A 15 year old girl attends the gynaecology clinic with her mother because she has not started menstruating. Justify your management.
The management will depend on the presence or absence of secondary sexual characteristics.
If secondary sexual characteristics are present then investigations can be deferred until the age of 16 as the likely cause is constitutional delay.
If secondary sexual characteristics are absent then an external examination of the external genitalia should be performed to exclude an imperforate hymen. Vaginal examination is unhelpful and may cause psychological trauma in this age group. A trans abdominal ultrasound scan will exclude uterine and ovarian pathology. Mayor-Rokistanky-Hutch syndrome is associated with a blind ending vagina and non-communicating uterine horn. Psychological support is needed in this cohort of patients there may be issues about sexual identity. The blind ending vagina can be elongated with the aid of dilators or reconstrutive surgery. Surgery to remove the non-communicating horn is indicated if there is a history of cyclical pain.
Ovarian failure may occur in the presence of chromosomal aneuploides such as Turner\'s syndrome. A blood sample should be taken for karyotype. This investigation will also provide information about whether the patient is genetically male or female. With Turner\'s syndrome, hormone replacement therapy will be required to aid breast development and induce menstruation. In the genetically male patient, further investigations should be undertaken to diagnose androgen insensitivity syndrome and 5a reductase deficiency. IIn the former, oestrogen therapy will aid breast development. Streak gonads should eb removed due to the high risk of cancer. In the latter, a uterus may be present on ultrasound scan owing to the lack of mullerian inhibiting substance. Psycological support should also be part of management in this group of patients.
Hypogonadotrophic hypogonadism can occur due to congenital or acquired causes. Congenital causes include Kallman\'s syndrome and there is usually a history of anosmia. Treatment consists of hormone replacement with oestrogen and progestogens. Bone scans may be necessary due to the high risk of osteoporosis.
A prolactin secreting adenoma will cause galatorrhoea and amenorrhoea. A blood test for prolactin should be performed. A head CT or MRI will help identify te presence of intracranial space occupying lesions. Liaison with a paediatric endocrinologist will be helpful. Suppression with bromocriptine may be necessary. Surgical excision may be indicated if there are signs of optic nerve compression.
Would be grateful for other comments!
Posted by Mark D.
Cyclical pain/ pms present?
Sexually active? Any symps of pregancy? Smell.?
History – pubertal miletsones. Breastbud, height spurt.
Family histry- age of menarche in sister mother.
Any s/ of hypothyriodism
Any history of cns tumors,radiation,meningitis in childhood.
Examination ht,wt, bmi, br n axillary pubic hair for tanner staging.
Thyriod swelling. p/a any mass. No pv pr.
Most of them are constitutonal.
If br buds less than 24 mnths back – reasure.
If more than that-
LH FSH TSH PROL
Usg presence of ovaries ut.
Hypogonadotr- pulsatile gnrh, gonadotropins.
CBT for eating disorders.
Hypergonadotropic – karyotyping.
If XY – gonadectomy.
If turners- HRT/ low dose COC pills.
If imperf hymen- excision.
If vaginal agenesis / transv septum - usg to r/o renal anomalies and refer to specialist for vaginal reconstruction.
if MRKH syndome- explain condition, supprt groups, vaginal dilators and surrogacy with own eggs for fertility.
If hypothyri- eltroxin
If hyperprolactenemia- bromocriptin.
anything more ?
Posted by Anjum M.
history of wt loss,any stress, level of routine activity,discharge from breast,any history of chemothearpyor raiothearpy
on examination look for low posterior hair line and webbed neck
