Obstetrics and Gynaecology
Puberty, Menstrual Disorders and Amenorrhoea
Puberty, abnormal uterine bleeding with PALM-COEIN and amenorrhoea workup for MBBS, including Turner syndrome, mapped to NMC codes OG23, OG24 and OG25.
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Puberty, Menstrual Disorders and Amenorrhoea
Puberty, abnormal uterine bleeding with PALM-COEIN and amenorrhoea workup for MBBS, including Turner syndrome, mapped to NMC codes OG23, OG24 and OG25.
This chapter covers normal and abnormal puberty, disorders of menstruation and the systematic approach to amenorrhoea. It sets out the pubertal sequence and Tanner staging, precocious and delayed puberty, the FIGO PALM-COEIN classification of abnormal uterine bleeding, and the investigation algorithm for primary and secondary amenorrhoea.
High-yield: Puberty, Menstrual Disorders and Amenorrhoea
- The normal sequence of puberty in girls is thelarche, then pubarche, then a growth spurt, then menarche.
- Tanner staging describes breast and pubic hair development from stage 1 (prepubertal) to stage 5 (adult).
- Precocious puberty is the onset of secondary sexual characters before 8 years in girls and is central (gonadotropin-dependent) or peripheral.
- Central precocious puberty is treated with GnRH agonists to halt progression and preserve final height.
- Delayed puberty is the absence of secondary sexual characters by 13 years or menarche by 15 years.
- Turner syndrome (45,X) is a key cause of delayed puberty and primary amenorrhoea with short stature and streak gonads.
- Abnormal uterine bleeding is classified by the FIGO PALM-COEIN system into structural and non-structural causes.
- PALM covers polyp, adenomyosis, leiomyoma and malignancy; COEIN covers coagulopathy, ovulatory dysfunction, endometrial, iatrogenic and not otherwise classified.
- Primary amenorrhoea is no menarche by 15 with normal secondary characters or by 13 with none.
- Secondary amenorrhoea is absence of menstruation for three or more cycles or six months in a previously menstruating woman.
- Pregnancy is the commonest cause of secondary amenorrhoea and must be excluded first.
- The workup of amenorrhoea includes beta-hCG, then prolactin, thyroid function, FSH, LH and a progesterone challenge.
- A raised FSH indicates ovarian failure, while a low FSH points to a hypothalamic or pituitary cause.
- Asherman's syndrome, intrauterine adhesions often after curettage, causes secondary amenorrhoea with normal hormones.
Amenorrhoea and bleeding at a glance
- **Secondary amenorrhoea:** No periods for 3 cycles or 6 months. Exclude pregnancy first.
- **PALM-COEIN:** FIGO classification of abnormal uterine bleeding: structural (PALM) and non-structural (COEIN).
- **High versus low FSH:** High FSH = ovarian failure; low FSH = hypothalamic or pituitary cause.
- **Turner syndrome:** 45,X; short stature, streak gonads, primary amenorrhoea.
NMC competencies in this chapter
- **OG23.1:** Normal puberty: Tanner staging, pubertal sequence and HPO axis maturation
- **OG23.2:** Precocious puberty: central and peripheral causes, investigation and treatment
- **OG23.3:** Delayed puberty: causes, investigation and Turner syndrome
- **OG24.1:** Abnormal uterine bleeding: FIGO PALM-COEIN classification, investigation and management
- **OG25.1:** Amenorrhoea: primary, secondary, WHO classification and investigation algorithm
Frequently Asked Questions
What is the normal sequence of puberty in girls?
Breast development (thelarche), then pubic hair (pubarche), then the growth spurt, and finally the first period (menarche). Tanner staging tracks the progress.
What is the PALM-COEIN classification?
The FIGO system for abnormal uterine bleeding. PALM lists structural causes (polyp, adenomyosis, leiomyoma, malignancy) and COEIN lists non-structural causes (coagulopathy, ovulatory dysfunction, endometrial, iatrogenic, not otherwise classified).
What is the first step in evaluating secondary amenorrhoea?
Excluding pregnancy with a beta-hCG test, as pregnancy is the commonest cause. Then prolactin, thyroid function and FSH or LH are checked.
How does FSH help localise the cause of amenorrhoea?
A high FSH indicates ovarian failure, whereas a low FSH points to a hypothalamic or pituitary problem, guiding further investigation.
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