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Amenorrhoea

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Arman Shahi

Amenorrhoea is the absence of menstrual periods in a woman of reproductive age. There are two main types: primary amenorrhoea, where periods do not start by age 16, and secondary amenorrhoea, where established periods stop for six months or more. Common causes of secondary amenorrhoea include pregnancy, breastfeeding, contraceptive use, stress, weight change, excessive exercise, and medical conditions affecting hormone levels like polycystic ovary syndrome. Treatment depends on the underlying cause but may involve lifestyle changes, hormone therapy, weight management, or fertility treatment.

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Volgograd State Medical University Department Of Gynaecology Report : Amenorrhoea Course 6th Group 39 Junaid Amenorrhoea is the absence of a menstrual period in a woman of reproductive age. Physiological states of amenorrhoea are seen during pregnancy and lactation (breastfeeding), the latter also forming the basis of a form of contraception known as the lactational amenorrhoea method. Outside of the reproductive years there is absence of menses during childhood and after menopause.
Production of the female sex hormones oestrogen and progesterone can be affected by a range of factors, including certain reproductive disorders, weight loss, weight gain, emotional stress or excessive exercise. Amenorrhoea is the absence of menstrual periods. The most common cause is hormonal disruption, which can be due to emotional stress, weight change, excessive exercise or certain reproductive disorders. Treatment for amenorrhoea depends on the cause and can include adopting a healthier lifestyle or starting hormone replacement therapy (HRT), such as the combined oral contraceptive pill. Amenorrhoea is the absence of menstrual periods. Apart from during childhood, pregnancy, breastfeeding and menopause, the absence of periods may be due to a problem with the reproductive system. One of the most common causes of amenorrhoea is hormonal disruption. Production of the female sex hormones oestrogen and progesterone can be affected by a range of factors, including certain reproductive disorders, weight loss, weight gain, emotional stress or excessive exercise. Causes of amenorrhoea A range of factors can cause the hypothalamus to malfunction and trigger amenorrhoea, including: emotional stress weight loss excessive physical exercise certain medications used to treat mental health conditions disorders of the endocrine system, such as hypothyroidism (an underactive thyroid gland) Primary and secondary amenorrhoea
Amenorrhoea is divided into two categories: Primary amenorrhoea – periods have not started by 14 years and there are no signs of other sexual characteristics (such as developing breasts and pubic hair), or periods have not started by 16 years, even though other sexual characteristics have developed. Secondary amenorrhoea – periods have stopped for about six months. The menstrual cycle Brain structures known as the hypothalamus and pituitary gland interact to control the menstrual cycle. The pituitary gland produces hormones that stimulate the ovaries to produce oestrogen and progesterone. These hormones thicken the lining of the uterus (womb) to prepare for a possible pregnancy. When a pregnancy does not occur, hormone levels drop and the lining of the uterus comes away. This is called a period or menstruation. The cycle then repeats. Disorders of the hypothalamus, pituitary gland or ovaries can disrupt menstruation, causing amenorrhoea. Secondary amenorrhoea - This is much more common and has several causes: Pregnancy and breastfeeding (lactation). Menopause. Contraceptives - Some women on the oral contraceptive pill ("The Pill" and "The Mini-Pill"), and many women on Depo Provera injections, experience no periods. This can cause some anxiety but providing that you are well, and you have been tested to make sure you are not pregnant, you can be reassured that this may be normal for you. Stress / low body weight / excessive exercise - The hormonal system can be affected by these states. It is not uncommon to have no periods while changing jobs or schools, travelling, or when you are under emotional stress. Women who are below their ideal weight can stop ovulating and therefore experience no periods. This weight is different for every woman although a "normal" body weight is defined as having a BMI (Body Mass Index) of 20-25, calculated as weight (kg)/height (m)2. Sufferers of anorexia nervosa often stop having periods for this reason. Excessive exercise, marijuana use and chronic illness can also cause amenorrhoea.
Polycystic ovaries (see article on this). This condition will often interfere with regular ovulation. Associated symptoms of acne and excessive hair may be noted due to a hormonal imbalance. Hormonal disorders - Rarely, benign (non cancerous) tumors can occur in the pituitary gland. This leads to an excess of the hormone Prolactin that can stop periods, and cause a milky discharge from the nipples. Disorders of other glands such as the thyroid, adrenal and the ovaries can also cause periods to stop but these are rare. Medical therapies - Occasionally periods can stop after pelvic surgery or chemotherapy. Prescription medicines such as Haloperidol can also cause amenorrhoea. Investigations A detailed history should be undertaken to assess for any obvious underlying cause. As already mentioned, it is important to ensure the patient is not pregnant. The patient's BMI should be calculated and documented. An examination should be undertaken to determine any underlying cause. In particular, patients should be examined for signs of excessive androgens (hirsutism, acne, temporal balding), thyroid disease and Cushing's syndrome.[3] There may be an unexpected mass arising from the pelvis, and after 16 weeks human chorionic gonadotrophin (hCG) falls and pregnancy tests are negative. Abdominal masses arising from the pelvis are not necessarily uterine. It may be a large ovarian cyst. The following investigations should typically be done: Pregnancy test Follicle-stimulating hormone (FSH) and luteinising hormone (LH) Total testosterone and sex hormone-binding globulin TSH A pelvic ultrasound may be useful in patients with suspected PCOS Additional investigations may be appropriate in some women.
Urinary or serum hCG should be measured, as exclusion of pregnancy is a basic initial investigation in all cases of secondary amenorrhoea, and in some cases of primary amenorrhoea. FSH and LH are raised in ovarian failure; an FSH level ≥20 IU/l in a woman aged under 40 with secondary amenorrhoea indicates ovarian failure. Low gonadotrophin concentrations indicate a hypothalamic cause for amenorrhoea, which is often associated with stress or excessive exercise or weight loss with or without an eating disorder. In cases associated with weight change or excessive exercise, serum gonadotrophin may be normal. Oestrogens are low when ovaries are not functioning and may be high in PCOS. Low oestrogen with high FSH and LH suggests a primary ovarian problem whilst a low FSH and LH with low oestrogens suggests a problem at the hypothalamic or pituitary level, including stress, exercise and low weight. Management Management depends upon the nature of the problem. In all cases of primary amenorrhea, treatment is directed by the diagnosis.[4] Women with secondary amenorrhoea should still be offered contraception, as there is still a risk of pregnancy. If the condition is due to extreme weight loss and excessive exercise, treatment will involve encouraging you to maintain a healthier body weight. Fertility is likely to be a concern in the younger woman, whether in the near or more distant future. Hormone replacement therapy (HRT) is indicated for women with premature ovarian failure (<40 years) until the average age of natural menopause, around 50 years. Constitutional late puberty requires reassurance and waiting. Eating disorders require psychiatric/psychological intervention, usually with cognitive and behavioural therapy. Obesity also requires dietary modification. If PRL is elevated due to drugs, they should be reviewed. Phenothiazines may possibly be replaced by newer medication. Metoclopramide may be replaced by domperidone. Thyroid abnormalities should be managed appropriately. Women who plan to become pregnant will need referral to a fertility clinic.

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Amenorrhoea

  • 1. Volgograd State Medical University Department Of Gynaecology Report : Amenorrhoea Course 6th Group 39 Junaid Amenorrhoea is the absence of a menstrual period in a woman of reproductive age. Physiological states of amenorrhoea are seen during pregnancy and lactation (breastfeeding), the latter also forming the basis of a form of contraception known as the lactational amenorrhoea method. Outside of the reproductive years there is absence of menses during childhood and after menopause.
  • 2. Production of the female sex hormones oestrogen and progesterone can be affected by a range of factors, including certain reproductive disorders, weight loss, weight gain, emotional stress or excessive exercise. Amenorrhoea is the absence of menstrual periods. The most common cause is hormonal disruption, which can be due to emotional stress, weight change, excessive exercise or certain reproductive disorders. Treatment for amenorrhoea depends on the cause and can include adopting a healthier lifestyle or starting hormone replacement therapy (HRT), such as the combined oral contraceptive pill. Amenorrhoea is the absence of menstrual periods. Apart from during childhood, pregnancy, breastfeeding and menopause, the absence of periods may be due to a problem with the reproductive system. One of the most common causes of amenorrhoea is hormonal disruption. Production of the female sex hormones oestrogen and progesterone can be affected by a range of factors, including certain reproductive disorders, weight loss, weight gain, emotional stress or excessive exercise. Causes of amenorrhoea A range of factors can cause the hypothalamus to malfunction and trigger amenorrhoea, including: emotional stress weight loss excessive physical exercise certain medications used to treat mental health conditions disorders of the endocrine system, such as hypothyroidism (an underactive thyroid gland) Primary and secondary amenorrhoea
  • 3. Amenorrhoea is divided into two categories: Primary amenorrhoea – periods have not started by 14 years and there are no signs of other sexual characteristics (such as developing breasts and pubic hair), or periods have not started by 16 years, even though other sexual characteristics have developed. Secondary amenorrhoea – periods have stopped for about six months. The menstrual cycle Brain structures known as the hypothalamus and pituitary gland interact to control the menstrual cycle. The pituitary gland produces hormones that stimulate the ovaries to produce oestrogen and progesterone. These hormones thicken the lining of the uterus (womb) to prepare for a possible pregnancy. When a pregnancy does not occur, hormone levels drop and the lining of the uterus comes away. This is called a period or menstruation. The cycle then repeats. Disorders of the hypothalamus, pituitary gland or ovaries can disrupt menstruation, causing amenorrhoea. Secondary amenorrhoea - This is much more common and has several causes: Pregnancy and breastfeeding (lactation). Menopause. Contraceptives - Some women on the oral contraceptive pill ("The Pill" and "The Mini-Pill"), and many women on Depo Provera injections, experience no periods. This can cause some anxiety but providing that you are well, and you have been tested to make sure you are not pregnant, you can be reassured that this may be normal for you. Stress / low body weight / excessive exercise - The hormonal system can be affected by these states. It is not uncommon to have no periods while changing jobs or schools, travelling, or when you are under emotional stress. Women who are below their ideal weight can stop ovulating and therefore experience no periods. This weight is different for every woman although a "normal" body weight is defined as having a BMI (Body Mass Index) of 20-25, calculated as weight (kg)/height (m)2. Sufferers of anorexia nervosa often stop having periods for this reason. Excessive exercise, marijuana use and chronic illness can also cause amenorrhoea.
  • 4. Polycystic ovaries (see article on this). This condition will often interfere with regular ovulation. Associated symptoms of acne and excessive hair may be noted due to a hormonal imbalance. Hormonal disorders - Rarely, benign (non cancerous) tumors can occur in the pituitary gland. This leads to an excess of the hormone Prolactin that can stop periods, and cause a milky discharge from the nipples. Disorders of other glands such as the thyroid, adrenal and the ovaries can also cause periods to stop but these are rare. Medical therapies - Occasionally periods can stop after pelvic surgery or chemotherapy. Prescription medicines such as Haloperidol can also cause amenorrhoea. Investigations A detailed history should be undertaken to assess for any obvious underlying cause. As already mentioned, it is important to ensure the patient is not pregnant. The patient's BMI should be calculated and documented. An examination should be undertaken to determine any underlying cause. In particular, patients should be examined for signs of excessive androgens (hirsutism, acne, temporal balding), thyroid disease and Cushing's syndrome.[3] There may be an unexpected mass arising from the pelvis, and after 16 weeks human chorionic gonadotrophin (hCG) falls and pregnancy tests are negative. Abdominal masses arising from the pelvis are not necessarily uterine. It may be a large ovarian cyst. The following investigations should typically be done: Pregnancy test Follicle-stimulating hormone (FSH) and luteinising hormone (LH) Total testosterone and sex hormone-binding globulin TSH A pelvic ultrasound may be useful in patients with suspected PCOS Additional investigations may be appropriate in some women.
  • 5. Urinary or serum hCG should be measured, as exclusion of pregnancy is a basic initial investigation in all cases of secondary amenorrhoea, and in some cases of primary amenorrhoea. FSH and LH are raised in ovarian failure; an FSH level ≥20 IU/l in a woman aged under 40 with secondary amenorrhoea indicates ovarian failure. Low gonadotrophin concentrations indicate a hypothalamic cause for amenorrhoea, which is often associated with stress or excessive exercise or weight loss with or without an eating disorder. In cases associated with weight change or excessive exercise, serum gonadotrophin may be normal. Oestrogens are low when ovaries are not functioning and may be high in PCOS. Low oestrogen with high FSH and LH suggests a primary ovarian problem whilst a low FSH and LH with low oestrogens suggests a problem at the hypothalamic or pituitary level, including stress, exercise and low weight. Management Management depends upon the nature of the problem. In all cases of primary amenorrhea, treatment is directed by the diagnosis.[4] Women with secondary amenorrhoea should still be offered contraception, as there is still a risk of pregnancy. If the condition is due to extreme weight loss and excessive exercise, treatment will involve encouraging you to maintain a healthier body weight. Fertility is likely to be a concern in the younger woman, whether in the near or more distant future. Hormone replacement therapy (HRT) is indicated for women with premature ovarian failure (<40 years) until the average age of natural menopause, around 50 years. Constitutional late puberty requires reassurance and waiting. Eating disorders require psychiatric/psychological intervention, usually with cognitive and behavioural therapy. Obesity also requires dietary modification. If PRL is elevated due to drugs, they should be reviewed. Phenothiazines may possibly be replaced by newer medication. Metoclopramide may be replaced by domperidone. Thyroid abnormalities should be managed appropriately. Women who plan to become pregnant will need referral to a fertility clinic.