Amenorrhoea
Amenorrhoea is the absence or abnormal cessation of menstruation, classified as primary (failure to menstruate by age 15) or secondary (cessation of previously established menses for three or more months).
Murtagh Diagnostic Strategy
| Category | Diagnosis | Key Discriminator | Cantonese Question / Finding | Probability |
|---|---|---|---|---|
| Probability Diagnosis | Pregnancy | Sexually active, missed period | 「有冇機會懷孕？最近一次性行為係幾時？」加尿液驗孕 | ~30% |
| PCOS [1] | Oligomenorrhoea + hyperandrogenism (acne/hirsutism) + polycystic ovaries on USS | 「你有冇發覺暗瘡多咗，或者面、下巴、胸口、肚嘅毛多咗？」 | ~25% | |
| Functional hypothalamic amenorrhoea (stress/weight loss/exercise) | Low BMI, excessive exercise, psychological stress, low FSH/LH/E2 | 「你最近有冇瘦咗好多、做運動做得好密，或者壓力好大？」 | ~15% | |
| Serious Not To Miss | Pregnancy complications (ectopic) | Positive pregnancy test with abdominal pain, bleeding | 「有冇肚痛或者陰道流血？」加驗孕同超聲波 | ~2% |
| Pituitary tumour (prolactinoma) [2] | Galactorrhoea + headache + visual field defect + elevated prolactin | 「有冇乳頭有奶水流出嚟？有冇頭痛或者視力變差？」 | ~2% | |
| Premature ovarian insufficiency (POI) [1] | Age < 40, elevated FSH (>25 IU/L on two occasions), low E2, hot flushes | 「有冇潮熱、夜晚出汗、陰道乾澀，似收經咁？」 | ~2% | |
| Hypothalamic/pituitary tumour (other) | Headache, visual symptoms, other pituitary hormone deficiencies | 檢查視野：「望住我個鼻，講我手指喺邊邊郁。」 | <1% | |
| Pitfalls | Hypothyroidism [1][2] | Fatigue, cold intolerance, weight gain, elevated TSH | 「有冇特別攰、怕凍、便秘、體重增加？」 | ~3% |
| Hyperthyroidism | Weight loss, palpitations, tremor | 「有冇心跳快、手震、怕熱、出汗多或者瘦咗？」 | ~1% | |
| Asherman syndrome | Secondary amenorrhoea after D&C/uterine surgery, negative Provera withdrawal test [1] | 「之前有冇刮宮、流產手術，或者子宮手術？」 | <1% | |
| Sheehan syndrome [3] | Postpartum haemorrhage → hypopituitarism → amenorrhoea, failure to lactate | 「上次生BB有冇大出血？之後有冇餵唔到奶？」 | <1% | |
| Congenital adrenal hyperplasia (late-onset) | Hyperandrogenism, elevated 17-OH progesterone | 「由細到大有冇毛多、暗瘡嚴重，或者月經一直唔準？」 | <1% | |
| Masquerades | Drugs [2] | Antipsychotics, metoclopramide, OCP → raised prolactin or direct suppression | 「你有冇食精神科藥、止嘔藥，或者避孕針/藥？」 | ~10% |
| Depression | Low mood, anhedonia, psychomotor changes → functional hypothalamic amenorrhoea | 「最近情緒有冇低落？有冇對平時鍾意嘅嘢冇晒興趣？」 | ~8% | |
| Anorexia nervosa | Very low BMI, distorted body image, restrictive eating | 觀察 BMI/消瘦：「你會唔會好擔心自己肥，所以刻意食好少？」 | ~5% | |
| Diabetes / chronic renal failure | Chronic illness disrupting HPO axis | 「有冇糖尿病、腎病、肝病，或者其他長期病？」 | ~2% | |
| Trying to Tell Me Something? | Desire to conceive / infertility concern | Main concern is inability to get pregnant | 「你係咪有計劃想生BB，所以擔心停經會影響懷孕？」 | ~15% |
| Fear of pregnancy | Anxiety about unplanned pregnancy | 「你最擔心係咪可能有咗BB？」 | ~10% | |
| Eating disorder concealment | Patient may minimize restrictive eating | 用非批判語氣問：「好多壓力大嘅人都會控制飲食，你最近有冇呢個情況？」 | ~5% | |
| Relationship / sexual concerns | Domestic violence, sexual abuse affecting wellbeing | 「屋企或者伴侶關係最近安唔安全？有冇人令你覺得受壓或者唔舒服？」 | ~3% |
Minute-by-Minute 6-Minute Consultation Structure
| Time | Task | Cantonese Key Phrases |
|---|---|---|
| 0:00–0:30 | Opening & rapport | 「早晨，我係醫科學生 [name]。我可以點樣稱呼你？」/「多謝你今日過嚟。今日有咩想我幫你？」 |
| 0:30–1:00 | Agenda setting & RFC | 「開始之前，我想問一問，係咩令你今日想嚟睇醫生？」/「你最擔心嘅係咩？」 |
| 1:00–3:30 | Focused HPI | Signpost: 「我想問多少少關於你月經嘅問題，幫我了解清楚啲，可以嗎？」Cover: 「最後一次嚟M係幾時？」/「有冇機會懷孕？」/「有冇用避孕？」/「有冇餵母乳、體重改變、壓力、食藥、乳頭有奶水、暗瘡多咗、毛多咗、怕凍/怕熱、潮熱、頭痛或者視力變？」 |
| 3:30–4:30 | ICE | Idea: 「你自己覺得可能係咩原因？」/ Concern: 「呢件事有冇咩令你特別擔心？」/ Expectation: 「你今日最希望我哋幫你做到啲咩？」 |
| 4:30–5:15 | Biopsychosocial screen | 「停經對你生活、返工/返學有冇影響？」/「屋企或者伴侶關係方面最近點？」/「最近情緒有冇低落或者好焦慮？」 |
| 5:15–6:00 | Closing & safety-net | Summarise: 「等我總結一下：你停咗M大約 X 個月，同時有……」/「我哋第一步會先做驗孕，之後安排荷爾蒙、甲狀腺血液檢查，可能需要照超聲波。」/ Safety-net: 「如果你有嚴重頭痛、視力轉差、肚痛、陰道流血，請即刻返嚟或者去急症室。」/「你仲有冇其他問題想問？」 |
Uncovering the hidden agenda: The presenting symptom is amenorrhoea, but the real reason for consultation may be:
- Fear of pregnancy (unplanned)
- Desire to conceive (infertility concern)
- Fear of cancer or serious disease
- Worried about early menopause / losing femininity
- Peer/family pressure about not having periods
- Body image / eating disorder the patient may not volunteer
Ask: "Apart from the missed periods, is there something else on your mind that you'd like us to address?"
| Domain | English Question | Cantonese Question | Why It Matters | If Positive Think Of |
|---|---|---|---|---|
| Characterise | "When was your last period? How long have your periods been absent?" | 你最後一次嚟M係幾時？停咗幾耐？ | Distinguishes primary (never had menses by age 15) vs secondary (absent ≥3 months in previously menstruating woman) | Primary: anatomical/genetic. Secondary: acquired causes |
| Menarche | "At what age did you first get your period?" | 你幾歲開始嚟M？ | Late menarche or absent = primary amenorrhoea workup | Turner syndrome, Müllerian agenesis, constitutional delay |
| Pregnancy | "Is there any chance you could be pregnant? When did you last have intercourse?" | 有冇機會係懷孕？最近一次性行為係幾時？ | Most important first step — always exclude pregnancy [1] | Pregnancy |
| Contraception | "Are you using any contraception? Which type?" | 你有冇用避孕措施？用邊種？ | Hormonal contraception (especially Depo-Provera, implants, Mirena) commonly causes amenorrhoea | Drug-induced amenorrhoea |
| Breastfeeding | "Are you currently breastfeeding?" | 你而家有冇餵母乳？ | Lactational amenorrhoea is physiological | Physiological amenorrhoea |
| Galactorrhoea | "Have you noticed any milky discharge from your nipples?" | 你有冇發覺乳頭有奶水流出嚟？ | Suggests hyperprolactinaemia [2] | Prolactinoma, drug-induced, hypothyroidism |
| Hirsutism/acne | "Have you noticed increased facial/body hair or acne?" | 你有冇發覺面上或者身上多咗毛，或者生暗瘡多咗？ | Hyperandrogenism suggests PCOS [1] | PCOS, adrenal tumour, CAH |
| Weight change | "Have you had any significant weight gain or loss recently?" | 你最近有冇明顯肥咗或者瘦咗？ | Significant weight loss / low BMI → hypothalamic amenorrhoea; weight gain → PCOS | Eating disorder, excessive exercise, PCOS |
| Exercise/diet | "How much exercise do you do? Have you been dieting or restricting food?" | 你做幾多運動？有冇節食或者控制飲食？ | Functional hypothalamic amenorrhoea from energy deficit | Athlete triad, anorexia nervosa |
| Stress | "Have you been under a lot of stress recently — work, studies, relationships?" | 你最近壓力大唔大？工作、學業、感情方面？ | Psychosocial stress → hypothalamic suppression of GnRH | Functional hypothalamic amenorrhoea |
| Thyroid symptoms | "Do you feel more tired, cold, or constipated? Or more anxious, sweaty, with tremor?" | 你有冇覺得特別攰、怕凍、便秘？定係心跳快、手震、出汗多？ | Thyroid dysfunction is a recognized cause [1] | Hypothyroidism, hyperthyroidism |
| Hot flushes | "Do you get hot flushes, night sweats, vaginal dryness?" | 你有冇潮熱、夜晚出汗、陰道乾澀？ | Suggests oestrogen deficiency → premature ovarian insufficiency (POI) [1] | POI (age < 40) |
| Headache/vision | "Any headaches or changes in your vision?" | 你有冇頭痛或者視力有冇變化？ | Pituitary tumour causing mass effect → bitemporal hemianopia [2] | Pituitary macroadenoma |
| Drug history | "Are you taking any medications? Antipsychotics, antidepressants, metoclopramide?" | 你有冇食緊任何藥？精神科藥、止嘔藥？ | Drugs affecting dopamine → hyperprolactinaemia → amenorrhoea [2] | Drug-induced hyperprolactinaemia |
| Chronic disease | "Do you have any long-standing illnesses — diabetes, kidney disease, liver disease?" | 你有冇長期病？糖尿、腎病、肝病？ | Chronic disease can disrupt HPO axis | Secondary causes |
| Past surgery/RT | "Have you had any surgery on your womb, ovaries, or brain? Any radiotherapy?" | 你有冇做過子宮、卵巢、或者腦部嘅手術？電療？ | Asherman syndrome (uterine), radiation damage to ovaries/pituitary | Asherman, POI, hypopituitarism |
| Family history | "Did your mother or sisters have early menopause or similar problems?" | 你媽媽或者姐妹有冇好早就收經或者類似問題？ | Familial POI, Turner syndrome, autoimmune POI | POI, genetic causes |
| Obstetric Hx | "Have you ever been pregnant? Any complications after delivery — heavy bleeding?" | 你有冇懷孕過？生完BB之後有冇大出血？ | Postpartum haemorrhage → Sheehan syndrome [3] | Sheehan syndrome |
| Sexual Hx | "Are you currently sexually active? Any pain during intercourse?" | 你而家有冇性行為？有冇性交痛？ | Relevant to pregnancy risk, vaginal outflow assessment | Pregnancy, imperforate hymen |
| Mood/self-image | "How have you been feeling emotionally? Any changes in appetite or body image?" | 你情緒點？食慾同對自己身材嘅睇法有冇變？ | Screen for eating disorder / depression | Anorexia nervosa, depression |
Case Report Form Answer Builder
Template: [Age]-year-old woman presents with amenorrhoea for [duration]. Previously regular/irregular cycles of [X] days. LMP [date]. Sexually active / not sexually active. Contraception: [type/none]. Associated symptoms: [galactorrhoea / hirsutism / acne / hot flushes / weight change / headache / visual disturbance / mood change]. No [relevant negatives]. PMH: [relevant]. DH: [relevant medications]. O&G Hx: G_P_, [relevant complications].
High-yield points to capture:
- Primary vs secondary amenorrhoea
- Duration of amenorrhoea
- Sexual activity and contraception
- Pregnancy test result
- Associated features pointing to cause (PCOS features, prolactin symptoms, thyroid symptoms, menopause symptoms, weight/exercise/stress)
- Relevant drug history
| Likely RFC Examples | How to Phrase |
|---|---|
| Worried about why periods stopped | "Patient is concerned about the cause of her amenorrhoea" |
| Worried about fertility | "Patient is concerned about her future fertility" |
| Worried about pregnancy | "Patient wants to exclude pregnancy" |
| Worried about cancer/serious disease | "Patient is worried about a serious underlying cause for absent periods" |
Pick the ONE reason that best captures why today. Often it is a concern (e.g., fertility) rather than just the symptom.
| Component | Likely Content | Exam Wording |
|---|---|---|
| Idea | "I think it might be stress / hormonal imbalance / early menopause / pregnancy" | "Patient thinks her amenorrhoea may be caused by stress/hormones" |
| Concern | "I'm worried I won't be able to have children" / "I'm worried something is seriously wrong" | "Patient is worried about infertility / serious underlying disease" |
| Expectation | "I'd like blood tests / an ultrasound / to know if I'm pregnant" | "Patient expects investigation to find the cause and reassurance" |
For a young woman with oligomenorrhoea/amenorrhoea + hirsutism/acne + overweight → PCOS [1]
For amenorrhoea in a sexually active woman → always exclude pregnancy first
Minimum supporting evidence for PCOS:
- Oligomenorrhoea/amenorrhoea
- Clinical or biochemical hyperandrogenism (hirsutism, acne, elevated testosterone)
- Polycystic ovaries on USS (≥20 follicles per ovary or ovarian volume ≥10 mL) [1]
- Rotterdam criteria: 2 of 3 required [1]
GC Lecture High Yield
The GC lecture slide on PCOS states the Rotterdam consensus: diagnosis requires 2 out of 3 — (1) oligo-anovulation, (2) clinical/biochemical hyperandrogenism, (3) sonographic polycystic ovaries (follicle number per ovary > 20 and/or ovarian volume ≥ 10 mL) [1]
| DDx | Key Discriminator |
|---|---|
| 1. Pregnancy | Positive urine β-hCG; always exclude first |
| 2. Hyperprolactinaemia (prolactinoma) | Galactorrhoea, elevated serum prolactin, MRI showing pituitary adenoma [2] |
| 3. Premature ovarian insufficiency | Age < 40, elevated FSH on two occasions ≥4 weeks apart, low oestradiol, vasomotor symptoms |
(Alternatives depending on stem: hypothyroidism, functional hypothalamic amenorrhoea, Asherman syndrome)
| Domain | Problem |
|---|---|
| Biological | Risk of long-term complications: e.g., osteoporosis from oestrogen deficiency, metabolic syndrome in PCOS, endometrial hyperplasia from anovulation |
| Psychological | Anxiety / low self-esteem related to fertility concerns, body image issues (hirsutism/acne/weight), or fear of serious disease |
| Social | Impact on relationship / marital stress (if trying to conceive); work/study disruption from frequent medical visits; social embarrassment from hirsutism |
| Diagnosis/DDx | Best Supporting Physical Sign | How to Elicit | Why It Supports Diagnosis |
|---|---|---|---|
| PCOS | Hirsutism (Ferriman-Gallwey pattern) | Inspect upper lip, chin, chest, lower abdomen and thighs for coarse terminal hair | Clinical hyperandrogenism is one of the Rotterdam criteria for PCOS [1] |
| PCOS / insulin resistance | Acanthosis nigricans | Inspect neck folds and axillae for velvety hyperpigmented plaques | Suggests insulin resistance, commonly associated with PCOS |
| Pregnancy | Enlarged uterus if pregnancy is advanced enough | Abdominal palpation for uterine enlargement; in early pregnancy, physical signs may be absent | Supports pregnancy, but urine β-hCG is the key first test |
| Ectopic pregnancy | Lower abdominal tenderness / cervical motion tenderness | Abdominal exam for tenderness and peritonism; pelvic exam only if appropriate and supervised | Positive pregnancy test plus pain/tenderness raises concern for ectopic pregnancy |
| Functional hypothalamic amenorrhoea | Low BMI / signs of undernutrition | Calculate BMI; inspect for cachexia, lanugo hair, bradycardia if severe | Energy deficit suppresses GnRH pulsatility |
| Prolactinoma / pituitary macroadenoma | Bitemporal visual field defect | Confrontation visual field testing | Suggests optic chiasm compression by pituitary macroadenoma [2] |
| Premature ovarian insufficiency | Signs of oestrogen deficiency may be subtle | Ask and, if clinically appropriate, assess for vaginal dryness/atrophy; check secondary sexual characteristics | Supports hypo-oestrogen state, but FSH/E2 confirm POI |
| Hypothyroidism | Delayed relaxation of ankle jerk | Elicit ankle reflex and observe slow relaxation phase | Classic sign of hypothyroidism causing menstrual disturbance |
| Hyperthyroidism | Fine tremor / tachycardia | Ask patient to outstretch hands with paper over fingers; check pulse | Supports thyrotoxicosis as an endocrine cause |
| Asherman syndrome | Usually no reliable external physical sign | Pelvic exam may be normal; history of D&C/uterine surgery and negative Provera withdrawal test are more useful | Amenorrhoea is due to intrauterine adhesions, not an external sign |
| Sheehan syndrome / hypopituitarism | Loss of axillary/pubic hair or breast atrophy | Inspect secondary sexual hair if appropriate; ask about failure to lactate | Pituitary failure reduces gonadotrophins and other pituitary hormones [3] |
| Androgen-secreting tumour / late-onset CAH | Virilisation | Look for severe hirsutism, deep voice, increased muscle bulk, clitoromegaly if appropriate | Rapid virilisation suggests pathological androgen excess |
Exam tip: For Q6, choose the sign that matches your Q4 most likely diagnosis. For PCOS, write hirsutism or acanthosis nigricans. For prolactinoma, write visual field defect. For hypothyroidism, write delayed ankle-jerk relaxation. If there is no reliable sign (e.g., Asherman), state the best supporting history/investigation instead.
Top Traps That Lose Marks
- Forgetting to exclude pregnancy — this is the #1 step in ANY amenorrhoea workup. Always ask about sexual activity and state "pregnancy test" as the first investigation [1].
- Confusing primary and secondary amenorrhoea — Primary = never menstruated by age 15. Secondary = absence ≥3 months (or ≥6 months if previously irregular) in someone who previously menstruated.
- Missing drug-induced causes — Antipsychotics, metoclopramide, domperidone, OCPs, Depo-Provera are common culprits. Always take a thorough drug history [2].
- Forgetting to check thyroid function — Hypothyroidism is a treatable and commonly tested cause [1].
- Not asking about galactorrhoea — This is the key question that opens up the prolactinoma differential.
- Writing only biological problems for Q5b — You MUST include psychological AND social problems to score full marks.
- Forgetting ICE — Many students skip expectations. Always ask all three.
Must Not Miss Red Flags — Urgent Referral
- Headache + visual field defect → pituitary tumour → urgent MRI and neurosurgical referral
- Positive pregnancy test + abdominal pain/bleeding → ectopic pregnancy → urgent O&G
- Severely low BMI (< 15–16) → medical emergency in anorexia → urgent medical admission
- Very high prolactin ( > 5000 mU/L) → macroprolactinoma → urgent endocrine/neurosurgery referral [2]
- Virilisation (deep voice, clitoromegaly) → androgen-secreting tumour → urgent investigation
Diagnostic Approach Algorithm (GC Lecture)
From GC 114 lecture slide [1]:
- Clinical assessment → Pregnancy test
- If negative → FSH, E2, prolactin, thyroid function, Provera withdrawal test
- FSH ↑ → POI (karyotype, Fragile X)
- Prolactin ↑ → MRI to exclude pituitary tumour
- Thyroid abnormal → Refer physician
- FSH ↓ → MRI to exclude hypothalamic/pituitary tumour
- FSH normal + Provera withdrawal positive → pelvic USS for PCO
- FSH normal + Provera withdrawal negative → endometrial or outflow tract problem (e.g., Asherman)
Shortest safe management/safety-net line for closing:
"I'd like to arrange a urine pregnancy test, blood tests including hormones and thyroid function, and possibly an ultrasound. If you develop severe headache, visual changes, or any heavy bleeding, please come back or attend A&E immediately. We'll review the results together at your next visit."
High Yield Summary
What to ASK: Pregnancy possibility (always first), LMP, duration, primary vs secondary, sexual activity/contraception, galactorrhoea, hirsutism/acne, weight/exercise/stress/diet, thyroid symptoms, hot flushes, headache/vision, drug history, obstetric history, mood, ICE.
What to WRITE: Chief complaint with duration; HPI covering associated features; ONE clear RFC (usually fertility concern or worry about cause); ICE; most likely diagnosis with Rotterdam criteria if PCOS or key evidence for other DDx; 3 DDx (pregnancy, prolactinoma, POI); 3 biopsychosocial problems (one each); supporting physical sign matching your diagnosis.
What NOT TO MISS: Pregnancy exclusion, drug history, thyroid function, pituitary red flags (headache/vision), eating disorder screening, ICE completion.
Active Recall - Family Medicine Clinical Test
[1] Lecture slides: GC 114. Climacteric symptoms menopause and related illness; amenorrhoea.pdf (slides on amenorrhoea causes, PCOS Rotterdam criteria, diagnostic approach algorithm) [2] Senior notes: Ryan Ho Endocrine.pdf (p110–112, hyperprolactinaemia causes, clinical presentation, approach); Ryan Ho Fundamentals.pdf (p443–445, hyperprolactinaemia and hypopituitarism); MBBS Final MB (Medicine) (Felix PY Lai).pdf (p1552–1555, prolactinoma diagnosis) [3] Senior notes: Ryan Ho Endocrine.pdf (p112, Sheehan syndrome under hypopituitarism causes); Ryan Ho Fundamentals.pdf (p445, Sheehan syndrome)
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