Amenorrhea is characterized as a loss of menopausal bleeding. This loss of bleeding in amenorrhea can be a great cause of grief to parents of female patients who are of reproductive age.

It is important to gather an appropriate history, physical examination and conduct proper investigations to find the root cause of amenorrhea.

Definition

Amenorrhea (or amenorrhoea) is defined as an abnormal absence of menstrual bleeding in females of reproductive age.

Causes

Amenorrhea can be caused by a variety of causes. There are the causes that are normal to the woman (physiological) and abnormal (pathological).

The possible physiological causes of amenorrhea are:

1.) Pregnancy: During pregnancy the hormone produced by an fertilized ova, the pregnancy is maintained by the hormone hCG (human chorionic gonadotropin) and this prevents the sloughing off of endometrium that normally occurs during menstruation. Amenorrhea will continue during the length of pregnancy (9 months)

2.) Lactation: After birth, amenorrhea continues during the period of lactation. Usually the period occurs around 6 months.

Here is a list of possible pathological causes for amenorrhea:

1.) Turner’s Syndrome: This is a genetic condition of the female that is caused by a loss (partially or completely) of the X chromosome in some or all the cells. This is a cause for Primary Amenorrhea

2.) Polycystic Ovarian Syndrome (PCOS): It is characterized by a set of symptoms that are the results of abnormal elevations of the male hormone. It is usually caused by a combination of genetic and environmental factors. Multiple cysts (hence the name) can be seen on a single ovary using ultrasound imaging. This is a cause of Secondary Amenorrhoea.

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3.) Congenital Adrenal Hyperplasia: This is a genetic condition. Usually there are a myriad of symptoms, in this case associated with amenorrhea, there is an excess or deficiency of sex steroids that results in altered primary (abnormal genitalia) or secondary sexual characteristics (absence of breast or pubic hair formation).

4.) Pituitary Adenoma: An adenoma is a benign growth (tumor) that occurs on the pituitary gland that can give rise to a myriad of symptoms that are not just associated with amenorrhea.

5.) Obesity: Increased BMI in a female patient can  result not only in primary or secondary amenorrhea. It doesn’t only affect the menstrual cycle and  fertility but other metabolic disorders such as diabetes mellitus and metabolic syndrome can occur as well leading to further issues associated with the menstrual cycle.

6.) Athletic: Athletic women such as long distance runners may suffer from secondary amennorhea.

7.) Anorexia: Due to lower BMI and nutritional deficiency, anorexic females will suffer from secondary amenorrhea.

8.) Obstructive causes: Several conditions; such as imperforate hymen, septum in vagina and isolated vaginal stenosis.

Types

The types of amenorrhoea are subdivided into:

  • Primary Amenorrhea: It is the absence of menstruation in a female by age 16. There are also no signs of thelarche or puberache.
  • Secondary Amenorrhea: Menarche (first menstruation) has occurred in the female, but then there is a loss of menstruation for 3 months in a woman with regular cycles previously or 9 months in a woman with irregular cycles.

Clinical features

As with all cases it is important to obtain an adequate history and physical examination.

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Always remember to take a proper history; chief complaint, history of presenting illness, systemic review, gynaecological history, obstetric history, sexual history, past medical history, family history and social history.

History of Patient

Most of the diagnosis can be confirmed by taking a brief history of the patient as follows:

1.) Developmental Milestones of patients should be inquired. Obtain a history of height, weight and the ages of thelarche and puberache.
2.) Constitutional Delay: The age of menarche of patient’s family members (mothers and sisters) need to be asked.
3.) Obstructive conditions: A history of cyclical pain may suggest cyrytomenorrhea which may be due to lower genital tract obstruction. The uterus may actually be functioning.
4.) Hypothalamic causes: This can be inquired during the social history. Substance abuse, excessive exercise, eating habits, home life. Also any past medical history related to the CNS; meningitis, irradiation, head trauma, tumors and craniopharygioma.
5.) Chromosomal abnormalities: Patient’s with turner syndrome presents with growth and mental retardation. CAD presents with virilization, change in voice and hirsutism.
6.) Endocrine disorders: Inquire history of thyroid disorders or symptoms of hyperprolactinemia.

Physical Examination of Patient

Proceed with a Physical Examination. Important points to look out for:

1.) Height and body weight measurement should be done. The BMI should be plotted.
2.) Sexual maturity should be assessed (thelarche and pubearche)
3.) Chromosomal stigmata: Features of turner syndrome, like short stature, webbed neck, wide carry angle (angle of elbow while at anatomical position) and poorly secondary characteristics.
3.) Signs of virilization: acne, hirsutism and galactorrhea
4.) Imperforate hymen: During abdominal examination, a palpable mass is felt as in cryptomenorrhea.
5.) Examination of external genitalia: pubic hair distribution, cliteromegaly,  imperforate hymen.
6.) Pelvic Examination

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Management

No treatment is needed for constitutional causes. If there’s a pathology associated with amenorrhea, the underlying cause must be diagnosed and treated as such.

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