Case 3: Amenorrhoea

 

Case 3: Amenorrhoea

CASE 3: AMENORRHOEA
History
A 32-year-old woman complains that she has not had a period for 3 months. Four home
pregnancy tests have all been negative. She started her periods at the age of 15 years and until
30 years she had a normal 27-day cycle. She had one daughter by normal delivery 2 years
ago, following which she breast-fed for 6 months. After that she had normal cycles again for
several months and then her periods stopped abruptly. She was using the progesterone only
pill for contraception while she was breast-feeding and stopped 6 months ago as she is keen
to have another child. She reports symptoms of dryness during intercourse and has experienced sweating episodes at night as well as episodes of feeling extremely hot at any time of
day. There is no relevant gynaecological history. The only medical history of note is that she
has been hypothyroid for 10 years and takes thyroxine 100 mg per day. She does not take any
alcohol, smoke or use recreational drugs.
Examination
Examination findings are unremarkable.

INVESTIGATIONS

Normal range Haemoglobin 12.2 g/dL 11.7–15.7 g/dL White cell count 5.1×109/L 3.5–11×109/L Platelets 203×109/L 150–440×109/L Thyroid-stimulating hormone 3.6 mu/L 0.5–7 mu/L Free thyroxine 21 pmol/L 11–23 pmol/L Follicle-stimulating hormone 45 IU/L Day 2–5 1–11 IU/L Luteinizing hormone 30 IU/L Day 2–5 0.5–14.5 IU/L Prolactin 401 mu/L 90–520 mu/L Oestradiol 87 pmol/L Day 2–5 70–510 pmol/L Testosterone 2.3 nmol/L 0.8–3.1 nmol/L

Questions
• What is the diagnosis?
• What further investigations should be performed?
• What are the key points in the management of this woman?

ANSWER 3
This woman has symptoms of amenorrhoea as well as hypo-oestrogenic vasomotor symptoms and vaginal dryness. The diagnosis is of premature menopause (premature ovarian failure), confirmed by the very high gonadotrophin levels. High levels occur because the ovary
is resistant to the effects of gonadotrophins, and negative feedback to the hypothalamus and
pituitary causes increasing secretion to try and stimulate the ovary. Sheehan’s syndrome
(pituitary necrosis after postpartum haemorrhage) would also cause amenorrhoea but would
have inhibited breast-feeding and all menstruation since delivery.
Premature menopause (before the age of 40 years) occurs in 1 per cent of women and has
significant physical and psychological consequences. It may be idiopathic but a familial
tendency is common. In some cases it is an autoimmune condition (associated with hypothyroidism in this case). Disorders of the X chromosome can also be associated.

!	Effects of premature menopause
• Hypo-oestrogenic effects: • vaginal dryness • vasomotor symptoms (hot flushes, night sweats) • osteoporosis • increased cardiovascular risk • Psychological and social effects: • infertility • feeling of inadequacy as a woman • feelings of premature ageing and need to take HRT • impact on relationships

Further investigation
Osteoporosis may be prevented with continuous oestrogen replacement, but progesterone
should also be given simultaneously (cyclically or continuously) to prevent the increased risk
of endometrial carcinoma from unopposed oestrogen. Bone scan is necessary for baseline
bone density and to help in monitoring the effects of hormone replacement. Chromosomal
analysis identifies the rare cases of premature menopause due to fragile X syndrome or
Turner’s syndrome mosaicism.
Management
Osteoporosis may be prevented with oestrogen replacement, with progesterone protection of
the uterus. Traditional HRT preparations or the combined oral contraceptive pill are effective, the latter making women feel more ‘normal’, with a monthly withdrawal bleed and a
‘young person’s’ medication. In terms of future fertility, this woman’s options are in vitro
fertilization (IVF) with donor oocytes, adoption or the acceptance of only having one child.
Occasionally premature menopause is a fluctuating condition (resistant ovary syndrome)
whereby the ovaries may function intermittently. Contraception should therefore be used if
it would be undesirable to become pregnant. Patient support organizations are a good source
for women experiencing such an unexpected and stigmatizing diagnosis.

KEY POINTS

• Premature menopause (<40 years) occurs in 1 per cent of women. • Oestrogen replacement is essential for bone and cardiovascular protection. • It may be possible to conceive with IVF using donor oocytes.