Oligo/amenorrhoea, hirsutism, acne, female infertility

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  Emergency

  If any of the following are present or suspected, please refer the patient to the emergency department (via ambulance if necessary) or follow local emergency care protocols or seek emergent medical advice if in a remote region.

  Adult conditions

  Pancreatic disease

  • Diabetic ketoacidosis  - A
  • Diabetes and severe vomiting -A
  • Acute severe hyperglycaemia
  • Acute severe hypoglycaemia -A
  • Hyperosmolar hyperglycaemic state (HHS) -A
  • Newly diagnosed type 1 diabetes –B (call registrar or consultant on call)
  • Foot ulcer with infection and systemically unwell or febrile -A
  • Invasive infection or rapidly spreading cellulitis of the foot (defined by peripheral redness around the wound >2cm) -A
  • Acute foot ischaemia -A
  • Wet gangrene foot -A

  Urgent cases – (refer to key below)A – client to present to emergency department immediately
  B – client to present to diabetes specialist service within 24 hours.  If no specialist service is available, present to an emergency department.

  High Risk Foot

  • Foot ulcer with infection and systemically unwell or febrile
  • Invasive infection or rapidly spreading cellulitis (defined by peripheral redness around the wound >2cm)
  • Acute ischaemia
  • Wet gangrene
  • Acute or suspected Charcot

  Thyroid disorders

  • Hyperthyroidism complicated by cardiac, respiratory compromise or other indications of severe illness (fever, vomiting, labile blood pressure, altered mental state)
  • Neutropenic sepsis in patient taking carbimazole or propylthiouracil
  • Hyperthyroidism with hypokalaemia or paralysis
  • Suspected myxoedema coma (altered consciousness, hypothermia, fluid overload, bradycardia, hyponatraemia)
  • Stridor associated with a thyroid mass
  • Possible tracheal or superior vena cava obstruction from retrosternal thyroid enlargement

  Adrenal disease

  • Addisonian crisis
  • Suspected or confirmed acute adrenal insufficiency
  • Phaeochromocytoma in crisis with uncontrolled hypertension

  Pituitary disorders

  • All patients with visual field loss (usually temporal and classically bitemporal superior quadrantinopia/hemianopia)
  • Pituitary tumour with severe headache
  • Pituitary tumour with evidence of symptomatic cortisol insufficiency
  • Hyperprolactinaemia with visual impairment or other neurological signs

  Oligo/amenorrhoea, hirsutism, acne, female infertility

  • Signs in the central nervous system that could indicate a pituitary tumour (visual field defect headaches)

  Calcium, electrolyte and metabolic bone disorders

  • Acutely symptomatic hypocalcaemia (e.g. tetany) with serum calcium <2.0mmol/L
  • Severe symptomatic hypercalcaemia (usually serum calcium > 3.0 mmol/l)
  • Hypernatraemia or hyponatraemia with acute confusion/delirium
  • Suspected or confirmed diabetes insipidus with hypernatraemia

  Paediatric Conditions

  Paediatric diabetes

  • New diagnosis of type 1 diabetes = polyuria and/or polydipsia and random BSL >11.0.
  • Ketoacidosis in a known diabetic with any of the following
    • systemic symptoms (fever, lethargy) or
    • vomiting or
    • inability to eat (even if not vomiting) or
    • abdominal pain or
    • headache

  Growth failure

  • Suspected pituitary mass (visual field loss/CNS signs)
  • Addisonian crisis (including unexplained hyponatraemia & hypoglycaemia)
  • Myxoedema coma
  • New onset diabetes insipidus (including unexplained hypernatraemia)
  • Hypocalcaemia (including acute rickets) with seizures
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  Other useful information for referring practitioners Not and exhaustive list

  • Refer to local Healthpathways or local guidelines
  • Focus of management should be on education and support with a strong emphasis on healthy lifestyle, with targeted medical therapy where indicated
  • Psychological features need to be screened for, acknowledged, discussed and counselling considered, to improve quality of life in PCOS and to facilitate effective and sustainable lifestyle change consideration of depression and/or anxiety and appropriate management
  • IVF not available in public hospitals
  • Lifestyle modification (increased activity, dietary, weight, smoking, alcohol)
    • simple moderate physical activity including structured exercise (at least 30 minutes/day) and optimising incidental exercise assists with weight loss and weight maintenance
    • 5-10% weight loss or optimal weight BMI 20-25.

  Infertility

  • Folic acid 0.5mg/day

  Hirsutism

  • Self-administered and professional cosmetic therapy are first line (laser recommended)
  • Eflornithine cream can be added and may induce a more rapid response
  • If cosmetic therapy is not adequate, pharmacological therapy can be considered
  • Pharmacological therapy – cyproterone acetate, spironolactone

  Diagnostic criteria for Rotterdam diagnosis of polycystic ovary syndrome: Monash International evidence-based guideline for the assessment and management of Polycystic Ovary Syndrome (PCOS) 2018

  • Two of the following three criteria are required:
    • Polycystic ovaries on ultrasound (either 25 or more follicles per ovary or increased ovarian size (>10 cc))
    • Oligo/anovulation
    • Hyperandrogenism
      • clinical (hirsutism or less commonly male pattern alopecia) or
      • biochemical (raised FAI or free testosterone)

  Amenorrhea in children or adolescents:

  • In adolescents – consideration needs to be given as to whether the patient should be referred to a paediatric or adult facility. Some general considerations would be:
    • primary amenorrhoea with growth failure and delayed puberty would more likely be best assessed by a paediatric service.
    • secondary amenorrhoea to an adult facility
    • Statewide Paediatric and Adolescent Gynaecology Service sees patients up to 18 years of age
  • Refer to Statewide Paediatric and Adolescent Gynaecology Service (SPAG) at Queensland Children's Hospital/RBWH