Amenorrhoea

INTRODUCTION

Amenorrhea is the absence of menses.

A lady is said to have primary amenorrhea if at the age of 16 years she is yet to have her first menses. Secondary amenorrhoea is said to occur when menses suddenly stops for 3 – 6 months in a lady previously having regular menses.

Pregnancy is the commonest cause of secondary amenorrhea.

Other natural causes include:

• breastfeeding,
• the use of contraceptive medications

The majority of women have established menses by age 16 years and have regular menses at intervals of 21 – 35 days. When the interval between 2 menses is greater than 35 days, there is likely to be some problem.

Normal menses usually last 2 – 7 days and occurs at intervals of 21 – 35 days. However, for a particular woman, the interval should not be more than 5 days between menses. For example, a lady may have a menstrual cycle interval of 28 days the first month, 30 days the next month, and 25 days in the 3^rd month, this is normal. The longest and shortest interval is still within 5 days.

If the interval between menses for the same lady is 28 days the first month, 35 days the next month and 23 days in the 3^rd month it is abnormal. This is because the longest and shortest interval is 12 days apart for her.

The normal menstrual cycle usually indicates that the higher centres [hypothalamus and pituitary], the ovaries and uterus are functioning normally and that the lady is ovulating.

Several factors could predispose a woman to secondary amenorrhea. They include weight less than 45kg in an adult lady, eating disorders, female siblings with a history of amenorrhea among others.

SYMPTOMS

The main symptom the client will present is the absence of menses. Other symptoms will be related to the problem causing the amenorrhea. These include:

• The male pattern of hair distribution [cases of Hyperandrogenism such as PCOS]
• Headache and blurring of vision [cases of intracranial brain tumour]
• Weight loss [could be due to cancerous conditions, excessive exercise, HIV/AIDS]
• Depression [Psychiatric conditions]
• History of induced termination of pregnancy.

CAUSES

Amenorrhea is usually a reflection of an underlying medical disorder that needs to be detected.

When amenorrhea occurs, it could be as a result of:

1. The hypothalamus and pituitary gland fail to provide an appropriate amount of hormonal [gonadotropin] stimulation to the ovary. This results in inadequate production of estradiol and progesterone and failure of ovulation. Conditions which could cause this include:

• Intracranial brain tumour. Such ladies will present with headache, blurred vision and milky discharge from the breast. They usually will need further evaluation and treatment.
• Sheehan syndrome. The lady has had a history of severe bleeding following childbirth. She fails to produce breast milk and menses fail to return.
• Eating disorder. Severe eating disorders could lead to loss of menstrual regularity. The lady has a morbid fear of adding weight and hence lives on a restrictive diet.
• Psychiatric disorders such as depression, schizophrenia, and drugs used for its treatment could alter regular menses.
• Cancer leading to weight loss.
• Substance abuse such as the use of cocaine and excessive drinking of alcohol.
• Hyperthyroidism, hypothyroidism could also lead to irregular menses.
• Excessive exercise.
• Chronic medical diseases such as AIDS, HIV.

 

2. Normal hormonal [gonadotropin] stimulation by the hypothalamus and pituitary, but the ovaries fail to produce adequate amounts of estradiol.

Conditions which could cause this include:

• Premature ovarian failure. Ladies with this condition complain of hot flashes, vaginal dryness, night sweats, poor memory, etc.
• Turner’s syndrome. In this disorder, the girl has only one X sex chromosomes instead of two. She will have a short stature, poorly developed ovaries, and heart problems.
• Chemotherapy or radiation therapy. When used for cancer treatment it may lead to ovarian failure and menstrual disturbances.

 

3. Normal hypothalamus, pituitary, and ovaries function but an obstruction in the outflow tract [uterus, cervix or vagina].

Conditions which could cause this include:

• Asherman’s syndrome. In this condition, there is a previous history of a surgical procedure such as a termination of pregnancy involving the endometrial cavity, especially if performed in the presence of infection. The walls of the uterus fuse following the procedure thus trapping any menstrual blood.

 

PREVENTION

If the cause of the amenorrhea is known the client can be counselled to avoid factors that could lead to it such as maintaining normal body weight, reducing exercises, etc.

 

COMPLICATIONS

It is important to make an early diagnosis of premature ovarian failure to avoid severe health challenges in this group of women.

Complications that could arise from the disorder include:

Infertility

This is usually a result of a lack of ovulation or the eggs getting exhausted.

Increased risk of bone fracture

The condition could result in low estrogen levels, thereby leading to weak bones which can fracture easily.

Increased risk of heart disease

Estrogen protects the heart from heart diseases. Early loss of estrogen predisposes women to heart problems

 

DIAGNOSIS

Diagnosing amenorrhea usually begins with a history of the above symptoms: loss of menses for 3 – 6 months after establishing a normal pattern of flow or lack of menses at the age of 16 years.

Useful Laboratory tests include:

• Pregnancy Test. This is done to exclude a pregnancy. Pregnancies are one of the commonest reasons why a woman may miss her period.
• Estradiol assay. Checking for estradiol levels on the 3^rd day of menses would usually reveal low levels in cases of ovarian failure. Estradiol levelsless than 50 pg/mL indicate low levels.
• Follicle Stimulating Hormone [FSH]. FSH values on day 3 of menses of 40 mIU/mL or higher are indicative of ovarian insufficiency.
• Luteinizing Hormone [LH]. LH levels are increased.
• Prolactin Hormone. The normal range for prolactin in non-pregnant females is 2 to 29 ng/mL. The test is best done before the morning meal. Values above 30 ng/ml are abnormal. Values above 200 ng/ml are indicative of a prolactin-secreting tumour and need further evaluation with an MRI. It is important to note that prolactin values are elevated in the presence of stress, after a meal and the use of some medications.
• Anti-Mullerian Hormone. This test can be carried out at any time during a woman’s menstrual cycle and values less than 1 ng/ml are indicative of ovarian failure.
• Other tests can be carried out depending on what disorder your doctor suspects.

Hysteroscopy. A hysteroscopy involves inserting a rigid lens into the uterus to check for problems within it. Women who have suspected uterine synechiae [ a condition in which the 2 walls of the uterus fuse together] will be asked to carry out this procedure. Other tests they could benefit from include Hysterosalpingogram.

Magnetic Resonance Imaging [MRI]. This test is useful in cases of suspected pituitary adenomas. If you present with headache, blurred vision and milky secretions from your breast along with menstrual disorders, your doctor would require you to carry out this test.

 

TREATMENT

Treatment for a woman with amenorrhea will depend on several factors.

1. The cause of the menstrual irregularity
2. The fertility requirement of the client

In many cases, treatment of the underlying pathology involves a multidisciplinary team of doctors including the:

• In cases where clients suffer from mental disorders such as depression and bulimia, a psychiatric evaluation should be sought.
• Clients who need nutritional counselling such as those with low weight would benefit from a review by the nutritionist.
• An endocrinologist review would be necessary in cases of disorders of the hypothalamus and pituitary glands.
• General medicine practitioner. Cases of chronic medical diseases such as HIV, AIDS would need a consultation by the physician.

Medical Treatment

Specific medical treatment includes:

1. Gonadotrophin Releasing Hormone. Used to stimulate induction in women who do not ovulate and in whom treatment of their conditions cannot cause a reversal.
2. Dopamine agonist. Used to treat ladies with galactorrhea [milky discharge from the breast]. Drugs include bromocriptine, cabergoline.
3. HRT [Hormone Replacement Therapy]. This is used to help prevent fracture of the bone from osteopenia.

Surgical Treatment

Clients with uterine synechiae will need surgery [Hysteroscopic adhesiolysis] to break down the adhesions in their uterus. Hysteroscopy involves inserting a rod with a light source into the womb to help break down the adhesions.

Clients with pituitary tumours may require the removal of the tumour from the brain.

 

WHEN TO SEE A DOCTOR

You are advised to see your doctor if you experience the following.

1. If you are 16 years or more and have not had your first menses
2. If you have missed your period for several months
3. If you stopped menstruating after induced termination of pregnancy or a fibroid surgery
4. If you have difficulty getting pregnant