Amenorrhea

Definition

Amenorrhea means absence of normal menstrual cycle (missed period). It can be physiological (pregnancy, breastfeeding, menopause) or pathological (hormonal imbalance, disease of reproductive organs) or drug induced (hormonal contraceptive methods-oral pills and injections). Amenorrhea can also be classified as primary (failure of starting menstruation even by 16 years of age) and secondary (stoppage of normal menstruation for at least three consecutive months).

Amenorrhea does not necessarily mean anovulation (stoppage of production of ovum), as breastfeeding mothers although not menstruating may conceive. Treatment is dependent on the cause. Where physiological amenorrhea (pregnancy) does not require any treatment in case of pathological amenorrhea drugs (hormones) even surgery (blockage in reproductive organs) can be required.

Symptoms

Depending upon the cause of amenorrhea symptoms vary.

Primary amenorrhea

Absence of menstruation (period) with (by the age of 16 years) or without (by the age of 14 years) development of secondary sexual character (signs of puberty).

Secondary amenorrhea

  • Change of breast size with nipple discharge.
  • Male pattern of facial hair growth.
  • Voice change.
  • Visual disturbances.

Amenorrhea of certain causes can (uterine adhesion) lead to infertility and sometimes osteoporosis (weakness of bones and easy fracture).

Causes

There are number of causes that can lead to amenorrhea. It occurs due to changes (physiological or pathological) at three different levels.

In case of primary amenorrhea :

  • Changes at the hypothalamic-pituitary axis (HPA): acts (via hormones FSH and LH) as the central regulatory center to influence the production of hormones by ovaries (estrogen and progesterone). This category of patients have favorable outcome when treated with hormones.
  • Changes at the level ovary: They fail to respond to the stimulus of HPA. Some chromosomal (genetic) abnormality (Turner’s syndrome) may be sometimes responsible.
  • Changes at the outflow tract (uterus and ovary): mullerian agenesis (missing uterus and upper part of vagina), vaginal atrophy (shrinkage of vagina), imperforated hymen.

In case of secondary amenorrhea :

  • Changes at hypothalamic-pituitary axis (HPA): excessive physical exercise, stress, obesity, weight loss, eating disorder (anorexia and bulimia), tumor in pituitary, imbalance of thyroid hormone.
  • Changes at ovarian level: pregnancy, breast feeding, natural menopause (between 45 and 50 years), drug induced (antipsychotic drugs, oral and injectable contraceptive agents), poly cystic ovarian disease (PCOD), premature menopause (before 40 years) .
  • Changes at the outflow level: adhesion in the uterine tissue due to pelvic infection or surgical maneuver.

Risk factors

  • Obesity or sudden weight loss
  • Stress
  • Disorder of thyroid gland (increased or reduced function)
  • Rigorous exercise
  • Intake of certain drugs: antipsychotic, antidepressant, anti cancer drugs, contraceptive medications

Treatment

Treatment depends upon the cause of amenorrhea. Physiological causes as such does not require any treatment like in case of pregnancy menstruation resumes after birth of the baby, in case of breastfeeding when the baby stops breastfeeding, in case of menopause it is inevitable. Slight modification of lifestyle improves some cases like weight reduction (in obesity), regular proper diet (in anorexia and bulimia) and curbing rigorous exercise. Drug treatment is necessary in some cases. External estrogen supplementation in reduced production . Surgical intervention as in pituitary tumor or in case of imperforated hymen is required.

 

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