Oligio/Amenorrhoea, Hirsutism, Acne, Female Infertility - Adult CPC

For clinical advice, please telephone the relevant specialty service.

Central Adelaide Local Health Network

• Royal Adelaide Hospital (08) 7074 0000
  
• The Queen Elizabeth Hospital (08) 8222 6000

Northern Adelaide Local Health Network 

• Lyell McEwin Hospital (08) 8182 9000
  

Southern Adelaide Local Health Network

• Flinders Medical Centre (08) 8204 5511
  

Exclusions

• In vitro fertilisation (IVF) - not provided in public hospitals

Triage categories

Category 1 - appointment clinically indicated within 30 days

• arrested puberty (16 years and over)
• suspected hypopituitarism or pituitary tumour
  
• new onset virilisation in a female e.g. hirsutism, acne, balding
  
• serum testosterone greater than 5nmol/l in a female
  

Category 2 — appointment clinically indicated within 90 days

• delayed puberty (16 years and over)
  

Category 3 — appointment clinically indicated within 365 days

• biochemical hyperandrogenism and/or related clinical signs of acne and/or hirsutism without severe androgen excess
  
• polycystic ovarian syndrome as per Rotterdam criteria
  
• primary or secondary oligo/amenorrhoea
  

Essential referral information

Completion required before first appointment to ensure patients are ready for care. Please indicate in the referral if the patient is unable to access mandatory tests or investigations as they incur a cost or are unavailable locally.

• past medical/surgical/reproductive history, including:
  
  • family history of delayed puberty or hypogonadism
    
  • history of chronic ill health or any medications
    
  • reproductive features (hirsutism, infertility and pregnancy complications)
    
  • metabolic implications (insulin resistance, metabolic syndrome, impaired glucose tolerance, type 2 diabetes and potentially cardiovascular disease)
    
• current medications and dosages
  
• use/frequency of alcohol, tobacco, and other drugs, including:
  
  • history of marijuana use (including partner)
    
  • other relevant medications that contribute to infertility e.g. illicit drugs, steroids, chemotherapy
    
• allergies and sensitivities
  
• onset, duration, and progression of symptoms
  
• management history including treatments trialled/implemented prior to referral
  
• height/weight
  
• body mass index (BMI)
  
• abdominal/pelvic examination
  
• transvaginal ultrasound (US) between days 1 to 4 menstrual cycle

Suspected infertility

• complete blood examination (CBE)
  
• electrolytes, urea & creatinine (EUC)
  
• liver function test (LFT)
  
• estimated glomerular filtration rate (eGFR)
  
• follicle-stimulating hormone (FSH)
  
• luteinizing hormone (LH) - Day 2 to 5
  
• prolactin
  
• thyroid stimulating hormone (TSH)
  
• blood group and antibody screen
  
• rubella immunoglobulin G (IgG)
  
• varicella-zoster IgG
  
• syphilis serology
  
• hepatitis B surface antigen (HBsAg)
  
• hepatitis C (HBC) serology
  
• human immunodeficiency virus (HIV) antigen/antibody
  
• day 21 serum progesterone level 7 days before the next expected period
  
• endocervical swab or first catch urine for chlamydia +/- neisseria gonorrhoeae nucleic-acid-based amplification assays (NAA)
  
• partner:
  • seminal analysis of partner
    
  • repeat in 4 to 6 weeks if abnormal

Suspected hirsutism

• fasting blood glucose
  
• lipids
  
• testosterone
  
• sex hormone binding globulin (SHBG)
  
• dehydroepiandrosterone sulphate (DHEAS)
  

Suspected amenorrhea

• human chorionic gonadotropin (ßhCG)
  
• oestradiol

Delayed puberty

• erythrocyte sedimentation rate (ESR) OR C-reactive protein (CRP)
  
• thyroid function tests (TFTs)
  
• insulin like growth factor (IGF1) or additional tests related to growth
  
• coeliac screen
  
• oestrogen (female)/testosterone(male)
  
• urinalysis
  
• karyotype (girls only) to exclude Turner Syndrome
  
• bone age study X-ray
  

Suspected hypopituitarism

• TSH
  
• free thyroxine (FT4)
  
• morning cortisol (8.00 am to 9.00 am)
  
• adrenocorticotropic hormone (ACTH)
  
• IGF1
  

Clinical management advice

Primary amenorrhoea is defined as the absence of menarche by:

• age 13 years in a female without breast development
• age 15 years in a female with normal growth and breast development
• 5 years after breast development that occurred before age 10 years

Secondary amenorrhoea is defined as the absence of menstruation for:

• more than 3 months in females with previously regular menstrual cycles
• more than 6 months in females with previously irregular menstrual cycles

Common causes of primary amenorrhoea include:

• hypogonadotropic causes such as constitutional delay, hypothalamic amenorrhoea and isolated gonadotrophin-releasing hormone deficiency e.g. Kalman syndrome, pituitary causes, hypopituitarism and hyperprolactinaemia
• hypergonadotropic causes such Turner syndrome, gonadal dysgenesis, premature ovarian insufficiency
• anatomical outflow tract abnormalities
• rare hormonal conditions such as androgen insensitivity and 5-alpha- reductase deficiency

Most common causes of secondary amenorrhoea or oligomenorrhoea include:

• hypergonadotropic causes such as premature ovarian insufficiency and early menopause
• hypogonadotropic causes, such as hypothalamic amenorrhoea, pituitary tumours causing hyperprolactinaemia, hypopituitarism
• intrauterine adhesions - Asherman syndrome
• perimenopause in females aged 45 years and older
• polycystic ovarian syndrome diagnostic criteria (Rotterdam Criteria) 2 of the following 3 criteria are required:
  • polycystic ovaries
  • oligo/anovulation
  • hyperandrogenism
• clinical (hirsutism or less commonly male pattern alopecia) or biochemical (raised FAI or free testosterone)
• pregnancy

Please ensure that recent pathology results are available. Consider providing the patient with a repeat pathology form at the time of referral.

Patients who have previously received care from a specialist should be encouraged to return to their care for additional assessment if needed.

Referrals are subject to the evaluation of the triaging clinician. If you believe your patient necessitates specialist assessment but may not meet the provided criteria, feel free to connect with the specialist team to discuss your concerns.

Infertility

When experiencing difficulty in conceiving, commence of 500mcg folic acid daily refer to gynaecology.

Hirsutism

Specialist referral is required for investigation and management of primary amenorrhea. Children or adolescents experiencing amenorrhea, referral to paediatric gynaecology services at the Women's and Children's Hospital (WCH) is advised.

Medications known to induce hypothalamic or pituitary suppression, such as combined oral contraceptives, depot medroxyprogesterone, Gosselin, or those causing hyperprolactinemia, such as antipsychotics, antiemetics, verapamil, selective serotonin reuptake inhibitors (SSRIs), and tricyclic antidepressants, can be responsible for these symptoms.

Clinical resources

• Therapeutic Guidelines - Acne
  
• Therapeutic Guidelines - Amenorrhoea
  
• Therapeutic Guidelines - Hirsutism
  
• Therapeutic Guidelines - Infertility
  

Consumer resources

• Better health - Absent Periods: Amenorrhoea
  
• Endocrine Society - Hirsutism
  
• Endocrine Society - Reproductive Infertility
  

Reason for request

• to establish a diagnosis
• for treatment or intervention
• for advice and management
• for specialist to take over management
• for a specified test/investigation the General Practitioner cannot order
• for other reason (e.g. rapidly accelerating disease progression)
• transfer of care from another tertiary service
• clinical judgement indicates a referral for specialist review is necessary.

Patient demographic details

• full name, including aliases
• date of birth
• residential and postal address
• telephone contact number/s – home, mobile and alternative
• Medicare number, where eligible
• name of the parent or caregiver, if appropriate
• preferred language and interpreter requirements
• identifies as Aboriginal and/or Torres Strait Islander

Clinical modifiers

• impact on employment
• impact on education
• impact on home
• impact on activities of daily living
• impact on ability to care for others
• impact on personal frailty or safety
• identifies as Aboriginal and/or Torres Strait Islander

Other relevant information

• Willingness to have surgery, where surgery is a likely intervention.
• Choice to be treated as a public or private patient.
• Compensable status, e.g. DVA, Work Cover, Motor Vehicle Insurance, etc.
• Relevant social history, including identifying if you feel your patient is from a vulnerable population, under guardianship/out-of-home care arrangements and/or requires a third party to receive correspondence on their behalf.
• Triage of a specialist outpatient referral is based on clinical decision making to allocate an appropriate urgency categorisation.
  
• Where appropriate and where available, the referral may be streamed to an associated public allied health and/or nursing service. Access to some specific services may include initial assessment and management by associated public allied health and/or nursing, which may either facilitate or negate the need to see the public medical specialist.
• A change in patient circumstance (such as condition deteriorating or pregnancy) may affect the urgency categorisation and should be communicated as soon as possible.
• All new referrals will be triaged by a consultant and appointment times scheduled according to clinical urgency.