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Amenorrhea - Causes, Symptoms And Treatment

Amenorrhea is the abnormal absence or suppression of menstruation. Absence of menstruation is normal before puberty, after menopause, or during pregnancy and lactation: it's abnormal and, therefore, pathologic at any other time. Primary amenorrhea is the absence of menarche in an adolescent (age 16 and older). Secondary amenorrhea is the failure of menstruation for at least 3 months after the normal onset of menarche. Primary amenorrhea occurs in 1 % of women: secondary amenorrhea is seen in about 4% of women. Prognosis varies depending on the specific cause. Surgical correction of outflow tract obstruction is usually curative.

Causes of amenorrhea

Amenorrhea usually results from:

  • anovulation due to hormonal abnormalities, such as decreased secretion of estrogen, gonadotropins, luteinizing hormone, and follicle
    stimulating hormone (FSH)
  • lack of ovarian response to gonadotropins
  • constant presence of progesterone or other endocrine abnormalities.

Amenorrhea may also result from:

  • absence of a uterus
  • endometrial damage
  • ovarian, adrenal or pituitary tumors
  • emotional disorders (common in patients with severe disorders, such as depression and anorexia nervosa), mild emotional disturbances tending to distort the ovulatory cycle, severe psychic trauma abruptly changing the bleeding pattern or completely suppressing one or more full ovulatory cycles
  • malnutrition and intense exercise, causing an inadequate hypothalamic
    response.

The pathogenic mechanism varies depending on the cause and whether the defect is structural, hormonal, or both. Women who have adequate estrogen levels but a progesterone deficiency don't ovulate and are, thus, infertile. In primary amenorrhea, the hypothalamic-pituitary-ovarian axis is dysfunctional. Because of anatomical defects of the central nervous system, the ovary doesn't receive the hormonal signals that normally initiate the development of secondary sex characteristics and the beginning of menstruation.

Secondary amenorrhea can result from several central factors (hypogonadotropic hypoestrogenic anovulation) or uterine factors (as with Asherman's syndrome, in which the endometrium is sufficiently scarred that no functional endometrium exists) as well as cervical stenosis and premature ovarian failure, among others.

Signs and symptoms

Because amenorrhea may result from one of several disorders, signs and symptoms depend on the specific cause. Signs and symptoms may include:

  • absence of menstruation
  • vasomotor flushes, vaginal atrophy, hirsutism (abnormal hairiness), and acne (secondary amenorrhea).

Complications of amenorrhea include:

  • infertility
  • endometrial adenocarcinoma (amenorrhea associated with anovulation that gives rise to unopposed estrogen stimulation of the endometrium).
Diagnosis

Diagnosis of amenorrhea is based on

  • history of failure to menstruate in females age 16 and older, if consistent with bone age (confirms primary amenorrhea)
  • absence of menstruation for 3 months in a previously established menstrual pattern (secondary amenorrhea)
  • physical and pelvic examination and sensitive pregnancy test ruling out pregnancy as well as anatomic abnormalities (such as cervical stenosis) that may cause false amenorrhea (cryptomenorrhea), in which men struation occurs without external bleeding.
  • onset of menstruation (spotting) within 1 week after giving pure progestational agents such as medroxyprogesterone (Provera), indicating (enough estrogen to stimulate the lining of the uterus (if menstruation doesn't occur, special diagnostic studIes, such as gonadotropin levels, are indicated)
  • blood and urine studies showing hormonal imbalances, such as lack of ovarian response to gonadotropins (elevated pituitary gonadotropin levels), failure of gonadotropin secretion low pituitary gonadotropin levels), and abnormal thyroid levels (Without suspicion of premature ovarian failure or central hypogonadotropism, gonadotropin levels aren't clinically meaningful because they're released in a pulsatile fashion; at a given time of day, levels may be elevated, low, or average.)
  • complete medical workup, including appropriate X-rays,laparoscopy, and a biopsy, to identify ovarian, adrenal, and pituitary tumors.

Treatment for amenorrhea

Treatment of amenorrhea may include:

  • appropriate hormone replacement to reestablish menstruation
  • treatment of the cause of amenorrhea not related to hormone deficiency (for example, surgery for amenorrhea due to a tumor or obstruction) . inducing ovulation (With an intact pituitary gland, clomiphene [Clomid] may induce ovulation in women with secondary amenorrhea due to gonadotropin deficiency, polycystic ovarian disease, or excessive weight loss or gain.)
  • FSH and human menopausal gonadotropins (Pergonal) for women with pituitary disease
  • improving nutritional status
  • modification of exercise routine.

Special considerations

  • Explain all diagnostic procedures.
  • Provide reassurance and emotional support. Psychiatric counseling may be necessary if amenorrhea results from emotional disturbances.
  • After treatment, teach the patient how to keep an accurate record of her menstrual cycles to aid in early detection of recurrent amenorrhea.


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