Amenorrhea Disease

BASICS

DESCRIPTION

The absence of menses.

Primary amenorrhea - no menses by age 14 with absence of secondary sexual characteristics, or no menses by age 16 with normal secondary characteristics
Secondary amenorrhea - the cessation of menses for three cycles or 6 months of amenorrhea
System(s) affected: Reproductive, Endocrine/Metabolic
Genetics: No known genetic pattern
Incidence/Prevalence in USA:
- Incidence of primary amenorrhea 0.3%
- Incidence of secondary amenorrhea 3.3%
Predominant age: Menarche to menopause
Predominant sex: Female only

SIGNS AND SYMPTOMS

The absence of periods
Galactorrhea
Symptoms of hypothyroidism
Symptoms of early pregnancy
Signs of androgen excess
Signs of estrogen deficiency

CAUSES

Primary amenorrhea
- Imperforate hymen
- Agenesis of the uterus and upper 2/3 of the vagina (Müllerian agenesis)
- Turner's syndrome
- Constitutional delay
Secondary amenorrhea
- Physiological - pregnancy, corpus luteal cyst, breast-feeding, menopause
- Suppression of the hypothalamic-pituitary axis - post pill amenorrhea, stress, intercurrent illness, weight loss, low body mass index
- Pituitary disease - ablation of the pituitary gland, Sheehan's syndrome, prolactinoma
- Uncontrolled endocrinopathies - diabetes, hypo- or hyperthyroidism
- Polycystic ovarian disease (PCOD), (Stein-Leventhal syndrome)
- Chemotherapy
- Pelvic irradiation
- Endometrial ablation (Asherman's syndrome)
- Drug therapy - systemic steroids, danazol, GRH-RH analogs, antipsychotics, OCP's
- Premature ovarian failure

RISK FACTORS

Over-training (e.g., long-distance runner, ballet dancer)
Eating disorders
Psycho-social crisis

DIAGNOSIS

LABORATORY

Pregnancy test if negative, obtain:
- Serum prolactin
- FSH
- LH
- TSH
- Blood sugar

Drugs that may alter lab results: N/A Disorders that may alter lab results: Pregnancy, menopause, hyperprolactinemia, ovarian suppression, endocrinopathy

PATHOLOGICAL FINDINGS

Due to underlying disease

SPECIAL TESTS

Progesterone challenge test - 10 mg of medroxyprogesterone acetate orally for 5 days
- If withdrawal bleeding occurs, amenorrhea most likely due to anovulation
- If no bleeding, evaluate estrogen status (FSH, LH)

IMAGING

Ultrasound may show cysts undetectable on pelvic examination
Radiologic evaluation of the sella turcica if prolactinomas suspected (elevated serum prolactin)

DIAGNOSTIC PROCEDURES

Laparoscopy - diagnosis of the streak ovaries of Turner's syndrome, or polycystic ovarian disease
Hysterosalpingogram - to rule out Asherman's syndrome

TREATMENT

APPROPRIATE HEALTH CARE

Outpatient

GENERAL MEASURES

Definitive treatment depends on determining the cause of the amenorrhea. May not be necessary to treat all cases especially if just temporary amenorrhea.

SURGICAL MEASURES

Hymenectomy, done as a day surgery, will be required for those whose primary amenorrhea is due to imperforate hymen
Lysis at adhesions in Asherman's syndrome

ACTIVITY

No restrictions

DIET

Correct overweight or underweight by dietary management

PATIENT EDUCATION

Consists of fully informing the patient of your findings, including the presence or absence of pregnancy, and of the underlying cause
Specific educational resources can be utilized as necessary, e.g., prenatal classes, menopause support groups
Specific information should be given about the expected duration of amenorrhea (temporary or permanent), effect on fertility, and the long-term sequelae of untreated amenorrhea (e.g., osteoporosis, vaginal dryness)
Appropriate contraceptive advice should be given, as fertility returns before menses
Additional support may be needed if the amenorrhea is associated with a reduction in, or loss of, fertility
Society for Menstrual Cycle Research, 10559 N. 104th Place, Scottsdale, AZ 85258, (602)451-9731

FOLLOW UP

PREVENTION/AVOIDANCE

Maintenance of proper body mass index (BMI)

POSSIBLE COMPLICATIONS

Estrogen deficiency symptoms, e.g., hot flushes, vaginal dryness
Osteoporosis, in prolonged hypoestrogenic amenorrhea
Increased risk of endometrial cancer in hyperestrogenism without progestin

EXPECTED COURSE AND PROGNOSIS

Reflects the underlying cause. In secondary amenorrhea from hypothalamopituitary suppression, spontaneous resumption of menses with time (99% within 6 months) and correction of body mass index.

MISCELLANEOUS

ASSOCIATED CONDITIONS

N/A

AGE-RELATED FACTORS

Pediatric: Primary amenorrhea commonly diagnosed in this group
Geriatric: N/A
Others: N/A

PREGNANCY

One of the primary causes

OTHER NOTES

Use of hormonal replacement therapy is symptomatic and is discretionary if amenorrhea is temporary (e.g., hypothalamopituitary suppression)
Patients who are amenorrheic and wish to become pregnant should not be given hormone replacement therapy, but should receive treatment for infertility based on specific cause
Women less than age 30 with ovarian failure should have Karyotype analysis

ABBREVIATIONS

N/A

Clinical Investigations

ROLE OF HOMOEOPATHY

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