Amenorrhoea/oligomenorrhoea
O&G
Introduction
Author: Idayat Oluwale
When taking a history from a patient with amenorrhoea or oligomenorrhoea, it is important to approach the conversation with empathy and clarity. Begin by clarifying the nature and timing of menstrual changes—whether periods have stopped completely or become infrequent—and establish the duration of the problem. Ask about age at menarche, previous cycle regularity, and any associated symptoms such as weight changes, stress, hirsutism, acne, or galactorrhoea. Inquire about lifestyle factors like exercise, diet, and psychological stress, as well as sexual activity, contraception, and the possibility of pregnancy. A thorough medical, surgical, and family history can also provide important clues. Ensure the patient feels supported and that the discussion remains respectful and private.
WIPER
Wash hands:
Introduction: Introduce yourself by your full name and your role
Patient details: Gather the patient’s full name and DOB
Explain/Establish: Explain what you are going to do and Establish consent
ExPose: Expose & Position the patient if necessary.
Presenting Complaint
History of presenting complaint:
Menstrual History
Onset - How long has this been going on for?
LMP
Primary or secondary amenorrhoea - Did you have normal periods before?
Duration of period
Age at menarche
Any chance of pregnancy?
Thyroid dysfunction - temperature intolerance, hair thinning, weight gain.
PCOS symptoms
Acne or hirsutism?
Weight gain?
Lifestyle: How often do you exercise?
Hyperprolactinaemia
Any discharge from your nipples?
Any headache or visual disturbances?
Past Medical History
Wash hands:
Introduction: Introduce yourself by your full name and your role
Patient details: Gather the patient’s full name and DOB
Explain/Establish: Explain what you are going to do and Establish consent
ExPose: Expose & Position the patient if necessary.
Medications
OTC, herbal or prescribed medications
Any current or recent history of contraception use?
Family History
Do any conditions run in your family?
Ask specifically about autoimmune disease and thyroid disease
Social History
Smoking, alcohol, drink, occupation, hobbies
Differential Diagnosis
Separate differentials into most likely, less likely and can’t miss. Each section will differ based on results from the history and examination
Amenorrhoea can either be primary (menses not started by age of 16 years) or secondary (previously normal menses ceased for at least 6 months).
Primary amenorrhoea:
Not reached menarche by age 16 years
Most commonly constitutional delay; less commonly due to Turner’s syndrome, testicular feminisation or polycystic ovarian syndrome
In constitutional delay, the patient’s mothers and sisters may also have been late in starting.
Other causes include:
Pregnancy
Drug-induced e.g. hormonal contraception. Can take up to a year for effects to reverse.
PCOS
Hyper or hypothyroidism
Hypogonadotropic hypogonadism - low FSH and LH.
Hyperprolactinaemia.
Management
Remember: Bedside --> Laboratory --> Imaging
Bedside examination includes:
Bimanual +/- speculum examination
Laboratory investigations include bloods such as:
Bloods - FSH, LH, oestrogen, TFTs and prolactin
Pregnancy test/ beta HCG
Imaging includes:
Ultrasound eg: TVUS, Abdominal ---- PCOS
MRI head to assess for pituitary or hypothalamic causes
Management plan
Tailor the management based on diagnoses
Discuss with all relevant persons ie: the patient and colleagues