11.     Secondary amenorrhoea.  

    (See also MCQ1, question 18 & MCQ 5, question 35.)

Secondary amenorrhoea is defined as cessation of menstruation for more than 6 months.

But not attributable to pregnancy or the menopause.

Presumably lactational amenorrhoea is also included in the exclusions.

Some of the books add "in a woman who has previously had regular periods".

But I wouldn't get bogged down in that as it leads to all sorts of pedantic musings.

What if a woman normally has six-week cycles?

Should her definition be 36 weeks?

ZZZZZZZZ. I hear your snores, so I'll move on.

Such definitions allow comparisons to be made between populations.

They are of little relevance when it comes to treating patients.

Most patients will seek investigation by the time they have missed a couple of periods.

Polycystic ovary syndrome is commonly found as the underlying cause.

Post-Pill amenorrhoea is often quoted, but its existence is disputed.

Surveys have shown that episodes of amenorrhoea are fairly common in healthy young women.

But not more so after stopping the Pill.

So it is a bit of a myth.

Weight loss is often associated.

And it may take time for ovulation to return in the girl who has got back to a normal weight after being too thin.

Heavy exercise is linked.

Ballerinas and long-distance runners are usually quoted.

Amenorrhoea affects ~ 50%.

Stress is often quoted as a cause of amenorrhoea.

It is a possible cause, but in reality is much less common that weight loss and excessive exercise.

Systemic disease may be associated, e.g. hyperthyroidism, T.B. and sarcoidosis.

If you damage your hypothalamus or pituitary you could lose FSH & LH production.

So brain tumours and their treatment, either surgery or radiotherapy, could be causes.

Similarly brain trauma or intracranial bleeding.

Sheehan's syndrome usually occurs after postpartum haemorrhage.

So it would cause persisting amenorrhoea after the pregnancy.

But is this "secondary amenorrhoea"?

What of the definitions that include "in a woman who has previously had regular periods"?

Does the amenorrhoea of pregnancy mean that she has not had regular periods?

Or do we discount it as physiological and look to the periods before the pregnancy?

ZZZZZZZZ.  Boring semantics.

My inclination would be to include it.

There are rarities such as premature menopause and oestrogen secreting ovarian tumours.

Asherman's syndrome occurs when the bulk of the endometrium has been hacked out.

This leaves minimal endometrium and a load of adhesions (synechiae).

As far as I know, this is the only situation in which the word "synechiae" is used. God knows why!

Hyperprolactinaemia has to be considered - see the next question.

The above is all you need for the DRCOG.

The following gives a bit more detail for the MRCOG.

You are probably best with a model in your head.

Not Naomi Campbell, boys -that won't get you through the exam. Concentrate!

You need a top-up or a top-down model.

To start at the top, you begin with the whole woman and work your way down to the cervix.

You don't need to go as far as the vagina: no one is going to have blocked it since her last period.

There is a good article in the BMJ. BMJ  2003;327:546-549.

One of the charts "Investigations for anovulation" lists the hormone levels associated with the various conditions.

Worth having a look and making  out cards.

Watch out: my browser gets them a bit out of sync.

Yours might do the same, so you have to use a bit of nous.