Amenorrhea is the absence of menstruation for 6 months or more. Amenorrhea is not an independent diagnosis, but a symptom indicating anatomical, biochemical, genetic, physiological or mental disorders.
True amenorrhea: there are no cyclical changes in the ovaries, endometrium and throughout the body, no menstruation. The hormonal function of the ovaries is sharply reduced (hypofunction), sex hormones are not enough to carry out cyclic changes in the endometrium.
False amenorrhea: the absence of periodic discharge of blood from the vagina in the presence of cyclical changes in the ovaries, uterus and throughout the body (for example, atresia of the hymen, atresia of the vagina and cervix: blood released during menstruation accumulates in the vagina, uterus, tubes).
Physiological amenorrhea: absence of menstruation before or immediately after the first menstruation, during pregnancy and lactation, after menopause. In many teenage girls, amenorrhea lasts from 2 to 12 months during the first 2 years after the first period.
Pathological amenorrhea: the absence of menstruation and other signs of puberty before the age of 14 or the absence of menstruation before the age of 16 with other signs of puberty, as well as the absence of menstruation for 3 consecutive cycles with previous normal periods.
- Damage to the ovaries: genetic disorders, abnormalities in the development of the uterus and ovaries, tumors, ovarian wasting syndrome;
- Extra-ovarian disorders: lesions of the endocrine glands (adrenal glands, hypothalamus, pituitary gland);
- Violation of patency of the entrance to the vagina, vagina, uterine cavity;
- Psychogenic amenorrhea (stress);
- Amenorrhea against the background of weight loss;
- Stop taking oral contraceptives, taking medications (oral glucocorticoids, danazol, gonadotropin-releasing hormone analogues, chemotherapy drugs), diabetes mellitus, increased and decreased thyroid function;
- Uterine causes: Asherman’s syndrome (intrauterine synechiae), endometritis of specific etiology.
The main symptom of amenorrhea is the absence of menstruation. However, there are a number of accompanying symptoms:
- lack of menstruation
- loss of the ability to become pregnant
- autonomic dysfunction (increased sweating, heart palpitations)
- obesity (in about 40% of patients)
- signs of courage, thyroid or adrenal dysfunction
- signs of excess of androgens – male sex hormones (increased oily skin, acne, excessive hair growth).
Pregnancy testing (determination of the level of hCG in the blood serum);
Determination of the level of prolactin in blood plasma. A normal prolactin concentration (below 20 ng / ml) in the presence of bleeding after discontinuation of progesterone and in the absence of galactorrhea excludes a pituitary tumor. With hyperprolactinemia, an examination of the pituitary gland is necessary;
Determination of the level of follicle-stimulating hormone (FSH) and luteinizing hormone (LH). If the cause of amenorrhea is gonadal dysgenesis, the FSH level will be high (more than 40 mIU / ml). It is necessary to examine the karyotype to exclude the Y chromosome. A low FSH concentration (below 5 mIU / ml) indicates hypofunction of the pituitary gland, possibly due to dysfunction of the hypothalamus. An increased LH / FSH ratio (not less than 2) is an important diagnostic sign of polycystic ovary disease. The LH content is usually increased, and the FSH concentration is at the lower limit of the norm;
Determination of the concentration of thyroid hormones – thyroxine (T4), thyroid stimulating hormone (TSH);
Determination of blood glucose level, glucose tolerance test;
Progesterone test (10 mg / day medroxyprogesterone for 5 days). Negative: menstrual bleeding does not occur in the absence of hormonal effects on the endometrium or with changes in the endometrium. Positive: with anovulation with preserved estrogen secretion, bleeding occurs;
Laparoscopy is indicated to determine dysgenesis of the Müllerian ducts and ovaries, with suspicion of polycystic ovary;
Ultrasound can detect cysts;
X-ray examination of the “Turkish saddle” with a suspicion of a pituitary tumor – prolactinoma;
Assessment of the state of the endometrium: sequential use of estrogens and progesterone (2.5 mg / day of estrogens for 21 days, and in the last 5 days – 20 mg / day of medroxyprogesterone). Subsequent bleeding is a sign of hypo- or hypergonadotropic amenorrhea. The absence of bleeding indicates either an abnormality of the genital tract, or the presence of a dysfunctional endometrium. The presence of a dysfunctional endometrium can be confirmed by hysterosalpingography or hysteroscopy;
Intravenous pyelography is necessary for all patients with dysgenesis of the Müllerian ducts, often combined with renal abnormalities;
Computer and magnetic resonance imaging.
The same symptoms can be signs of different diseases, and the disease may not proceed according to the textbook. Do not try to heal yourself – consult your doctor.
The effectiveness of treatment for amenorrhea depends on the identification of causative factors. Hormone replacement therapy is started after 6 months of amenorrhea.
Treatment of eugonadotropic amenorrhea
Treatment of congenital anomalies: dissection of the overgrown hymen or transverse septum of the vagina, creation of an artificial vagina in its absence.
Treatment of acquired anomalies: curettage of the uterine cavity, introduction of a baby Foley balloon catheter or intrauterine device into the uterus, use of broad-spectrum antibiotics for 10 days to prevent infection, cyclic hormone therapy with high doses of estrogens (10 mg / day estrogen for 21 days, 10 mg / day.medroxyprogesterone daily in the last 7 days of the cycle for 6 months) to restore the endometrium.
Treatment of polycystic ovary syndrome: two goals of treatment are to reduce the severity of excess male sex hormones-androgens and restore the ability to reproduce. The achievement of the first goal (for example, with contraception) may precede the achievement of the second. To weaken the signs of excess androgens: oral contraceptives with antiandrogenic gestagens – ethinylestradiol + cyproterone (Diane-35), ethinyl estradiol + dienogest (Janine), cyproterone (with the ineffectiveness of oral contraceptives). Glucocorticoid drugs, for example, dexamethasone 0.5 mg at night, spironolactone 100 mg 1-2 r. / Day. The effects of hormone therapy on unwanted hair growth on the face and body rarely do not come quickly (improvement is observed no earlier than after 3–6 months). Artificial hair removal is often necessary: shaving, electrolysis, chemical hair removal. With infertility: when administered from the 5th to the 9th day of the cycle, clomiphene stimulates follicular maturation and ovulation (50 mg each, increase to 150 mg by the 3rd month). For chronic anovulation and abnormal menstrual bleeding, a progestin (eg, dydrogesterone, linestrenol, or progesterone, 10 mg medroxyprogesterone for 10 days every 1-3 months).
With hypertecosis and ovarian tumors that secrete male sex hormones, ovarian excision is indicated.
Treatment of congenital adrenal hyperplasia: hydrocortisone replacement therapy to suppress hormone secretion, surgical correction of external genital anomalies.
Treatment of amenorrhea associated with hyperprolactinemia
Estrogen replacement therapy is indicated for genetic disorders in order to form secondary sexual characteristics (2.5 mg of estrogen for 21 days and medroxyprogesterone 10 mg / day daily in the last 7 days of the cycle). When estrogens are prescribed with progesterone, regular menstrual bleeding occurs, but fertility is not achieved.
Bromocriptine is recommended for patients with hyperprolactinemia with a normal pituitary gland or microadenoma in a continuous mode from 2.5 to 7.5 mg / day. After 30-60 days, the menstrual cycle is restored, in 70-80% of patients, if desired, pregnancy occurs in 2-3 months. Alternatively: quinagolide – start with 1 tablet (25 mcg), increasing the dose to 3 tablets (75 mcg) for 2-3 months.
Surgical excision of the gonads containing the Y chromosome.
Treatment of hypogonadotropic amenorrhea
Therapy in the treatment of this type of amenorrhea depends on the patient’s interest in the onset of pregnancy.
Periodic progestin therapy (medroxyprogesterone 10 mg / day for 5 days every 8 weeks) is prescribed for women who are not interested in pregnancy.
Recently, the stimulation of ovulation and even the onset of pregnancy have become possible with the use of synthetic analogs of gonadoliberin (with a potentially active pituitary gland).
For women wishing to become pregnant, ovulation is stimulated with clomiphene or gonadotropins.
Surgical treatment is indicated for tumors of the central nervous system.
Treatment of diseases of the thyroid or adrenal glands.
Replacement therapy in the treatment of amenorrhea is recommended to be discontinued after 6 months for the independent resumption of menstruation.
The course and prognosis depend on the cause of the amenorrhea. With the hypothalamic-pituitary cause of amenorrhea, the appearance of menstruation within 6 months was noted in 99% of patients, especially after correction of body weight.