A Family Doctor's Tale- AMENORRHEA

DOC I HAVE NO MENSES THIS MONTH

This obviously apply to girls and women only. First thing is to check whether there is a possibility of pregnancy. So always do a urine pregnancy test first!

Amenorrhea( A Simple Guide to Amenorrhea) is a symptom defined as absence of menstruation.


1.Primary Amenorrhea


is defined as the absence of onset of menstruation (menarche) in a girl who has reached the age of 18 years.


2.Secondary Amenorrhea


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.



The causes of Amenorrhea are:



1.Physiological(hormonal):

pregnancy hormones - pregnancy is the still the most common cause of secondary amenorrhea.
Growth hormone deficiency
Abnormal production of testosterone


2.Genetic Causes:

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:

adhesions from previous operation
endometriosis
tuberculosis infection
radiation


4.Ovarian:

Agenesis(no ovaries)
Abnormal ovaries(again congenital)
Polycystic Ovaries
Granulosa-thca tumors of ovaries
radiation of ovaries


5.Pituitary:

Pituitary tumors
Hypopituitarism
Hypothalamic abnormalities


6.Psychological:

Stress
Anorexia nervosa

There was a 17 year girl who did not have her menses since her O Level examinations  1 year ago.
It was the stress of the major examination which has affected her menses to the extent of amenorrhea. 
Her parents were worried sick about her condition.
I had to put her on female hormones every 21 days until her menses became normal. 
She was advised to relax and her medicines was reduced slowly until her menses remain normal even without the medication. Today she is a proud housewife with 2 children. 
Her menses remains regular.



7.Systemic Diseases:

Hypothyoidism
Cushing syndrome


8.Medical causes:

Chemotherapy
oral contraceptive
corticosteroids
hypotensive drugs


A diagnosis of Amenorrhea require:




History:
1.Primary Amenorrhea


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


Metabolic disorders:
symptoms of hypothyroidism
symptoms of polycystic ovarian syndrome
Obesity


Pyschologic disorders:
Stress
depression
anorexia nervosa


Pelvic examination:

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


Investigation:


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
Brain CAT or MRI scans to exclude pituitary tumours


Treatment of Amenorrhea:


Medications:


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


7.Treatment of underlying systemic disease like thyroxine for hypothyroidism,


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


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


10.Healthy lifestyle for those who are obese