Oligo/amenorrhoea, hirsutism, acne, female infertility

ADULT

  • 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.

    • Pituitary tumour with sudden severe headache, acute onset visual loss/diplopia or adrenal crisis (hypotension, tachycardia, vomiting, altered level of consciousness)
    • 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 were 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 is not available through 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)
    • 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) 2023

    • Require 2 of:
      1. Oligo- or anovulation
      2. Clinical and/or biochemical hyperandrogenism,
      3. Polycystic ovaries on ultrasound (vaginal USS not needed if 1 and 2 are present, and not recommended for <20 years due to high incidence of polycystic ovary morphology)
    • (and exclusion of other aetiologies such as thyroid disease, hyperprolactinaemia, premature menopause or non-classical congenital adrenal hyperplasia)

    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
Minimum Referral Criteria
Category 1
(appointment within 30 calendar days)
  • Arrested puberty (16 years and over)
  • Suspected hypopituitarism
  • New onset virilisation in a female (hirsutism, acne, balding)
  • Serum testosterone >5nmol/l in a female
Category 2
(appointment within 90 calendar days)
  • Delayed puberty (16 years and over)
  • Primary or secondary oligo/amenorrhoea
  • Menopause:
    • Age <45 years, and/or
    • Severe symptoms not responding to, or contraindication to, Menopausal Hormone Therapy.
Category 3
(appointment within 365 calendar days)
  • Biochemical hyperandrogenism and/or related clinical signs of acne and/or hirsutism without evidence of severe androgen excess
  • Polycystic ovarian syndrome as per Rotterdam criteria in the absence of any other explanation
  • All referrals for infertility (definition: - infertility is the failure to achieve pregnancy after 12 months or more of regular unprotected intercourse)

Please insert the below information and minimum referral criteria into referral

1. Reason for request Indicate on the referral

  • To establish a diagnosis
  • For treatment or intervention
  • For advice and management
  • For specialist to take over management
  • Reassurance for GP/second opinion
  • For a specified test/investigation the GP can't order, or the patient can't afford or access
  • Reassurance for the patient/family
  • For other reason (e.g. rapidly accelerating disease progression)
  • Clinical judgement indicates a referral for specialist review is necessary

2. Essential referral information Referral will be returned without this

  • History including
    • family history of delayed puberty or hypogonadism.  History of chronic ill health or any medications
    • reproductive features (hirsutism, infertility, and pregnancy complications), and
    • metabolic implications (insulin resistance, metabolic syndrome, IGT, T2DM and potentially CVD)

Infertility includes:

  • History of
    • previous pregnancies, STIs and PID, surgery, endometriosis
    • other medical conditions
  • Include the following information about partner
    • age and health, reproductive history, testicular conditions
  • Weight/ BMI
  • FBC, group and antibodies, rubella IgG, varicella IgG, syphilis serology, Hepatitis BsAg, HBC serology, HIV
  • FSH, LH (Day 2 - 5), prolactin, TSH if cycle prolonged and/or irregular
  • Day 21 serum progesterone level (7 days before the next expected period)
  • Endocervical swab or first catch urine for chlamydia +/- gonorrhoea NAA
  • Partner
    • Seminal analysis of partner (≥4 days of abstinence) report
    • Repeat in 4-6 weeks if abnormal

Polycystic ovarian disease investigations include

  • SHBG
  • Testosterone, DHEA-S
  • 17-OH progesterone (D3-10 of cycle)
  • Fasting blood glucose, HbA1c
  • Lipids, TSH

Hirsutism investigations include

  • Fasting glucose, lipids
  • Testosterone, SHBG, calculated free testosterone
  • 17-OH progesterone (D3-10 of cycle)

Amenorrhea include

  • Duration of amenorrhoea (i.e. >6 months)
  • Weight/BMI - information about change in weight and exercise history
  • ßeta HCG
  • FSH, LH, prolactin, oestradiol, TSH/fT4
  • Testosterone, SHBG, calculated free testosterone
  • Anti-TTG

Delayed Puberty

  • Short stature screen
  • TFTs, renal function, FBC, ESR, or CRP, Anti TTG
  • Urinalysis
  • Chromosomes (Karyotope) in girls only (Turner Syndrome)
  • Bone age

3. Additional referral information Useful for processing the referral

  • Consider pelvic USS (day 1-4 menstrual cycle). Trans Vaginal USS preferable if acceptable for the woman.
  • If suspected hypopituitarism then check other anterior pituitary hormones e.g. prolactin, TSH, T4, morning (08:00-09:00) cortisol, ACTH, IGF1, growth hormone

Infertility

  • History of marijuana use (including partner) or other relevant medications that contribute to infertility e.g. illicit drugs, steroids, chemotherapy
  • AMH (Anti-Mullerian Hormone) levels

4. Request

  • Patient's 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

    Referring Practitioner Details

    • Full name
    • Full address
    • Contact details – telephone, fax, email
    • Provider number
    • Date of referral
    • Signature

    Relevant clinical information about the condition

    • Presenting symptoms (evolution and duration)
    • Physical findings
    • Details of previous treatment (including systemic and topical medications prescribed) including the course and outcome of the treatment
    • Body mass index (BMI)
    • Details of any associated medical conditions which may affect the condition or its treatment (e.g. diabetes), noting these must be stable and controlled prior to referral
    • Current medications and dosages
    • Drug allergies
    • Alcohol, tobacco and other drugs use

    Reason for request

    • To establish a diagnosis
    • For treatment or intervention
    • For advice and management
    • For specialist to take over management
    • Reassurance for GP/second opinion
    • For a specified test/investigation the GP can't order, or the patient can't afford or access
    • Reassurance for the patient/family
    • For other reason (e.g. rapidly accelerating disease progression)
    • Clinical judgement indicates a referral for specialist review is necessary

    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.)

  • 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.

    • Please note that 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 becoming pregnant) may affect the urgency categorisation and should be communicated as soon as possible.

    • 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.

Last updated: 2 December 2024

© State of Queensland (Queensland Health) 2023

Except as permitted under the Copyright Act 1968, no part of this work may be reproduced, communicated or adapted without permission from Queensland Health. To request permission email ip_officer@health.qld.gov.au1.