O&G Vivas · Reproductive endocrinology & infertility
Amenorrhoea & oligomenorrhoea — structured oral station (12 minutes)
FRANZCOG oral-format station on secondary amenorrhoea from premature ovarian insufficiency: FIGO HyPO-P placement, ESHRE 2024 and NICE NG23 diagnostic criteria, causal testing, fertility counselling, hormone therapy and the adolescent Turner variant.
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FRANZCOGMRCOGABOG
Prompt
A 38-year-old woman presents with secondary amenorrhoea for six months, hot flushes, night sweats, and vaginal dryness. Her serum FSH is 78 IU/L on two occasions six weeks apart, and her oestradiol is low. Serum prolactin and TSH are normal. The examiner will ask you to interpret the results, place the disorder in the FIGO classification, plan the investigations for a cause, and counsel on fertility and hormone therapy.
Candidate task
Reading time, then a structured examination. Answer each probe in short structured sentences, and check understanding before moving on.
Reveal the examiner script and model responsesShowHide
Opening prompt: "What is your interpretation of these results?"
- "She is under 40 with six months of amenorrhoea, oestrogen-deficiency symptoms and a raised FSH, so I am thinking of premature ovarian insufficiency."[2]
- "ESHRE 2024 diagnoses POI on disordered cycles for at least 4 months and an FSH over 25 IU/l, repeating the FSH after 4 to 6 weeks only if there is uncertainty."[2]
- "NICE NG23 asks for elevated FSH on 2 samples 4 to 6 weeks apart. She meets both definitions."[5]
- "A low oestradiol is not diagnostic on its own, but together with a raised FSH it adds confirmation."[2]
Probe 1: "Where does this sit in the FIGO classification?"
- "FIGO HyPO-P has three levels. The first is anatomic: Type I hypothalamic, Type II pituitary, Type III ovarian and Type IV PCOS."[1]
- "The second level, GAIN-FIT-PIE, stratifies Types I to III by mechanism: Genetic, Autoimmune, Iatrogenic, Neoplasm; Functional, Infectious and Inflammatory, Trauma and Vascular; Physiological, Idiopathic, Endocrine. The third level is the specific entity."[1]
- "POI with high gonadotrophins and low oestrogen corresponds to the original WHO Group III, primary ovarian failure."[1]
Probe 2: "How would you look for a cause?"
- "Chromosomal analysis and FMR1 premutation testing, because both are recommended for all women with non-iatrogenic POI."[2]
- "21-hydroxylase autoantibodies, because the cause is unknown; if positive I refer to an endocrinologist for adrenal testing."[2]
- "TSH now and every 5 years. I would not routinely test TPO or anti-ovarian antibodies."[2]
- "A DXA scan at diagnosis."[2]
Probe 3: "How would you counsel her on fertility?"
- "POI substantially reduces the chance of natural conception, but ovarian activity may occur, so she should use contraception if she does not want to be pregnant."[2]
- "No intervention has been reliably shown to increase ovarian activity or natural conception. Oocyte donation is an established route to pregnancy."[2]
- "One national position statement puts spontaneous pregnancy at around 6%."[3]
Probe 4: "What about her long-term health?"
- "Without hormone therapy, POI is associated with reduced life expectancy, largely from cardiovascular disease."[2]
- "I recommend hormone therapy until the usual age of menopause, whether or not she has symptoms, with a progestogen because she has a uterus."[2]
- "NICE offers a choice of HRT or a combined hormonal contraceptive; both protect bone, HRT may benefit blood pressure compared with the combined pill, and HRT is not a contraceptive."[5]
Probe 5: "She asks why this happened."
- "I would explain that a cause is often not found: one national position statement reports that more than 60% of primary POI has no identifiable cause."[3]
- "I would convey the diagnosis with compassion, give her time for questions, and offer support groups and mental health care."[2]
- "Her sisters and daughters have an increased risk of POI and should be counselled."[2]
Probe 6: "How would your approach differ if she were 17 with primary amenorrhoea and short stature?"
- "Turner syndrome is the most common cause of primary amenorrhoea, affecting about 1 in 2500 liveborn girls; I would request gonadotrophins and a karyotype."[4]
- "A standard karyotype may miss mosaicism, so FISH on 300 interphase cells is appropriate when Turner syndrome is suspected."[4]
- "With a diagnosis, I would arrange thyroid function, cardiac evaluation, renal ultrasound and a formal hearing test."[4]
- "If a Y chromosome is present, gonadectomy is needed because of the risk of gonadoblastoma or dysgerminoma."[4]
- "Puberty is induced with low-dose transdermal estradiol, increased roughly every 6 months to adult dosing over 2 to 3 years."[4]
References5ShowHide
- [1]Munro MG, Balen AH, Cho S, et al. The FIGO Ovulatory Disorders Classification System†. Human reproduction (Oxford, England), 2022.PMID 35984284
- [2]Panay N, Anderson RA, Bennie A, et al. Evidence-based guideline: premature ovarian insufficiency(). Human reproduction open, 2024.PMID 39660328
- [3]Christin-Maitre S, Givony M, Albarel F, et al. Position statement on the diagnosis and management of premature/primary ovarian insufficiency (except Turner Syndrome). Annales d'endocrinologie, 2021.PMID 34508691
- [4]Yatsenko SA, Witchel SF, Gordon CM Primary Amenorrhea and Premature Ovarian Insufficiency. Endocrinology and metabolism clinics of North America, 2024.PMID 38677871
- [5]National Institute for Health and Care Excellence Menopause: identification and management (NG23). Recommendations NICE guideline NG23, 2026.Source