TEALE FENNING

Nick Raine-Fenning · Posted: Sun Aug 06, 2006 12:57 pm Post subject: Primary amenorrhoea - management

This is from the EMQ Solutions Course group this weekend.

They want to know how to manage a girl with primary amenorrhoea.
_________________
"Teale Fenning Medical Education" delivering evidence-based, exam-orientated learning since 1997

mridulaben · Posted: Sun Dec 17, 2006 10:37 am Post subject:

Management as taught by you would include history, examination & treatment.

Primary amenorrhoea is absence of onset of menstruation. It requires investigation from 14 yrs if secondary sexual characters have not developed, otherwise by the age of 16 yrs.It is distressing for the parents & the patient both esp. if her peers have achieved menarche. It has to be dealt with sympathetically with proper counselling in privacy with enough time available.

Depending on our basic knowledge of HPO axis & genital development the causes can be divided accordingly.

Causes

Physiological

Pregnancy, early menopause

Pathological

Local- testicular feminization, Congenital absence of uterus, imperforate hymen.

Hypothalamic
a. Cong - Kallaman's
b. Acquired - Anorexia, wt. loss, stress, tumour

Pituitary - Prolactinoma, surgery, RT

Ovarian- Ovarian dysgenesis, resistant ovarian syndrome, RT, CT, surgery for tumours.

Endocrine- PCOS, Hypothyroidism

Familial, Nutritional

Management would depend on the cause.

Begins with a detailed history of any symptoms of Headache, visual disturbances (Prolactinomas), wt. loss & gain, cold intolerance, hair fall , dry skin ( Hypothyroidism ) , galactorrhoea, detailed family history of delayed puberty in sisters or mother as most of ( ? 90% ) causes are constitutional. Also social history including any problems at home or school as it could be because of stress , including her sporting activities, or use of any illicit drugs. Her appetite & eating habbit as could point out to eating disorder. Also her development history, as this should determine her age at breasts & pubic hair dev. to see if she is still in growth phase. Also medical history regarding illnesses in past & treatment with RT or CT. Surgical history for removal of ovarian mass. Any history of monthly pain abdomen pointing to crypto. Also perception of smell.

Examination would focus on Hirsutism, acne & baldness for the signs of hyperandrogenism. Look for thyroid, galactorrhoea. Tanner's staging for breast , pubic & axillary hair development. Also her BMI as below 19 onset of menses is delayed. Look for signs of turner's as short stature, webbed neck etc. Abdominal, inguinal sites( testis), Local genital exam. for hymen, blind vagina.

Investigationts

FSH, LH, TSH, Prolactin, S. testosterone, USG, karyotyping depending on history & examination.

Treatment would depend on the cause-

Crypto- incision

Constitutional- Reassurance

Pcos, anorexia, stress- behavioural changes & reassurance

Turner's- Lots of support with family & genitic counselling, induction of puberty & continuation of hormones

Test. Feminization- Lots of support, gonadectomy, reconstruction of genitals

Hyperthyroidism, hyperprolac. , hirsutism to be dealt accordingly.

Issues like fertility, contraception may need to be answered.

ALWAYS RULE OUT PREGNANCY

Nick Raine-Fenning · Posted: Mon Dec 18, 2006 12:16 pm Post subject:

Nick Raine-Fenning · Posted: Mon Dec 18, 2006 12:28 pm Post subject:

Good answers and a comprehensive list of causes.

This is actually a very good question to demonstrate why it is still important to plan waht you write with the new style of question.

Your introduction is clear and correct but this ios the one thing that seems not to offer you much anymore. This is a shame as it helped set the essay up and ensure you addressed the key points.

What we also asked you to do was to define the commonest cause (constitutional, familial, weight related, imperforate hymen) and any sinister causes (Turner's, congenital abnormalities - sinister here as they affect her fertility). You have not done this. Ask yourself what are the most likely causes and then concentrate on these. Mention the other points but with less detail. Most marks will be for acknowledging most cases resolve spontaneously and for excluding the key pathological causes through karyotyping and scanning.

Nick Raine-Fenning · Posted: Mon Dec 18, 2006 12:37 pm Post subject:

We proposed this very open question prior to the September exam and the new formatted style of question the College has moved towards.

The question would probably read like this now:

You are referred a 16-year old girl who has not started to menstruate.

What would you want to know from her history? [8 marks]

What would you look for on clinical examination? How would this affect your management? [5 marks]

What tests would you organise and why? [7 marks]

or ....

You are asked to review a 15-year old girl who has not started to menstruate. She was seen in clinic 12 weeks earlier when a series of tests were organised.

What tests would have been requested and why? [8 marks]

How would you manage the patient? [9 marks]

All of the tests are normal but the girl is underweight with a BMI of 18. How would you counsel the patient [3 marks]

mridulaben · Posted: Tue Dec 19, 2006 10:22 am Post subject:

Thanks for the guidance. Hope will be able to answer in new pattern. Will try later.