Amenorrhoea

Differential diagnosis

• Primary
  • No periods by the age of 16 (or 14 if no secondary sexual characteristics)
• Secondary
  • PCOS – acne, hirsutism
  • Prolactinoma – headache, visual changes, galactorrhoea
  • Pregnancy – LMP
  • Weight loss – exercise, stress
  • Premature ovarian failure – hot flushes, vaginal dryness
  • Others – thyroid, medications

Data gathering

• Red flags – see prolactinoma, ovarian failure
• Others – ever had period, pregnancy, abdo pain, hot flushes, vaginal dryness, weight change, diet, exercise, stress
• Examination – BMI, secondary sexual characteristics, visual fields

Clinical management

• Investigations
  • Bloods – TFTs, LH, FSH, prolactin, HbA1c, testosterone, SHBG
  • Pregnancy test
  • USS pelvis

• Explanation
  • several reasons inc hormonal changes (from pregnancy, menopause, breastfeeding), contraception, surgery, medical condition (e.g. thyroid)

• Treatment
  • Primary
    • refer if no periods by 14 years old (and no breasts/pubic hair) otherwise by 16 years old
  • Secondary
    • treat underlying cause, refer if cause not established

• Follow-up / Safety net – PIL
  • Consider referral if persisting > 6 months
  • Delay investigation until 9 months if obvious cause e.g. active sports person