Amenorrhea, oligomenorrhea

Rationale

Amenorrhea and oligomenorrhea are common patient concerns and can be associated with potentially serious underlying pathology. Primary amenorrhea is the absence of menarche by age 15 years in the presence of normal growth and secondary sexual characteristics. Secondary amenorrhea is the absence of menstruation for more than three cycles or six months in patients who were previously menstruating. Oligomenorrhea refers to infrequent menstruation, a cycle of menstrual periods with an interval of more than 35 days. Infrequent or absent menstruation in these circumstances is a reason for investigation and management.

Causal Conditions

(list not exhaustive)

1. Primary amenorrhea
   1. Central
      1. Hypothalamus (e.g., functional)
      2. Pituitary
   2. Ovary (e.g., ovarian dysgenesis, polycystic ovarian disease)
   3. Genital tract outflow obstruction (e.g., imperforate hymen)
2. Secondary amenorrhea and/or oligomenorrhea
   1. Pregnancy
   2. Central
      1. Hypothalamus (e.g., functional, exogenous hormones)
      2. Pituitary (e.g., prolactinoma)
   3. Other endocrine (e.g., thyroid disorders, adrenal disorders)
   4. Ovary (e.g., oophorectomy, chemotherapy, polycystic ovarian disease)
   5. Uterus (e.g., Asherman syndrome)

Key Objectives

Given a patient with oligomenorrhea or amenorrhea, the candidate will complete a relevant history and physical examination, and order pertinent investigations to determine the most likely diagnosis. In particular, the candidate will first rule out pregnancy. In amenorrhea, the candidate will then differentiate between primary and secondary. The candidate will initiate an appropriate management plan.

Enabling Objectives

Given a patient with amenorrhea or oligomenorrhea, the candidate will

1. list and interpret critical clinical findings, including results of an appropriate history and physical examination, including a pelvic examination;
2. list and interpret critical investigations, including appropriate laboratory and radiologic studies; and
3. construct an effective initial management plan, including
   1. on pregnancy if applicable;
   2. on primary amenorrhea if applicable;
   3. on secondary amenorrhea other than pregnancy if applicable;
   4. determining whether the patient requires specialized care; and
   5. counselling and education as appropriate.