A Simple Guide to Amenorrhea

A Simple Guide to Amenorrhea
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What is Amenorrhea?
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Amenorrhea is a symptom defined as absence of menstruation.

What are the types of Amenorrhea?
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1.Primary Amenorrhea
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is defined as the absence of onset of menstruation (menarche) in a girl who has reached the age of 18 years.

2.Secondary Amenorrhea
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is defined as the absence of menstruation for a peroid of at least 6 months in a girl who has previously experienced normal menstruation and is not pregnant.

What are the causes of Amenorrhea?
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1.Physiological(hormonal):
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pregnancy hormones - pregnancy is the still the most common cause of secondary amenorrhea.
Growth hormone deficiency
Abnormal production of testosterone

2.Genetic Causes:
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abnormal formation of genital tract causing cryptomenorrhea -obstruction to the flow of menstrual blood such as imperforate hymen
Chromosonal abnormalities:
Turner syndrome
Ovarian agenesis

3.Uterine Pathology:
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adhesions from previous operation
endometriosis
tuberculosis infection
radiation

4.Ovarian:
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Agenesis(no ovaries)
Abnormal ovaries(again congenital)
Polycystic Ovaries
Granulosa-thca tumours of ovaries
radiation of ovaries

5.Pituitary:
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Pituitary tumours
Hypopituitarism
Hypothalamic abnormalities

6.Psychological:
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Depression
Anorexia nervosa,
starvation

7.Systemic Diseases:
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Hypothyoidism
Cushing syndrome

8.Medical causes:
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Chemotherapy
oral cotraceptive
corticosteroids
hypotensive drugs

How to establish a diagnosis of Amenorrhea
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History:
1.Primary Amenorrhea
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Genetic disorders:
failure to develop female sex characteristics
anatomic abnormalities due to chromosonal defects such as Turner syndrome
hirsutism-excessive male hormones

2.Secondary Amenorrhea
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Metabolic disorders:
symptoms of hypothyroidism
symptoms of polycystic ovarian syndrome
Obesity

Pyschologic disorders:
depression
anorexia nervosa

Pelvic examination:
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vulval and vaginal examination for cryptomenorrhea,
bimanual palpation for ovarian masses like polystic ovaries
abnormal uterus or ovaries

Investigations:
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Pregnancy test

blood for follicle stimulating hormones, luteinising hormones, prolactin

Progesterone withdrawal bleeding test
Luteinizing hormone releasing tests

Serum testesterone and androsterones

Transvaginal ultrasound to check on the uterus and ovaries
X-ray Skull, Brain CAT or MRI scans to exclude pituitary tumours

What is the Treatment of Amenorrhea?
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Medications:
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Specific treatment for amenorrhea depends on:

1.age,
2.overall health,
3.cause of the condition (primary or secondary)
4.the preference of the patient

Treatment for amenorrhea may include:
1.Pregnancy - no treatment if the patient wish to continue with pregnancy. Usually a referral to an obstetrician may be necessary

2.hormonal replacement(oestrogen and progesterone supplements ) in genetic cases and androgen producing tumours.

3.Cyproterone acetate is an anti-androgen which counters the effects of male hormones. It is usually given with a small dose of oestrogen.

4.Hyperprolactinaemia -treatment with bromocriptine which acts by stimulating the prolactin Inhibiting factor in the hypothalamus.

5.Polycystic ovary Disease -clomiphene and gonadatrophins may be given to improve menstruation and help fertility

6.Adrenal dysfunction due to deficiency of the enzyme 21-hydroxylase (androgegenital syndrome) results in excess ACTH and excessive production of androgens-treatment is with corticosteroids such as prednisolone

Other Treatments:
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1.Treatment of underlying systemic disease like thyroxine for hypothyroidism,

2.dietary changes to include increased caloric and fat intake especially in cases of low fat due to self induced dieting, anorexia nervosa

3.Pyschiatric treatment for women with depression, anorexia nervosa, or genetic dysfunction.

4.Healthy lifestyle for those who are obese