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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 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
  • Malignant 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

 

  • 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

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)
  • Category 3
    (appointment within 365 calendar days)
    • Primary or secondary oligo/amenorrhoea.  For optimum care, patient should be seen within 6 months.
    • 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)

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 include

  • 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
  • Fasting blood glucose
  • Lipids, TSH

Hirsutism investigations include

  • Fasting glucose, lipids
  • Testosterone, SHBG

Amenorrhea include

  • Duration of amenorrhoea (i.e. >6 months)
  • Weight/BMI
  • ßeta HCG
  • FSH, LH, prolactin, oestradiol, TSH

Delayed Puberty

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

3. Additional referral information Useful for processing the referral

  • Consider pelvic USS (day 1-4 menstrual cycle)(TVS preferable) TVS USS may not be appropriate in virginal young girls
  • If suspected hypopituitarism then check other anterior pituitary hormones e.g. prolactin, TSH, T4, morning (08:00-09:00) cortisol, ACTH, IGF1, growth hormone
  • Consider 08:00 17 (OH) progesterone for Congenital Adrenal Hyperplasia

Infertility

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

Delayed puberty

  • LH/FSH, Oestrogen or testosterone (highly desired)

 

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.)
  • 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.