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Oligo/amenorrhoea, hirsutism, acne, female infertility

Emergency department referrals

Phone on call Diabetic and Endocrinology Registrar via:

  • Royal Brisbane & Women’s Hospital switch - (07) 3646 8111
  • The Prince Charles Hospital switch - (07) 3139 4000
  • Redcliffe Hospital switch – (07) 3883 7777
  • Caboolture Hospital switch – (07) 5433 8888

and send patient to the Department of Emergency Medicine (DEM) at their nearest hospital.

If any of the following are present or suspected, refer the patient to the emergency department (via ambulance if necessary) 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)

Does your patient wish to be referred?

Minimum referral criteria

Does your patient meet the minimum referral criteria?

Category 1

Appointment within 30 days is desirable

  • 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 days is desirable

  • Delayed puberty (16 years and over)
  • Primary or secondary oligo/amenorrhoea.

Category 3

Appointment within 365 days is desirable

  • 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)

If your patient does not meet the minimum referral criteria

Consider other treatment pathways or an alternative diagnosis.

If you still need to refer your patient:

  • Please explain why (e.g. warning signs or symptoms, clinical modifiers, uncertain about diagnosis, etc.)
  • Please note that your referral may not be accepted or may be redirected to another service

Other important information for referring practitioners

Not an 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 is not available 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, COCP

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

Referral requirements

A referral may be rejected without the following information.

Essential Referral Information

  • 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 results if cycle prolonged and/or irregular
  • Day 21 serum progesterone level results (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
  • Lipids, TSH

Hirsutism investigations include

  • Fasting glucose, lipids
  • Testosterone, SHBG, calculated free testosterone
  • 17-OH progesterone level (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 include

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

Additional Referral Information (useful for processing the referral)

  • Consider pelvic USS (day 1-4 menstrual cycle). Trans Vaginal S 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

Out of catchment

Metro North Health is responsible for providing public health services to the people who reside within its boundaries. Special consideration is made for patients requiring tertiary care or services that are not provided by their local Hospital and Health Service. If your patient lives outside the Metro North Health area and you wish to refer them to one of our services, inclusion of information regarding their particular medical and social factors will assist with the triaging of your referral.

  • 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

  • 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

  • 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

  • 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

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

  • 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.)
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