Amenorrhea may be defined as the absence of menstruation for
3 or more month in women with past menses (designated secondary amenorrhea) or
the absence of menarche (i.e., the onset of menses) by the age of 16 years in
girls who have never menstruated (termed primary amenorrhea). The term postpill
amenorrhea is often used to refer to women who do not menstruate within 3 month
of discontinuing oral contraceptives. The absence of menstruation is
physiologic in prepubertal girls, during pregnancy and lactation, and following
the menopause.
Etiology Of Amenorrhea
a) Anatomic abnormalities of the genital tract that prevent
or obstruct menstrual bleeding include developmental anomalies (e.g.,
transverse vaginal septum), intrauterine adhesions (Asherman syndrome), or
cervical obstruction (stenosis).
b) Ovarian failure, which is characterized by markedly
elevated levels of FHS, includes those disorders in which the ovaries are
devoid of oocystes or will not respond appropriately to FSH.
c) Chronic anovulation is present in variety of disorders in
which the ovaries contain appropriate numbers of oocytes but the affected women
fail to ovulate. This group accounts for the largest number of patients and
includes individuals with hypothalamic and/or pituitary dysfunction, adrenal
and thyroid disorders, and inappropriate steroid feedback such as occurs in
PCO, (described above).
Diagnosis Of Amenorrhea
The most important assessment of the amenoreic patients is
careful history and a thorough physical examination. Patient should be
questioned about dietary and exercise habits, life-style, psychologic problems,
family history of amenorrhea etc. Evidence of increased androgen secretion,
including hirsutism, acne, temporal balding, deepening of the voice should be
sought.
Any evidence of decreased estrogen. including hot flashes, night
sweats, dyspareunia due to decreased vaginal secretion should be defined.
Although the entire physical examination is important, special attention should
be directed toward evaluating body dimensions and habitus, the extent and
distribution of androgen-stimulated body hair, breast development and the
external and internal genitalia, with emphasis on evidence of exposure to
androgens and estrogens in appropriate quantities, and patency of the genital outflow
tract.
Treatment Of Amenorrhea
Abnormalities of the genital outflow tract generally require
surgery if a normal uterus is present; otherwise, retrograde menstruation may
result in intra-abdominal endometriosis. If the amenorrhea is judged to be
caused by stress or emotional problems,
spontaneous recovery is to be expected if the problem can be removed or
alleviated by the passage of time. If it is caused by some underlying disease
or nutritional deficiency this must be treated or removed. If no cause and the
patient wants periods and contraception, the combined OC pill may be given.
If
the wishes to conceive, induction of ovulation can be produced by clomid,
gonadotrophins or pulsatile GnRH. A polycystic ovary syndrome may be treated by
laser drilling or wedge resection of the ovaries. The high prolactin level can
be reduced with dopamine agonist, bromocriptine. The dose has to be varied
according to the prolactin level and his treatment should be employed only in
units that have the facilities for hormone assays. The dose is increased very
cautiously, starting at 2,5 mg daily.
In summary, provided the uterus is present, primary
amenorrhea can be treated with hormones to induce menstruation. With secondary
amenorrhea, the ability to induce menstruation will depend on the state of the
endometrium and the hypothalamic-pituitary-ovary axis. The latter can be
influenced by drug therapy. Conception in both cases can only occur if there
ovarian tissue with primary ovarian follicles.
Adapted from: http://www.gyne.cz
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