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

A Simple Guide to Menorrhagia2(Excessive Menstrual Bleeding)

A Simple Guide to Menorrhagia2(Excessive Menstrual Bleeding)
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What is a Menorrhagia?
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Menorrhagia is a symptom defined as heavy, prolonged and/or irregular menstruation .

What are the causes of Menorrhagia?
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1.Physiological(hormonal): most common
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Excessive menstrual bleeding occurs when no ovulation takes place in a menstrual cycle with resultant excess oestrogen stimulation of the endometrium that results in the shedding of the thickened uterine lining and heavy bleeding when the oestrogen drops.

A defective persistent corpus luteum which results from an abnormal ovulation can also cause the shedding of the nedometrium for a longer period resulting in prolonged bleeding.

Other factors that may make heavy menstrual bleeding are:
2.Uterine Pathology:
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polyps,
fibroids
endometriosis
infection
carcinoma

3.Systemic Diseases:
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Bleeding diseases
Hypothyoidism
liver disease
Pelvic inflammatory Disease(PID)
Polycystic Ovarian syndrome(PCOS)

4.Medical causes:
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anticoagulants which are preventing clotting of blood
intrauterine device for contraception

How to establish a diagnosis of Menorrhagia?
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History:
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Menstrual history:
cycle length, number of bleeding days, degree of blood loss(number of pads used per day), presence of blood clots, dysmenorrhea

Contraception:
use of IUD
contraceptive pills

Symptoms suggesting underlying pathology:
Metabolic disorders:
symptoms of hypothyroidism
symptoms of polycystic ovarian syndrome

Bleeding disorders:
easy bruising
anticoagulants

Pelvic inflammatory Disease:
pelvic pain especially during intercourse
vaginal discharge
dysmenorrhea

Endometriosis:
pelvic pain
dysmenorrhea

Physical Examination:
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Signs of underlying diseases:
bruising
hypothyroid features
pallour(anaemia)
PCOS features(hirsutism,acne,overweight)

Abdominal examination:
tenderness,
palpable uterine or ovarian masses

Pelvic examination:
vulval and vaginal examination
bimanual palpation for masses
cervical smear

Investigation:
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Full blood count including hemoglobin(to exclude anemia from loss of blood) and platelets(low platelets can cause bleeding)

Transvaginal ultrasound to exclude uterine fibroids and polyps -postmenstrual scans is best when the endometrium is at its thinest.

Endometrial hysteroscopy and biopsy in women over 40 to exclude uterine cancer

What is the Treatment of Menorrhagia?
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Medications:
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1.Tranexamic acid- oral antifibrinolytic, given only when there is heavy bleeding

2.Combined oral contraceptives - prevent proliferation of the endometrium, reduces blood flow. Side effects are fluid retention, nausea, headache,deep vein thrombosis, mood changes, breast tenderness

3.oral progesterone - also prevent proliferation of the endometrium-usually less side effects bloating, headache, mood changes, breast tenderness

4. Injected progesterone -also prevent proliferation of the endometrium -similar side effects as oral progesterone. One additional side effect is the possibility of bone density loss. Evaluation of bone density should be done.

5. Levonorgestrel-releasing intrauterine system(LNG-IUS)
-also prevent proliferation of the endometrium
-side effects includes irregular bleeding up to 6 month, amenorrhea(no menses),
breast tenderness, and headache.

Surgery
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1.Endometrial ablation
may be done only
a.if medications has failed
b.if no desire to coceive
c.if the uterus is normal

Usually involve the removal of the endometrium through the cervical opening.
There are forms of endometrial ablation:
a.First generation:
hysteroscopy with general anaesthesia
-Rollerball ablation
-Transcervical resection of the endometrium

b.Second Generation:
non-hysteroscopy, no general anaethesia, day surgery,fast recovery
-Impedance-controlled bipolar radiofrequency ablation
-balloon thermal ablation
-microwave ablation
-free fluid thermal ablation

2. Hysterectomy
used only as a last resort in treatment of menorrhagia
if other treatment are contraindicated
there is a desire for amenorrhea
there is no desire to retain uterus and fertility

Treatment of Underlying causes:
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hypothyroidism with thyroxine tablets

intrauterine device removal

reduce anticoagulant treatment if possible

treat any bleeding disease with platelets or blood factor deficient infusion

treatment of endometriosis,

antibiotic treatment of pelvic inflammatory idsease

treatment of uterine carcinoma

surgical removal of fibroids and polyps