of virilising symptoms with high testosterone to rule out late-onset CAH.
Hysteroscopy is needed to confirm Ashermann’s syndrome.
(c) I will explain that this is a relatively common condition with hyperandrogenemia with unknown etiology .Weight loss with diet and exercise is the first line of management. 10% weight loss may correct hormonal abnormalities and lead to regular menses in more than 70% cases. Proper counseling and help of a dietician are very important for motivation. Her wishes for contraception or fertility should be considered. Low-dose oral contraceptive pills with non-androgenic progesterone or with androgen antagonist like cyproterone acetate are useful. Cyproterone has added benefit of relieving acne and preventing further hirsutism. If she does not wish to use COCP, medroxy progesterone acetate (10 mg) is given for 14 days every monthly for withdrawal bleed. I will give her written information and details of support groups like www.verity-pcos.org.uk. Routine use of insulin sensitizers like metformin in healthy woman is not recommended.
Posted by hoping ..
A healthy 30 year old nulliparous woman is referred to the gynaecology clinic because she has not had a menstrual period for 9 months. (a) Justify the information you would obtain from the history [8 marks]. (b) Logically outline your investigations, given that clinical assessment is unremarkable [7 marks].(c) She is found to have the polycystic ovary syndrome. Evaluate the non-surgical treatment options to enable her have regular menstrual cycles [5 marks].
Further information regarding her periods nine months ago if they were regular or not should be obtained.Also if those were merely withdrawl bleeds secondary to pill should be confirmed.Sexual and contraceptive history to asses possibility of pregnancy and amenorrhea due to long acting progestogens should be asked. Any features of hyperandrogenism like hirsutism, acne may suggest polycystic ovarian syndrome or ovarian or adrenal pathology. If she had any previous uterine currettage may suggest Asherman syndrome. Any hotflushes, vaginal dryness or similar history in mother or sisters may suggest premature ovarian failure. Headaches or galactorrhea may indicate hyperprolactinaemia. If she has lost significant weight or increased excercise should be checked to rule out hypothalamic amenorrhea. Weight gain, intolerance to cold and neck swelling may suggest hypothyroidism. Any recent onset of stress should be enquired as stress related amenorrhea is common.
Urine pregnancy test to rule out pregnancy should be done. If negative bloods should be checked for gonadotrophin levels. High FSH and LH indicate ovarian failure and low levels suggest hypothalamic etiology. Normal FSH with elevated LH indicate pitutary ovarian axis dysfunction. Serum prolactin levels should be checked and if higher than 1000 MRI head should be arranged to look for prolactinoma or other tumour causing stalk effect. I f thyroid dysfunction is suspected from history and examination then thyroid function tests should be checked. Pelvic ultrasound to look for polycystic ovaries or ovarian tumour should be arranged. If Ashermans is suspected hysteroscopy is investigation of choice. Rarely karyotyping may be indicated if previous periods were withdrawl bleeds due to exogenous hormones as in Gonadal dysgenesis.
If she is overweight then weight loss may enable spontaneous return of menstruation. This is effective and also has additional benefit on improving her general health. Combined pill enables cyclical bleeding and also improve hyperandrogenic symptoms. It may not be appropriate in patients with BMI more than 35 or those not wishing to use contraception. Cyclical progestogens are other alternative. This could be taken for 7- 10 days regularly to induce bleeding and donot increase risk of thromboembolism as combined pill. These donot improve associated symptoms of acne or hirsutism and are not contraceptive.
Posted by Drxyz A.
DRXYZ

a) History will be taken for her menstrual cycle pattern since age of menarche to look for oligomenohorea or amenohrea. I will ask any history of acne, abnormal hair, discharge from breast and weight gain to look for hyper-androgenism. I will ask for history of hot flushes, aggressiveness and dysparunea for premature menopause. Any history of heat or cold intolerance, change of appetite to look for thyroid disease. Any history of stress, sternness exercise, weight loss to look for hypothalamic causes of amenorrhoea. Medical history for diabetes and hypertension. Any surgical history like laproscopy, ovarian diathermy. Any family history of PCOD or premature menopause. I will ask about her wishes for conception, any history of contraception. Any history of treatment for infertility and menstrual disturbance like clomenphen citrate or contraceptive pills. History of nausea, vomiting to look for pregnancy. I will ask her the impact of this condition on her social life.

b) Urine Pregnancy test
Fasting and post prandial blood sugar as in PCOD there is insulin resistance so the risk of type 2 diabetes is there.
FSH and LH ratio as this will be reversed in PCOD and levels will be high in premature menopause.
TSH to rule out thyroid disease.
Serum prolactin to rule out hyperprolactinemia
Pelvic Ultrasonography to see the volume of the ovaries and distribution and size of the follicles to rule out polycystic ovaries.
Even the patient\'s clinical assessment is unremarkable, I will investigate her for hyperandrogensim i.e serum testosteron which may be high in PCOD.

c) I will ask the patient about her wishes for conception. If patient is not keen for conception then I will give her oral contraceptive pills to regulate her cycle after withdrawal bleeding with progesterone. As in PCOD the endometrium is hyper-estrogenised so progesterone like provera, desogestral will be given from day 5 to 25. She will explained about the side effects of these drugs like weight gain, blotting sensation.. If patient has abnormal hairs or acne along with menstrual disturbance then will give ciproteron acetate and ethinyl estradiol along with contraception. This will act as anti-androgen. If the patient is obese, I will ask for exercise and weight reduction with the help of dietician. I will consider to give metformin as this will help to reduce the insulin resistance and hyperandrogenism. If she wants to be pregnant then I will give cyclicle progesterone for withdrawal bleeding and if there is no other cause of infertility I will give her clomephen citrate for ovulation induction. I will explain the choices to patient and written information will be provided to her.
Posted by Vaishali Sriniv J.
a) I will take detailed history of the patient with respect to her last menstrual period and previous menstrual cycle. Irregular periods, scanty bleeding, delayed periods are suggestive of anovulation. I will note contraceptive history. I will enquire if there is any history of significant increase in weight or significant loss in weight as both can lead to amenorrhoea. I will ask her if she is exercising and try to assess the amount of exercise she is doing as excessive exercise can lead to amenorrhoea. I will also enquire about her eating habits, any history of forced vomiting and obsession t o lose weight. She should be asked about any history of galactorrhoea, headache and visual disturbances which may suggest hyperprolactinaemia.I will also enquire about symptoms suggestive of premature ovarian failure such as hot flushes, night sweats, vaginal dryness. History suggestive of thyroid dysfunction such as excessive weight gain, lethargy,cold intolerance should be asked. She should be enquired about symptoms suggestive of excess androgens such as acne, oily skin, hirsuitism which may indicate polycystic ovarian syndrome(PCOS). Family history of PCOS, premature ovarian failure should be asked. Patient should be asked about any history of surgery involving uterus or cervix such as D and C, cervical cautery or cervical cone biopsy. Any history of head injury, chronic systemic illness also should be enquired.
b) I will do urine pregnancy test to rule out pregnancy. Patient should be given progesterone challenge test. she is to be given medroxyprogesterone acetate 10 mg daily for 5 days. If she gets withdrawl bleeding then it indicates anovulation. If she does not get withdrawl bleeding then should be given estrogen and progesterone challenge test. Absence of withdrawl bleeding indicates outflow tract pathology. Blood should be checked for FSH , LH, Prolactin hormones. Thyroid profile including T3, and TSH levels also should be carried out. If FSH levels are high more than 20 Iu/l then it indicates premature ovarian failure. Ovarian biopsy is not recommended to confirm the diagnosis. If hormone levels are low or normal then it is indicative of hypothalamic or pituitary causes. In patients with raised LH levels polycysti c ovaries should be suspected. Transvaginal ultrasound should be carried out to detect ovarian or uterine pathology. Polycystic ovaries can be diagnosed by noting presence of 12 or more follicles situated in the ovarian stroma. Raised prolactin levels more than 1000mIu/ml are suggestive of prolactinoma. These patients should be subjected to CT scan or MRI to confirm the diagnosis.
c) Patient should be told about the diagnosis . she should be explained that PCOS can cause menstrual abnormalities such as oligomenorrhoea, amenorrhoea and Infertility.. I will tell her that simple lifestyle modifications can correct her menstrual abnormality. Loss of weight by about5 to 10% may result in regular ovulation and menses. Advice about diet and exercise should b e given. Though it is effective patient compliance is poor. . She can be given combined oral contraceptive pills to induce cyclical menstrual bleeding. They are easy to use and provide additional contraception. They can not be given in patients with migraine or VTE. If patient does not wish for contraception then can be given progesterone every month or every three months for 10 days to induce withdrawl bleeding .In patients with associated infertility ovulation can be induced using clomiphene citrate or gonadotrophins. Patient is to be given leaflets to read so that she can make informed choice.
Posted by SK K.
a> History taking is of utmost importance in this case as it would point to likely diagnosis, indicates investigation & guide mangement.

I would ask her if her previous cycles were regular or have they been irregular since onset of menarche. Are there any also symptoms of excessive hair growth, weight gain, acne? As these are common finding in PCOS.

I would also ask for virilising symptoms. Eg: deepening of voice, hair growth on chest, clitromegaly as they would point towards androgenic ovarian or adrenal tumours.

History of excessive weight loss , stress, intake of psychogenic drugs are likely cause hypothamic-pituitary dysfunction & cause amenorrhea.

Cold intolerance associated with sluggish behaviour and weight gain would point to hypothyroidism. Wheras galactorrhea , visual symptoms & headache could indicate hyperprolaceinemia with or without pitutory adenoma.
Hot flushes, vaginal dryness, family history of premature menopause could indicate premature ovarian .
Pelvic tuberculosis suggested by h/o weight loss, lowgrade fever, progressive hypomennorhea leading to amenorrhea ,is also an important cause of secondary amenorrhea.

She is nulliparous but it is necessary to ask, if she has undergone any curettage of uterus for obstetric or gynecologic cause as it would well lead to ashermans syndrome.

Also during history taking I would ask wheteher she is concerned only of regularity of cycles or fertility is also desired and if she has taken any previous treatment for her condition. These points will help in treating her as per her concerns and also knowing her response to previous treatment.

b> Fbc needs to be done and anemia needs to be ruled out as it may well be a cause of amenorrhea. The total & differential counts along with high ESR would point to systemic cause like tuberculosis. Hormonal profile consisting of raised LH, and increased LH/FSH ratio,raised serum testosterone and DHEA would support a diagnosis of PCOS & indicte severity of androgenicity . elevted DHEAS would indicate adrenal cause .17-OHP will be elevated in late onset CAH and would also lead to anovulation & amenorrhea.
TFT s & PL are increased in common cause of anovulation such a hyporthyroidism & prolactinemia and thereby need to be checked .
Urine routine & culture sensitivity can be done as sterile pyuria may be associated as a part of pelvic tuberculosis.
Pelvic USS, TAS or preferably TVS to check for endometrial thickness and ovarian cause, eg: PCOS or tumour.
Also progesterone challenge test could be undertaken as a part of the investigation. If there is bleeding it would indicate unctional end organ that is endometrium & presence of endogenous estrogen. The contrary is indicated with no bleeding as well as no bleed follwing repeat progesterone challenge test after exogenous estrogen supplementation.

c> In the treatment of POCS it is very important whether she desires fertility along with aiming for regular menses . The first step towards ovulation & regular mensus is weight redcution & lifestyle modifications. As liitle as 5 % reduction in her weight would help in resumption of regular mensus.
Combined OC pills are convenient method of ensuring regular periods as well as helping alleviating hirsutism. Diane which includes cyperoterone acetate is particularly helpful. Also it will provide her contraception. If she has contraindications to use of COCs she can take sequential progesterone for 10-12 days each cycle so that regular withdrawal bleeed is ensured Metformin will help in m difiying her hormonal milieu by helping in reducing weight, decreasing insuline resistance and help in ovulation and & regularizing of menses. However renal function test need to be reviewed occasionally due to the sideeeffect of lactic acidosis.
Any associated hypothyroidism & hyperprolactinemia need to be corrected.
Clomiphene citrate , gonadotrophines need to be considered if she desires fertility but they do carry a risk of OHSS & multiple pregnancy. Also treatment cyclers >12 in lifetime are associated with increased risk of ovarian cancer.
Posted by g.b. D.
a)

I will obtain information regarding the previous periods. The regularity duration and flow. i will also ask if she has noticed increased hair growth overy face chest lower abdomen and thighs.such symptoms of increased androgens and previous episodes of oligomenorrea,irregular periods suggest polycystic obvaries .
I will enquire for any milky discharge from the nipples .Such galactorrea may be accompanied by headache,visualdisturbances.this points to hyperprolactenemia.
I will ask for symptoms like lethargy, weight gain with suggest hypothyroidism.
I will enquire regarding the wt loss, excessive exercise stress. this pionts towards hypothalamic cause.
I will ask for any hot flushes, mood disturbances which suggest premarure ovarian failure.
I will enquire regarding previous contraceptive use.


b)

I will order for complete hormonal profile including FSH LH TSH PROLACTIN AND TESTOSTERONE.
I will also get one pelvic ultrasound to assess the ovarian morphology. multiple cysts(more than 8) in the ovaries in a necklace pattern and high lh:fsh ratio suggest polycystic ovaries.
high tsh indicate hypothyriodism.If so she will need complete thyriod profile including t3 t4 tsh,and antithyriod antibodies to conform diagnosis and etiology. she will need referal to an endocrinologistfor further investigations and treatment.
high prolactin should be confirmed with a repeat sample because of its pulsatile secretion. if high then she will need perimetry and ct scan brain to rule out macroadenoma.
high FSH and LH suggest hypergonadism.at this age this indicates premature ovarian failure. 10% cases are associated with chromosomal abnormalities like turners syndrome hence a blood sample should be collected for karyotyping.
I will prescribe her progestogens like oral medroxyprogesterone acetate for 10 days to check if she gets withdrawal. Withdrawal bleed suggests adequate oestrogenisation and rules out any outflow tract abnormalities.with every test i will do adequate pretest counselling should be done to inform her regarding the reason for the test , time reqd for results to be available, next step if result if positive etc.


c)

I will counsel her regarding weight loss with diet and regular exercise. 10%of weight loss restores regular menstruation in 70-80% of females.Combined oral contraceptive pills for 6months will regularise the periods.they increase the shbg levels and bind excess androgens.oestrogen component will decrease the fsh and progesterone component the lh by negative feed back action. they are suitable in this patient because she is healthy and there is no contraindication for oestrogens.
If there is associated hirsuitism and she wants treatment for that too then coc pill dianette should be preffered. This contains progesterone - cyproterone acetate which has an antiandrogenic effect.
If she get any adverse effects like headache or severe nausea or she is not willing for pills then she can be given regular withdrawals with medroxyprogesterone acetate for 10 days every month. there may be a few side effects like acne or premenstrual symptoms with it.
It is not an contraception and she should be asked to use barrier along with it to prevent pregnancy.
If she wishes to be pregnant then she can be given ovulation induction agents like clomephene citrate.This will correct anvoulation and she will get regular withdrawals. In Clomephine resistant cases Metformin can be given along with clomephine. It can also be continued in preg.


Posted by Farina A.

a) I would like to ask about her last menstrual period and is she feeling any nausea, vomiting, dizziness as pregnancy is the commonest cause of secondary amenorrhoea. Then it is important to know about her age of menarche and weather spontaneous or induced as some cases of chromosomal anomalies (Turner’s syndrome) may present as delayed menarche and regular menses with OCP’s followed by a period of amenorrhoea when she stops taking OCP’s. Previous pattern of menstrual cycle should be asked for, because if there is any history of oligomenorrhoea, excessive hair growth and infertility, they may suggest PCO. History of galactorrea and visual field disturbances may suggest hyperprolactenemia. History of excessive hair growth, voice changes, increased muscle mass and clitoromegaly may suggest androgen secreting tumour or congenital adrenal hyperplasia. History of hot flushes, loss of libido, vaginal dryness and irritability, chemotherapy and surgical removal of ovaries may suggest premature ovarian failure. Severe weight loss associated with exercise and self induced vomiting may suggest bulimia and anorexia nervosa. Ingestion of drugs like phenothiazines and butyrophenones for psychiatric diseases should be asked for. History of endocrinal disease like hypothyroidism, acromegaly (giagantism) and Cushing syndrome may present as secondary amenorrhoea. Previous uterine curettage may lead to Asherman’s syndrome which should be kept in mind during history taking.

b) I would like to do a pregnancy test to rule out pregnancy, Serum prolactin levels and MR of skull to rule out hyperprolactenemia. Ultrasonography is required to see the polycystic ovaries. High serum FSH and LH levels are highly suggestive of premature ovarian failure, while low levels are found in anorexia nervosa and bulimia. Raise serum 17-hydroxiprogesterone suggest congenital adrenal hyperplasia. An ultrasound and MRI of abdomen may show an adrenal or ovarian mass. High serum TSH levels are found in hypothyroidism. Dexamethasone suppression test is useful in diagnosing Cushing’s syndrome. Hysteroscopy is required to diagnose Asherman’s syndrome.

c) Wt reduction is one of the most effective and noninvasive form of therapy which effectively regularize the menstrual cycle and return fertility, Progestational support can be given for 21 days with a 7 days withdrawal bleeding. COCPs can be given effectively to regularize the cycle, however patient compliance is required and some times the hormonal side effects limit their long term use. Metformin is one of the recognized treatments for PCO as it acts by increasing insulin sensitivity of the peripheral tissues and in conjunction with wt reduction found to be very effective. If the pts main issue is fertility, then she can be induced by clomid with increasing doses. Resistant cases can be induced by gonadotrophins, provided risk of hyperstimulation is explained and monitored by follicular tracking and serum estradiol. Hirsuitism can be managed by regular cosmetic measures, and cyproterone acetate along with eastrogens. Other anti androgenic drugs like finasteride, antifungals and spironolactone are also useful measures for hirsuitism however they are not widely used.
Posted by R M.
a) Secondary amenorrhoea is absence of menstruation for a period equivalent to three times previous cycle length or six months in a woman who had regular menses.

I’ll ask her about her LMP, contraceptive use and sexual activity to exclude pregnancy. Knowledge of the contraceptive method will help to exclude post-pill amenorrhoea or amenorrhoea following injectable progestogen (like DMPA). History of weight changes/dietary habits/exercise/stressful events will help to exclude the possibility of hypothalamic causes ( like anorexia nervosa/bulimia nervosa/exercise or stress induced amenorrhoea). A history of weight gain along with symptoms of hyperandrogenism (acne, hirsuitism) and amenorrhoea (preceded by oligomenorrhoea) suggestive of PCOS. I’ll look for pointers in history for other endocrine disorders - cold intolerance and lethargy (hypothyroidism); weight gain, striae and weakness (Cushing syndrome). Menopausal symptoms like hot flushes and vaginal dryness along with history/symptoms of autoimmune disorders suggestive of premature ovarian failure (POF); previous history of chemotherapy/radiation also suggestive of POF. Galactorrhoea and visual symptoms (bitemporal hemianopia) suggestive of hyperprolactinaemia due to pituitary micro/macro adenoma. If there is past history of tuberculosis, uterine synechiae is a possibility. If there is past history of ERPC/cone biopsy, uterine synechiae/cervical stenosis should be excluded. History of intake of antipsychotics (like phenothiazines or TCAs) or antihypertensives (like reserpine or methyl dopa) can cause hyperprolactinaemia and amenorrhoea. Family history of POF/autoimmune disorders/CAH will also be specifically asked .

b) Pregnancy has to be excluded by doing a urine pregnancy test/serum beta hcg. Baseline serum prolactin (to rule out hyperprolactinaemia), thyroid function tests (to exclude hypothyroidism) and gonadotrophins – LH and FSH – will be done. I’ll assess the endogenous estrogen status and patency of outflow tract by doing a progesterone challenge test (PCT). If withdrawal bleeding occurs(positive test), a diagnosis of anovulation can be made with relative security. PCT will be positive in PCOS (pelvic USG and serum free androgen index will help to confirm the diagnosis), moderate stress, exercise, weight loss or hypothalamic pituitary dysfunction. Negative PCT is seen in ovarian failure and hypothalamic/pituitary abnormalities. If PCT is negative, I’ll stimulate endometrium with estrogen and progesterone. Absence of withdrawal bleeding points to the diagnosis of uterine synechiae (hysteroscopy/HSG will be done to confirm diagnosis) or lower genital tract pathology ( pelvic examination will help to confirm diagnosis). GnRH dynamic test will help to differentiate between hypothalamic and pituitary causes. Resumption of menstruation following administration of GnRH is suggestive of hypothalamic cause. Pituitary tumor has to be excluded by X-ray sella turcica, CT/MRI scan even if the prolactin level is normal.

c) It is important to induce menstrual bleeding as unopposed estrogenic state in PCOS carries the risk of endometrial hyperplasia and endometrial carcinoma.

The methods used to induce menstrual bleeding depend on whether she is desirous of pregnancy or not. A low dose COCP will be the easiest way to control menstrual cycles if she is not planning a pregnancy. This will result in artificial cycles and regular shedding of endometrium. A brand with non-andogenic progestogen (like Yasmin) or cyproterone acetate (Dianette) should be taken. She will be counseled regarding slightly increased risk of venous thromboembolism and symptoms of nausea and headache.

If she is concerned about fertility, a progestogen such as medroxy progesterone acetate for 5 – 10 days every 1 – 3 months will help to induce withdrawal bleeding without affecting ovulation.
Advice on weight loss is very important in managing PCOS. A weight loss of ~10% may result in spontaneous resumption of ovulation and regular menstruation. Also improves physical fitness, glucose metabolism and endocrine profile. But difficult to achieve –takes time and requires strong motivation with specific exercise and dietary programme. Use of metformin (improves glucose utilization and reduces insulin levels)or orlistat (decreases intestinal absorption of fat) along with weight reduction programmes will improve endocrine profile and help to achieve regular menstruation. She should be advised of stress reduction and encouraged to join support groups (like Verity).
Posted by Iffat ara M.
A):I would like to as about LMP and regularities of menstrual cycle( to exclude Pcos). About contraceptive, I will get information, as they also causes secondary amenorhoea. I will take a detailed obstetrical history regarding especially any PPH or ERPOC to exclude asherman syndrome or cervical stenosis. I would like to ask about sexual history and lactation. I will enquire about history of recent excessive weight loss. I will ask about, did she faced any stressful event recently?` I would take family history of premature ovarian failure, autoimmune diseases or fertility problem. I will enquire about any history of hot flushes & virginal dryness to exclude premature ovarian failure.
B): I would request for FBC (to exclude anemia), pregnancy test, serum prolactin level, serum FSH, LH levels, (to see hypothahlmic Pituitary axis), Serum estrogen level, Serum testosterone level. I will request pelvic ultra sonography to exclude or conform the PCOS. If H/O PPH & ERPOC then hysteroscopy would be requested.
C): In PCOS I would recommend her multidisciplinary care including gynecologist, endocrinologist and dietician. I will reassured her with regarding the presence of ovariancysts & discussion of long term health risk. I will explain her that with simple lifestyle changes especially diet control, exercise & reducing weight, 10 % of women get regular ovulation & menstrual cycle. For withdrawal bleeding she can be given medroxyprogesterone acetate for 5-10 days.If she wants contraception she can be given low dose oral combined contraceptive pills ( less androgenic progestogen) preferably diane 35 which contain estradiol & cyproterone acetate. Combined contraceptive preparation should not contain 17 nor testosterone derivative progestogen(as they further decrease SHBG& increase free testosterone). I would like to make her aware about the side effects related to estrogen(leg cramps, headache, bloating, nausea & vomiting) and regarding progesterone side effects(mood swing, depression, acne, fluid retention, breast tendencies). She will be given written information & contacts numbers of support group.

Posted by A P.
A.There are several causes of secondary amenorrhoea and a thorough history is directed towards elucidating the aetiology. A menstrual cycle history is obtained to see regularity of previous cycles. Associated symptoms eg increase in facial or body hair, acne and weight gain may suggest an ovarian cause such as polycystic ovarian syndrome. A less common possibility is Cushing’s disease which may reveal similar symptoms leading to serious consequences if missed. Weight gain, hair thinning, tiredness, mental slowness, insomnia may imply symptoms of thyroid disease although not exclusively. Surgical history is important as previous cone biopsy can result in cervical stenosis and amenorrhoea. Hypothalamic causes may present with anorexia, excessive exercise, psychological stress or may be idiopathic. Hypothalamic or pituitary damage can result from head injury, tumours, tuberculosis or sarcoid. Hence symptoms of chest problems or visual disturbance may be relevant. Pituitary causes eg prolactinoma may present with amenorrhoea, galactorrhoea and visual disturbance. A family history of fertility problems, autoimmune disorders or premature menopause may also provide clues.
B.A beta-HCG test is performed to exclude pregnancy having explained it to the patient first. Baseline blood tests to assess endocrine status include serum luteinising(LH) and follicle stimulating hormones(FSH), which can help distinguish between hypothalamic or pituitary failure and gonadal failure. Elevated gonadotrophins (above 40iu/l) are suggestive of ovarian failure but will need repeat tests for confirmation. If LH alone is raised it may suggest polycystic ovarian syndrome but this will be supported by a raised testosterone, oestrone and androstendione and insulin levels and reduced sex hormone binding globulin level. Rarely an elevated LH may be seen in androgen insensivity. Oestrodiol levels may be difficult to interpret as they vary even in a patient with amenorrhoea. A prolactin test forms part of the baseline investigation and a level greater than 1000miu/l warrants further investigation via computed tomography or magnetic resonance imaging to exclude a pituitary tumour. Other endocrine tests eg thyroid function and cortisol tests are performed if suggested by the history A pelvic ultrasound scan is useful as it may reveal ovarian or uterine pathology requiring further investigation by hysteroscopy in the latter. Karyotyping may be useful in women with possible chromosomal abnormality eg turner’s mosaicism.
C.Non-surgical treatment to enable her to have menstrual cycles may be conservative or medical and requires a multidisciplinary approach. The former includes weight reduction, hypocaloric dieting and exercise which results in resumption of ovulation and menses by normalisation of androgens in obese patients. This requires motivation. Hence referral to a dietician is appropriate. Weight loss may be assisted by the drug orlistat®. The effect of losing weight, however, is not marked in women of normal habitus although it is prudent to maintain their weight. If the patient is an otherwise healthy non-smoker with no family history of venous thromboembolism, medical management involves the use of a low dose oral contraceptive pill which will induce a monthly bleed if taken correctly. This requires careful counselling with a back up leaflet for reference. It is useful if contraception is also needed. Side effects include nausea, headache and breast tenderness, breakthrough bleeding and an increased risk of venous thromboembolism 15/100000 (noresthisterone/levonorgesterel pill) compared with non-users. An alternative is medroxyprogesterone acetate which can be given for 5 days each month to encourage a withdrawal bleed. Side effects include bloating , breast tenderness, weight gain and nausea which may be unacceptable.
Posted by Priti T.
a] Hx of amenorrhea with morning sickness,breast tenderness and urine frequency is taken to rule out early pregnancy.Hx of hot flushes,breast atrophy,tiredness should be taken for the menopausal symptoms associated with premature ovarian failure.Hx of LNG-IUS,depo medroxy progestrone acetate,other contraceptives are taken as they can cause secondary amenorrhea. History of associated loss of weight or excessive exercise can point towards anorexia nervosa. History of headache,galactorrhoea is taken to rule out pitutary adenoma. History of virilising signs and hirsuitism with or without obesity/weight gain points towards virilising hormone tumors or PCOS or cushing\'s syndrome. Any history of excessive currettage should be taken to rule out Asherman syndrome.

(b)Various investigations should be done to rule out the causes elicited above in the history. Serum sample is taken for the pregnancy test,serum gonadotrophins like serum FSH/LH/prolactin and TFT are done. This should be able to diagnose pre mature ovarian failure,PCOS,thyroid disorders. 17 OH progestrone is done to rule out late onset CAH. Serum testosterone and DHEA/DHEA sulphate levels are done to diagnose virilising tumors and cushing\'s syndrome. RFT with U & E are done to rule out chronic renal failure and other renal diseases. TVS is done to diagnose PCOS. CT scan is done to rule out pitutary adenoma. Hysteroscopy is done to diagnose Asherman syndrome.

(c)There are various non-surgical treatment available to achieve regular menstrual cycle. Patient should be advised to reduce weight if obese and advised diet and exercise plan. Loss of weight as low as 4-5 kg can improve the fertility for PCOS patients.She should be given low dose COC to regulate the cycle. This is cheap and easily available and will provide a cycle control if patient does not want to conceive immediately. Metformin has a controversial role but can correct hyperandrogenism associated with PCOS. Clomiphene can be used for the induction of ovulation in the infertile patients and it has 80% rate of ovulation. Patients with hyperprolactinemia should be treated with cabergoline/bromocriptine to ensure regularity of the cycles. For the patients with endocrinal problems correction of thyroid disease or cushing\'s syndrome will correct secondary amenorrhoea.
Posted by SHAGUFTA T.
A) I will take detailed history to exclude causes of secondary amenorrhea. I will take her menstrual history regarding LMP, age at menarche, previous cycles whether regular or irregular. If she is using any contraception as DMPA injections or Implanon can cause amenorrhea. I will ask her about symptoms suggestive of pregnancy like nausea, vomiting, mastalgia to exclude pregnancy. Any recent history of excessive weight loss to exclude anorexia nervosa, history of heavy exercise or athletic activities to exclude hypothalamic causes of amenorrhea. I will take history of symptoms suggestive of PCOS like weight gain, trunkal obesity, acne, hirsutism, voice change, or if sudden onset hirsutism may suggest Androgen secreting tumour / late onset CAH. I will also ask her if she is suffering from hot flushes, vaginal dryness to exclude Premature Ovarian Failure as the cause, H/O Premature Ovarian Failure in family as genetic factor may be the reason. I will take history of any Medical disorder like Hypothyroidism which can cause amenorrhea. Any history of frequent headaches, visual disturbance, galactorrhea to suggest hyperprolactinemia will be asked. I will also ask if she has any Psychiatric illness like severe depression or if she is on any medication. I will enquire about any past surgical history, if she has undergone uterine curettage for any reason before may lead to Asherman’s syndrome.
B) Investigations: Pregnancy will be excluded by pregnancy test. Baseline FSH, LH, estradiol, will be done as LH, FSH high & low Estradiol will be suggestive of Premature ovarian failure. If this is the case Karyotyping may be offered to look for Chromosomal anomaly like Turner’s syndrome. Serum Prolactin level will be checked as high level may suggest Hyperprolactinemia associated with Prolactinoma, CT or MRI will be suggested. Check free androgen level, if >5nmol/l will suggest PCOS. USS pelvis will be advised to look for Polycystic ovaries, can exclude other uterine or adnexal anomalies. FBC, TFT(thyroid function) & FBS to be done to exclude anemia & other metabolic disorders.
C) Non surgical Tt options: I will counsel the woman & inform her that Lifestyle measures like weight reduction, diet & exercise will be the best non interventional method to correct hormonal imbalance, reduce Insulin resistance. Inturn this will regulate her menstrual cycle & promote ovulation. This will also reduce the risk of NIDDM by 58%. COCP will be the ideal method to regulate her menstrual cycles by decreasing androgen level. Cyclical progestogens can also be given for withdrawal bleeding, to prevent Endometrial hyperplasia (Ca Endometrium in long run). If woman wishes to conceive, ovulation induction by clomiphene citrate will be tried. I will provide written information regarding long term consequences of PCOS.
Posted by Atashi S.
(a)From history Iwould like to find out the possible cause of her amenorrhoea.I will ask her LMP , pattern of her previous menstrual cycle ( regular or irregular),sexual history ,presence of pregnancy symptoms like nausea , vomiting ,whether she use any contraception or not .I will ask her any H/O taking injectable contraceptive or insertion of hormonal IUCD that may be the cause of amenorrhoea. To rule out PCOS I will take H/O irregular period followed by amenorrhoea , weight gain ,hirsutism but sudden or rapid onset of hirsutism ,presence of virilism , vioce change ,cliteromegaly may suggest ovarian or adrenal androgen producing tumour or late onset congenital adrenal hyperplasea. Presence of hot flush , night sweat , irritability and mood change indicative of premature ovarian failure.Decrease appetite, loss of remarkable body weight , H/O stressfull event is suggestive of Anorexia nervosa. To rule out hyperprolactinoma , presence of visual symptoms(bi temporal hemianopia) , galactorrhoea , headache need to be asked . Presence of straiae, pigmentation , muscle wasting suggestive of Cushing syndrome . H/O increase or decrease appetite , heat or cold intolerance, change in bowl habit (diarrhoea or constipation) indicative of thyroid dysfunction . H/O excessive exercise need to be taken .

(b)Urine for pregnancy test is to be done . Base line serum gonadotrophin level is to be tested . In PCOS LH level will be >10mIU/ml or LH: FSH rario >3. In case of premature ovarian failure FSH level will be >40mIU/ml. In this case karyotyping is to be done. Serum base line prolactin should be measured . High level suggestive of prolactinoma .CT scan or MRI of brain can be done to detect any pituitary tumour. Serum testosterone/androgen level is mildly elevated in PCOS but if level above 4.8mmol/L requires further investigation to exclude late onset CAH, Cushing syndrome or an adrenal or ovarian tumour. 17hydroxy progesteron is elevated in CAH. Thyroid function need to be assessed to rule out thyroid disorder. Pelvic ultrasonography is to be done to detect polycystic ovary .
(c)Adequate explanation is to be given to her regarding cause and reassurance is to be given .Dietary advise and reduction of body weight to achieve ideal BMI may resume her normal menstrual cycle. If she desire for pregnancy then she should be treated with Clomiphen citrate or Metformin or both .This will induce ovulation , resume normal menstruation and will conceive . GnRh can be use when PCOS is resistant to Clomiphen citrate . If she does not wishes for pregnancy then combind oral contraceptive pill is to be given cyclically for three months. To induce withdrawal bleeding medroxy progesteron for five days in a month for three month can be used. Cyclical progesteron along with oestrogen is an another option.
Posted by Hadia K.
a. Past menstrual history is taken, if she has oligomenorrhoea or amenorrhoea before, this may indicate PCOS particularly if associated with difficulty of getting pregnancy. We ask if she is sexually active and whether she use regular contraceptives or not. Medroxyprogesterone acetate injection can cause amenorrhoea for several months in some women, also Progesterone only pill and progesterone implants. We inquire also about social factors like heavy exercise, significant weight loss or weight gain as all these can cause hypothalamic amenorrhoea. Family history of premature menopause in her mother or sisters is also taken as this condition is run in families. Symptoms of hot flushing, sweating, vaginal dryness and insomnia can support the diagnosis. We ask her if she noticed any increase in her hair growth over face, chest or abdomen as this can reflect hyperandrogenic state also if she has acne or she develop creasy skin in the previous months. We ask her if she had any symptoms of pregnancy like morning sickness or increase abdominal girth, also if she has secretion coming from her breast as this can reflect hyperprolactineamia. Past surgical history is taken like cervical cauterization or conisation as these procedures may be complicated by cervical stenosis.
b.
Pregnancy test is done to exclude pregnancy if the uterus is not palpable per abdomen but if clinical assessment reveals gravid uterus or abdominal mass, ultrasonography will confirm pregnancy, also it may reveal ovarian or adrenal pathology. Hormonal essays are done including serum FSH and LH, if FSH equal or more than 20 iu/l, premature ovarian failure (POF) is suspected. FSH levels equal or more than 40 iu/L confirm the diagnosis of POF. If LH/FSH ratio is 2:1 or 3:1, this can support the diagnosis of PCOS. Serum prolactin is done to diagnose hyperprolactineamia. Level more than 1500 mmol/l should be followed by further investigation. Level more than 5000 mmol/l can be caused by macroadenoma; therefore, skull X-ray is required and in some cases CT-scan or MRI is needed. Serum free testosterone is done also and if it is elevated > 4mmol/l, Dihydroepiandrostendione sulphate [ DHEAS] is required to diagnose adrenal causes of hyperandrogenism. 17 Hydroxyprogesterone may be required to diagnose late onset congenital adrenal hyperplasia. If PCOS is suspected, fasting serum insulin level is needed to detect hyperinsulineamia and insulin resistance.
FBC, CRP and ESR id done to assess her general health.

c. Non-surgical treatment includes life style changes with or without pharmacological treatment. Life style modifications includes weight loss if her BMI > 28. We encourage regular exercise and reduction of smoking and alcohol. We educate about healthy diet jointly with the help of dietician. Insulin sensitizing agent like Metformin can be helpful in reducing insulin level and insulin resistance, also it can lead to spontaneous ovulation and subsequent cycle regulation. If patient require conception we can induce withdrawal bleeding by oral progesterone then start clomiphene citrate for induction of ovulation from the second day of induced menstruation for 5 days, oral progesterone is used to support luteal phase, this can enable her to get regular cycle till pregnancy occur, but is she didn\'t want contraception, combined oral contraceptive pills can be used cyclically from day 5 of the cycle till day 25 with one week pill free interval and she will get withdrawal bleeding on regular bases. If she has hirsutism, Dinette can be prescribed for 3-4 months, it can lower her serum free testosterone by the antiandrogen effect of cyproterone acetate and by increasing sex hormone binding globulin due to the effect of ethenyl estradiol, and this can also result in cycle regulation. Patient with hyperprolactineamia can regain cycle regulation by using bromocriptin, cabergoline or guinacolide.
Posted by Najah Ali A.
(a) Secondary amenorrhea is a distressing complain putting the woman under a significant anxiety and fear regarding the possibility of under lining a serious illness and worrying about the future fertility, so I will give her enough allocated time to assess and evaluate her condition to alleviate her anxiety when it is appropriate .I will enquire more details about her menstrual cycle, when did she got menarche, regularity, length of the cycle, is it heavy or normal. Taking obstetric and gynecological history, what is her parity, mode of delivery, did she experienced any excessive post partum bleeding, history of previous curettage .If she is nullipara did she tried to conceive, currently is she suffering from nausea, vomiting or morning sickness so un expected pregnancy should be ruled out .Previous history of contraception should be obtained, using of long acting injectable progestogen can be associated with such presentation even after a single administration. With mirena intrauterine system secondary amenorrhea is expecting in 20% of women at one year of insertion. Causes related to hypothalamic pituitary dysfunction, sensitive enquiry if she is suffering from social or work pressure, losing weight (anorexia nervosa) ,or she is practicing aggressive excessive. Facial hair growth or secreting milk by her breast. Does she suffer from unusual headache, visual disturbance, mood swing, irritability, hot flushing, sweating? Family history should not be overlooked; history of polycystic ovarian syndrome, pre mature ovarian failure, or history of CAH should be obtained.
Urine for pregnancy test to rule out physiological reason for her complains .TSH and free T4 to rule out thyroid dysfunction. Elevated prolactin level more than 800mu/l on two occasions , if it is higher than 1000mu/l CT should be considered , MRI is ideal . I will request LH, FSH if FSH is more than 30 u /l could be indication of pre mature ovarian failure, this could be due to viral infection, chemoradiotherapy exposure however the test need to be repeated 6 weeks apart as the level is fluctuating rarely could be due to aneuploidy [xo,xxx] Turner syndrome or super female syndrome , so karyotyping is indicated If LH: FSH ratio is high possibility of PCOS should be ruled out by doing pelvic ultrasound looking for Small peripheral follicles should be twelve or more in number or the ovarian volume is more than 10cm3, free testosterone level will be high >3mmol/l . If testosterone is higher than 5mmol/l androgen secreting tumours have to be ruled out, Cushing syndrome, late onset CAH should be excluded, where 17 hydroxy progesterone is high. With low level of LH and FSH suggestive of hypothalamic cause. © If the lady is obese advice regarding reducing weight, through regular exercise low calories intake this alone able to resume spontaneous ovulation and regulate her cycle .If she is sexually active and not welling to be involved in pregnancy cocp if there is no contra indication will be the best option as it will prevent the long term risk of un opposed oestrogen (endometrial carcinoma), and will regulate her cycle ,cyclical progestogens for at least 12 days/monthly will cause withdrawal bleeding and at the same time will convey endometrial protection .If she is welling to get pregnant regulate her cycle and ovulation induction through clomifene citrate +/- IUI is the first line option on her case . Metformine is un licensed in PCOS in non diabetic patient and this should be emphasized ,although there is accumulated evidence regarding its safety ,reduce androgen level by about 11%, so reduce hyper insulinaemia and induce the ovulation and subsequent regulate her period and improve the fertility.
Posted by areeba F.
Ammenorrhoea more than six months is secondary ammenorrhoea and needs to be investigated.A detailed history and relevent investigations would help to reach a possible diagnosis.
Pregnancy is the most common cause of sec ammenorrhoea in women of rproductive age.h/o nausea,voiting,increasing abdominal girth/fetal movements taken to rule out preg.Menstrual history is taken regarding the duration ,length and regularity of menstrual cycle.h/o contraception,particularly long acting propogestogens which may cause irregular bleeding and periods of amenorrhoea.
h/o D&C or septic abortion may be acause of Ashermans syndrome.h/o hot flushes and nightsweats in case of POF.h/o headache and visual disturbances taken to suggest prolactinoma causing hyperprolactinemiia.
h/o wt gain with acne,hirsutism and abnormal pigmentation may be point to PCOS.
h/p of excessive excercise and anorexia may be obtained in cases of hypothalamic causses of reduced gonadotophins.
h/o thyroid symptoms ,wt gain ,slow actions,dry skin in case of hypothyroidism or h/o diarrhoea ,intolerance to heat ,tremors and palpitations in case of hyperthyroidism.h/o cronic renal disease is taken.
b)Investigations include PT,positive test would reassure.FSHand LH-levels are high in case of POF.low levels would be found in cases of hypothalamic causes i.e stress,excercise.Elevated levels of LH more than FSH would be found in cases of PCOS.
Prolactin levels,if >1500 would require CT/MRI to rule out ppituitary tumor.Testosterone levels are checked and if found to be >5nmol/l,adrenal tumor should be ruled out by CT/MRI.
Pelvic USS done to see the ovaries -size and presense of cysts,suggest PCOS.Endometrial thickness would reflect estrogen status.progesterone challenge test would be positive in estrogenised endometrium and the pt will have withdrawal bleeding.
c)In cases of PCOS ,menstrual irregularities are easily corrected by low dose COCPs.this will cause an artificial cycle and regular shedding of endometrium.Progestogens such as MPA or dydrogesterone for 12 days every 1-3 months.
Woman should be encouraged to lose wt ,as wt loss of 5-10% would result in improved endocrine profile,ovulation and regular mentruation.Ovulation inducing drugs such as clomid would also regularise menstruation.
Posted by rasiah B.
A healthy 30 year old nulliparous woman is referred to the gynaecology clinic because she has not had a menstrual period for 9 months. (a) Justify the information you would obtain from the history [8 marks].
In the history, I would ascertain the date of her last menstrual period, her menstrual history (menarche, regularity of cycle previously and duration of periods) to exclude mullerian agenesis or Turners, history of sexually transmitted infections, obstetric history (dates and outcome of any pregnancy) to exclude physiological amenorrhoea.In her medical history I would exclude hypothyroidism (symptoms of weight gain, cold intolerance, thinning of hair) and thyrotoxicosis (tremor, weight loss, palpitations), recent surgery, medications (eg. cimetidine, chemotherapy) and recent weight loss, smoking and stress levels. Affiliated symptoms such as galactorrhoea, change in vision and headaches are also relevant to exclude a prolactinoma, as are changes in voice and hair distribution and changes in weight to exclude PCOS. I would also like to exclude current pregnancy, a history of hot flushes dyspareunia and mood swings, which may suggest premature menopause

(b) Logically outline your investigations, given that clinical assessment is unremarkable [7 marks].
A pregnancy test should be performed to identify pregnancy as a physiological cause of amenorrhoea, particularly if the patient is obese.

Serum FSH, LH, testosterone and DHEAS are required to diagnose PCOS or premature menopause (serum oestradiol is also used). Low FSH and LH may also be seen in those suffering from anorexia nervosa.

Serum prolactin should be measured to identify a prolactinoma, and if raised, a CT head should be organised to identify a macro or microadenooma

Thyroid function tests (TSH, free T4) should be performed to ensure that hypothyroidism is not causing amenorrhoea.

Ultrasound of the pelvis may identify ovarian cysts, tumours or follicles characteristic of PCOS

Hysteroscopy or HSG can be used to identify Mullerian agenesis or uterine hypoplasia.

Karyotyping may be used to confirm the diagnosis of Turner\'s where suspected.

(c) She is found to have the polycystic ovary syndrome. Evaluate the non-surgical treatment options to enable her have regular menstrual cycles [5 marks].

Weight loss may spontaneously result in the return of a regular menstrual cycle, if obese, and weight gain in those with a low
BMI.

The reduction of stress may also help regulate her menstrual cycle, together with a balanced diet, reduction of smoking and alcohol.

Metformin is a biguanide which may also be used to regulate the menstrual cycle.

The combined oral contraceptive pill would also be useful in regulating her menstrual cycle, although this would not necessarily ensure she ovulates.