Oligomenorrhoea and amenorrhoea

Important causes

 MRCP  endocrinology

Gonadotrophin deficiencyTurner's syndromePolycystic ovarian syndromeProlactinomaCushings
PresentationSlimming teenagers, anorexia nervosa, athletes, ballet dancers.Primary amennorrhoeaObesity, hirsutism, or sub-fertilityErratic menstrual cycles sometimes following stopping the oral contraceptive pill or after a pregnancyObesity, hypertension, glucose abnormalities
PathologyGonadotrophin deficiencyChromosomal abnormality typically 45, X0.Enlarged ovaries with follicular cystsPituitary adenomaAdrenal or pituitary adenoma, and other causes.
Clinical featuresLow body massShort stature, short neck, shield chest, wide carrying angle. Coarctation of the aorta, aortic stenosis.Variable obesity and hirsutism.GalactorrhoeaCentripetal obesity, proximal muscle weakness, abdominal striae, osteoporosis, depression, psychosis. Mild hirsutism and acne.
BiochemistryLow LH and FSHHigh LH and FSHinappropriately high LH, modestly increased androgens, mild hyperprolactinaemiamarkedly raised prolactinraised 24 hour urinary free cortisol
RadiologyMRI / CT sometimes used to exclude craniopharyngioma.Hydronephrosis may be seen. Skeletal abnormalities.Polycystic ovaries on ultrasound scan.MRI / CT to demonstrate pituitary mass.Adrenal, pituitary and thorax MRI/CT depending on other investigations.
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Gonadotrophin deficiency with normal body weight and anosmia is termed Kallman's syndrome. May also be seen in craniopharyngioma.

In Cushings consider alcohol excess (features disappear during hospital investigation), corticosteroid use obviously, and ectopic ACTH (pigmentation, marked hypokalaemia) as possible causes.



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