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ESSAY 160 - SECONDARY AMENORRHOEA

Posted by khalid M.
Secondary amenorrhia is defined as absence of menstruation for more than six months in a woman who has previously menturated normally.
The common physiological causes include pregnancy, lactation and menopause.

The pathological causes include dysfunction of hypothalamus, pituitary, ovarian, uterine and secodary to systemic diseases.

Hypothalamic causes include anorexia nervosa, excessive exercise, stressful events . These disorders cause hypogonadotrophic hypogonadism.

Pituitary disorders include hyperprolactinaemia, pituitary adenomas(Cushing synd.), pituitary necrosis(Sheehan synd.)

Ovarian causes include Polycystic ovarian disease, gonadal dysgenesis( Turner synd), premature ovarian faiure( autoimmune disease, mumps infection, chemo & radiotheapy), resistant ovarian synd., estrogen( granulosa cell tumor) and androgen(arrhenoblastomas) producing tumors.

Uterine causes include Asherman syndrome, tuberculosis and schistosomasis. Systemic diseases include chronic diseases like chronic renal failure, liver failure and thyroid dysfunction.

Investigations include hormonal assays( FSH, LH, TFT, Proactin, testosterone), pelvic ultrasound examination, Karyotyping-(Turner synd., premature ovarian failure)

A low LH( <5 i.u/l) suggest hypogonadotrophic hypogonadism. A high FSH( >40 i.u/l) successively indicate ovarian failure. A low FSH & LH (<3 i.u/l) suggest hypothalamic amenorrha. Raised LH (>10 i.u/l), raised testosterone and normal FSH are suggestive of PCOS.

Treatment mainly depends on the cause. Anorexia nervosa and stressful events can be treated with counselling, estrogen replacement therapy.

Hyperprolactenemia can be treated medically ( dopamine agonists) or surgically for adenomas. PCOS can be treated with weight reduction, medical regimes(COCP, gestogens). In cases of premature ovarian failure estrogen replacement therapy is indicated to reduce the risk of osteoporosis.

Uterine adhesions can be broken down hysteroscopicallyand IUCD inserted to minimise the risk of synache reformation.
Posted by khalid M.
Secondary amenorrhia is defined as absence of menstruation for more than six months in a woman who has previously menturated normally.
The common physiological causes include pregnancy, lactation and menopause.

The pathological causes include dysfunction of hypothalamus, pituitary, ovarian, uterine and secodary to systemic diseases.

Hypothalamic causes include anorexia nervosa, excessive exercise, stressful events . These disorders cause hypogonadotrophic hypogonadism.

Pituitary disorders include hyperprolactinaemia, pituitary adenomas(Cushing synd.), pituitary necrosis(Sheehan synd.)

Ovarian causes include Polycystic ovarian disease, gonadal dysgenesis( Turner synd), premature ovarian faiure( autoimmune disease, mumps infection, chemo & radiotheapy), resistant ovarian synd., estrogen( granulosa cell tumor) and androgen(arrhenoblastomas) producing tumors.

Uterine causes include Asherman syndrome, tuberculosis and schistosomasis. Systemic diseases include chronic diseases like chronic renal failure, liver failure and thyroid dysfunction.

Investigations include hormonal assays( FSH, LH, TFT, Proactin, testosterone), pelvic ultrasound examination, Karyotyping-(Turner synd., premature ovarian failure)

A low LH( <5 i.u/l) suggest hypogonadotrophic hypogonadism. A high FSH( >40 i.u/l) successively indicate ovarian failure. A low FSH & LH (<3 i.u/l) suggest hypothalamic amenorrha. Raised LH (>10 i.u/l), raised testosterone and normal FSH are suggestive of PCOS.

Treatment mainly depends on the cause. Anorexia nervosa and stressful events can be treated with counselling, estrogen replacement therapy.

Hyperprolactenemia can be treated medically ( dopamine agonists) or surgically for adenomas. PCOS can be treated with weight reduction, medical regimes(COCP, gestogens). In cases of premature ovarian failure estrogen replacement therapy is indicated to reduce the risk of osteoporosis.

Uterine adhesions can be broken down hysteroscopicallyand IUCD inserted to minimise the risk of synache reformation.
Posted by rakhshinda Z.
Secondary amenorrhea is defined as cessation of menstruation for 6 consecutive months in a woman who has previously had regular periods. An important cause of secondary amenorrhea is pregnancy, other than that various pathologies in uterus, ovaries, hypothalamus, pituitary and systemic diseases can cause secondary amenorrhea. Uterine causes include asherman syndrome and cervical stenosis. Polycystic ovary syndrome and premature ovarian failure (genetic, autoimmune, infection, radiotherapy and chemotherapy) are the ovarian causes of secondary amenorrhea. Hypothalamic causes leading to hypogonadotrophic hypogonadism include weight loss, exercise, chronic illness, psychological distress and idiopathic. Pituitary causes include hyperprolactinemia, hypopituitarism and sheehans syndrome. Causes of hypothalamic or pituitary damage include tumors like craniopharyngioma, glioma, germinoma and dermoid cysts, cranial irradiation, head injury, sarcoidosis, tuberculosis. All these can lead to secondary amenorrohea though these are less common. Various systemic causes like chronic debilitating illness, weight loss, and endocrine disorders like thyroid disease, Cushings syndrome and diabetes can also lead to secondary amenorrhea.
Evaluation of a patient with secondary amenorrhoea requires history, examination and various investigations. Important points in history include medical history and family history of fertility problems, autoimmune disorders and premature menopause. Examination includes body mass index, signs of endocrine diseases like acne, hirsutism, deepening of voice, central obesity, galactorrohea and visual field defects. A careful examination will aid in excluding pregnancy. Investigations include pregnancy test, serum prolactin, gonadotrophins and thyroid function to check the endocrine status. With elevated prolactin levels, progestogen challenge test will help in assessing estrogen deficiency as in polycystic ovary syndrome related hyperprolactinemia progesterone challenge test is positive as woman is well estrogenised. CT/ MRI will help in excluding hypothalamic pituitary tumor. Pelvic ultrasound scan will assess pelvic pathology and endometrial thickness can also be checked in view of premature ovarian failure. Karyotyping and autoantiboby screen will also help in genetic causes of premature ovarian failure. Hysteroscopy is a useful investigation for ashermanns syndrome. Serum cholesterol measurement, impaired gluose tolerance, x ray dorsolumbar spine and bone mineral density is other useful investigations.
Therapeutic options for cases of secondary amenorrohea are directed towards treating the cause. For ashermanns syndrome hysteroscopy adhesiolysis with cyclical estrogen progesterone therapy for 3 months or IUCD for 3 mths. For cervical stenosis careful cervical dilatation is required. For polycystic ovary syndrome general measures including weight loss and medical treatment like low dose combine ocps are given. Metformin is also given for pcos. For associated hirsutism dianette which contains antiandrogen is useful. For secondary amenorrhoea due to hyperprolactinemia it is important to stop the drug if it is due to any medication patient is taking. Low dose ocps can be given if the causative drug for example antipsychotics cannot be stopped. For other causes bromocriptine is given. For tumors like prolactinomas surgery like transsphenoidal adenectomy or radiation therapy may be required. For weight related amenorrhoea it is important to explain to the patient that normal menstrual cycle will not occur if BMI is less than 19 kg/m2. Help with a psychiatrist may be required. Cyclical estrogen progesterone therapy may be required.
Posted by uma M.
Secondary amenorrhoea is defined as absence of menstruation for more than six months or for duration 3 times her regular cycle in a woman who has previously menturated normally.
Among the various causes pregnancy is the commonest cause of secondary amenorrhoea and this needs to be excluded. other physiological causes include lactation and menopause which need to be considered and history elicited. Age of the woman ,menopausal symptoms would suggest menopause.
Pathological causes of amenorrhoea are Uterine causes--Asherman\'s syndrome, Tuberculosis, and schistosomasis.Ovarian causes--PCOS,Turner SYNDROME ,premature ovarian faiure (due to autoimmune disease, mumps,chemo & radiotheapy,)androgen producing tumors like arrhenoblastoma.Surgical removal of both ovaries,
Pituitary causes- hyperprolactinaemia, pituitary timours ,post partum pituitary necrosis(Sheehan syndrome ), craniopharyngioma, sarcoidosis,Cushings syndrome.cranial irradiation, head injury can also cause hypothalamic dysfunction.
Hypothalamic causes -- anorexia nervosa, excessive exercise, stressful events, weight loss athletes, ballet dancers. Pitutary and hypothalamic conditions causes hypogonadotrophic hypogonadism.
Systemic diseases include chronic diseases like chronic renal failure, liver failure, uncontrolled diabetes. Other endocrine causes -thyroid dysfunction(both hypo and hyper thyroidism), late onset congenital adrenal hyperplasia, adrenal tumours.

Urine pregnancy test excludes pregnancy.Progesterone challenge test assess endogenous estogen status, if withdrawal is positive after 10mg of MPAfor 5 days it sugests anovulation as in PCOS,MODARATE stress, early hypothalamic/pitutary dysfunction.Negative progesterone challenge is further assessed by giving Estrogen and progesterone.Negative withdrawal with this indicate uterine abnormalities.
USG may show polycystic ovarian morphology
serum prolactin, FSH ,LH and TSH are performed . Elevated serum FSH ( >40 iu/l) is indicative of ovarian failure .Repeat 2months later to ensure that results are not transient. .Karyotyping and autoantiboby screen will help further evaluation of ovarian failure.Altered LH/FSH ,with USG evidence of PCO is suggestive of pCOS.
low FSH OR low normal suggest hypogonadotrophic hypogonadism. Pitutary and hypothalamic causes need to be excluded by further evaluation.CT/ MRI will help in excluding hypothalamic / pituitary tumor.Similarly high prolactin values need evaliation with X-ray skull /MRI .
If any evidence of hyper androgenism on clinical examination -acne ,hirsuitism, greasy skin , frontal baldness needs androgen assay(17-OHP,testosterone,androstenedione,DHEA,) 17 -OHP is elevated in late onset CAH.High testosterone ,androstenedione, DHEA levels
warrant evaluation of adrenal and ovary for tumors.
Uterine cause like ashermans when suspected is evaluated by either HSG/ Hysteroscope.

Therapeutic options of secondary amenorrohea are directed based on identified cause. Ashermans syndrome NEEDS hysteroscopy + adhesiolysis with estrogen progesterone therapy for 3 months AND IUCD for 3 months to prevent recurrence.For polycystic ovary syndrome general measures including weight loss and medical treatment like low dose combined OCP\'s or with drawal with progesterones every month or 3 are given depending upon pt\'s need .Hyperprolactinaemia , prolactinoma is treated with bromocriptin or cabergoline.or surgery if no response to drug therapy. IF Hyperprolactinemia is due to some drug it is advisable to stop taking.
Hormone replacement therapy if amenorrhoea is due to premature ovarian failure. She should be advised contraception as pregnancies can occur occassionally. Also if woman desires fertility advise her chance of conception is very small with ovulation induction even advice donor oocytes.tHOSE WITH ABNormal karyotype with Y chromosome requrie gonadectomy.

Any stress,anorexia is identified as cause of amenorrhoea psyclological councelling, Psychiatrist referral if necessary is needed. with weight gain menstruation returns to normal.
Late onset cong.adrenal hyperplasia requires steroid(prednisolone) replacement.
Any underlying abnormalities like thyroid, cushings if corrected will correct amenorrhoea.
Any tumour identified in ovary/adrenal -surgery


Posted by jyoti D.
In case of secondary amenorrhea the physiological causes like pregnancy,lactation and menopause can be ruledout by relevant history including the age ,LMP,obstetric history for any recent delivery and history of breast feeding .History of contraception as Inj.Depoprovera,combined oral contraceptive pills may be associated with delay in resumption of the periods. Gynaecological history for any pelvic infections as certain pyogenic infections and tuberculosis may be associated with amenorrhea.Surgical history including any uterine curettage to rule out intrauterine adhesions(asherman\'s syndrome) due to excessive destruction of endometrium,cevical surgeries leading to stenosis.History of drus like antidepressants,metoclopromide,chemotherapy,radiotherapy should be enquired.Family history for maternal age for menopause which will support the diagnosis of premature menopause along with history of menopausal symptoms like hot flushes,mood changes and investigations include chromosomal analysis(karyotype)to rule out turner\' syndrome,history of autoimmune disorders like diabetes and thyroid problems are important and should be confirmed by hormonal assay(FSH) which will be >30u on 2 occasions 8 weeks apart.
Nutritional causes like extreme obesity,anorexia nervosa ,severe anaemia can be associated with secondary amenorrhea.Polycystic ovarian syndrome causes hypothalamic pituatary dysfunction and may be associated with secondary amenorrhea features of PCOS including hirsutism should be elicited.Strenous exercise may be associated with amenorrhea.
Pateint should be asked about symptoms of visual disturbances ,headache to rule out any prolatinomas the dignosis can be confirmed by s.prolactin levels and subsequently CT/MRI if required.So the initial investigations include urine pregancy test to rule out pregnancy.Serum FSH to confirm dignosis of prematureovarian failure.Progesterone challenge test where 10 mg of medroxy progesterone TDS given for 5 days if the subject has withdrawl bleed that means endometrium is primed with estrogen and like possiblity of PCOS as it is associated with anovulation.
Th e therapeutic options depends upon the cause if pregancy and lactation then reassure that this is physiological.If PCOS weight reduction and exercise may help otherwise treatment depending upon the concerns has to be started.In case of patients having eating disorders referral to dietician and psychiatric referral is recommended.For premature menopause Counselling depending upon her needs and symptoms is required like HRT should be discussed.
If exercise induce she should be adviced to put on weight and avoided strenous exercise.
Complementary therapies may help relieve stress by means of relaxation techniques mqy be beneficial but its role not yet known.
fro hyperprolactiomas dopamine agonist like bromocriptine or cabergoline prescribed and monitors the prolactin levels.If contraceptive induced reassurance that menses willresume spontaneously should be told to the patient.
Posted by jyoti D.
In case of asherman\'s syndrome hysteroscopy and adhesiolysis with IUCD in situ along with COC\'pills may be help ful.In case of tuberculosis Mantoux/heaf test is carried out and accordingly AKT including rifampacin,etambutoland pyriznamide may be started after consulting the physician.In case of sheehans syndrome which is caused as a result of PPH resulting in Anterior pituatary necrosis consultation with the neurologist may help .Thyroid ,cushings and addisons disease should be treated after consultation with the endocinologist.
Overall the management plan should be made after a joint consultation with the multidisciplinary team.
Posted by Shakira B.
A) Cessation of menstruation for 6 consecutive months in a woman who previously had regular periods is defined as secondary amenorrhea. Pregnancy is the commonest physiological cause, other causes are lactation menopause. This can be excluded from LMP, history of recent delivery and breast feeding. Any use of contraception (DMPA) associated with delay in resumption of periods.
Pathological causes are classified according to its aetiological site of origin:-
1) Uterine Causes: - Asherman?s syndrome, Cervical Stenosis
2) Ovarian Causes: - PCOS, Premature ovarian failure (genetic, autoimmune, infective, radio/chemotherapy)
3) Hypothalamic Causes: - Weight Loss, Exercise, Chronic Illness, Psychological distress, Idiopathic.
4) Pituitary Causes: - Hyperprolactinaemia, Hypopituitarism, Sheehan
Syndrome
5) Causes of hypothalamic/pituitary damage: - Tumors (craniopharyngiomas, gliomas), Cranial irradiation, Head injuries, Tuberculosis
6) Systemic Causes: - Chronic debilitating illness, Weight loss, Endocrine disorders (thyroid disease, Cushing?s syndrome, etc.)
A through history and a careful examination should be carried out to
help in diagnosis. A history of secondary amenorrhea may be misleading, as the periods may have been the result of exogenous hormone administration. In a patient who was treated with HRT for primary amenorrhea. A family history of autoimmune disorder or premature menopause may give clues to the aetiology.

Examination: - Measurement of height and weight should be done in order to calculate BMI. Normal is 20-25. Value above or below this suggest a diagnosis of weight related amenorrhea. Signs of hyperandrogenism (acne, hirsuitism, balding) are suggestive of PCO, although biochemical screening helps to differentiate other causes of androgen excess.
In cushing syndrome: - Central obesity, moon face, abdominal striae are seen along with other stigmata of PCOs. Acanthosis Nigricans (dark pigmentation in axilla) is a sign of insulin resistance, seen in obesity and PCO. Amenorrhea might be due to hyperprolactinoma and galactorrhoea (complains of headache, visual disturbance). So serum prolactin level is checked and visual fields (bitemporal hemianopia).
Hypo/Hyper Thyroidism is associated with amenorrhea. In Hypo, dry thin skin, bradicardia, prox myopathy. In Hyper: - Goiter, weight loss, exopthalmos is seen.
Bimanual Exam is in appropriate in young female who has never been sexually active. TAS is good noninvasive method.
Endocrine Test: - Hyper prolactinemia seen in stress, hypothyroidism, PCO, micro adenoma. Increase LH seen in Hypo gonado tropic hypogonadism. Decrease LH, FSH seen in hypothalamic amenorrhea. Increase FSH seen in x0, pof. Karyotype done in pof patient, auto antibodies to thyroid, x0. History of recent endometrial curettage with normal endocrinology and absence of withdrawal bleeding with progesterone challenge test is suggestive of Asherman?s Syndrome. It is confirmed by hysteroscopy.
Treatment: - Depends upon the cause. If pregnancy or lactation related, reassure her.
For Asherman: - Hysteroscopy adhesiolysis, IUCD insertions for 2-3 months along with cyclical estrogen progesterone treatment. If PCO weight reduction, exercise is advised. For eating disorder refer to dietitian, psychiatrist. For pof, counseling depends upon her symptoms, HRT advised.
Posted by manjula C.
Secondary amenorrhea is defined as cessation of menstrual cycle for 6mths in a previously menstruating woman of normal cycles.
The causes being, physiological-pregnancy, lactation.
The pathological causes can be broadly classified as uterine,ovarian,pituitary,hypothalamic,iatrogenic and systemic causes. uterine causes are ashermans syndrome due to adhesions as a result of vigorous curettage, tubercular endometritis,cervical stenosis.ovarian causes are commonest being pcos,premature ovarian failure, androgen producing tumors like sertoli-leydig cell tumors,etc.pituitary causes are Sheehan?s syndrome as a result of profound hypotension following PPH,hypothyroidism,hyperprolactinaemia,pituitary adenoma. Hypothalamic causes may be due to excessive stress and anxiety, anorexia nervosa, exercise related as is seen in athletes. Systemic causes are severe anaemia, extreme obesity. However iatrogenic causes amount to a significant number of cases. like post pill amenorrhea following prolonged use of cocp,progesterone implants like Norplant and implanon,and marina a levonorgestrln releasing IUCD,which produces amenorrhea in 35% of individuals by 12 mths.other causes being prophylactic oophorectomy for various reasons, following chemotherapy ,and radiation.TCRE and other endometrial ablative procedures also cause amenorrhea in 40% of women by 12mths.
A good history which may suggest a probable diagnosis is very essential, like age, use of contraceptives, drugs, previous history of severe pph, where there will be clinical features of panhypopituitarismlike associated hypothyroidism. a clinical examination is doneto look for galactorrhoea,though not all cases of hyper prolactinemia present with it ,and vice versa is also being true.BMI should be calculated and also features suggestive of hirutism is likely to suggest PCOS.fetures of turners syndrome like short stature, widely placed nipples,cubitus valgus will also be looked for. Pelvic examination will help in diagnosing ovarian tumors, PCOS.by history and examination most of the differential diagnosis could be eliminated. Then the patient is given progesterone challenge test by medroxy progesterone acetate 5-10 twice daily for 5 days. if the woman has withdrawal bleed, it shows that she has an endometrium which is primed with estrogen, that means an ovarian activity and also rules out ashermans.if she doesn?t bleed then she should be given a course of both estrogen and progesterone, like cocp.if she bleeds then PRL, TFT, LH and FSH is done to rule out PCOS.an ultrasonography is also done for ovarian size and features of pcos like dense stroma and peripherally placed medium sized follicles.
If she doesn?t bleed following E+Pthen.LH ,FSH,LEVELS are detected. in premature ovarian failure these are high especially FSH>35IU/l.she should be then subjected for antibodies or karyotyping depending on the clinical features. if the LH/FSH levels are low -hypoganadotrophic hypogonadism .other pituitary hormones of pituitary could also be low(TSH,GH,ACTH) suggesting pan hypopituitarism. .then she has to be distinguished
from hypothalamic causes by doing GNRH-RH assay. if it is low it indicates hypothalamic amenorrhea.
The treatment depends on the causative factor.ashermans syndrome is treats by dilatation and curettage followed by insertion of IUCD.however adhesiolysis can be done better by hysteroscopy.PCOS-many of them can be treated by wt reduction,metformin therapy has been found to be very effective in resolving menstrual problem. it also helps in return of ovulation if treated for about 6mths,500mg/day initially, gradually increasing to 500mg ,tds.if it fails she needs other means like clomophene,ovarian drilling etc.hyperprolactinemia depending on levels is treated by bromocriptine starting with a low dose of 2.5mg increasing up to 12.5mg/day.recently cabergoline is found to be more effective with twice wkly dosage ,however expensive.
Premature ovarian failure ha s to be treated with HRT,however a few instances are there where there is spontaneous return of ovarian activity.throxine has to be supplemented in hypothyroidism.sheehans syndrome needs treatment with thyroxin supplements and HRT.anorexia nervosa needs a reassurance, lifestyle changes. most of the cases of progesterone only contraceptive induced amenorrhea revert back to normal once they are withdrawn, however DMPA may take up to 9-12 mths.return to normal is quick with mirena and implanon.
All said and done patient needs reassurance, counseling regarding long term treatment. and also the consequences of long-term HRT has to be explained both verbally and by written information.
Posted by Nitin P.
Secondary amenorrhoea is defined as the absence of periods for 6 months in a woman who is regularly menstruating or for a time period 3 times the previous cycle length.
Physiological causes include pregnancy, lactation and menopause.
Pathological cause may be because of hypothalmic pituitary axis failure. This is seen in cases of Hyperprolactinaemia, Sheehan\'s syndrome, intra cranial tumours, intra cranial surgery or radiation. Exercise, severe weight loss and anorexia nervosa also lead to this failure.
Hypothalamo pituitary axis dysfunction as in Poly cystic ovaries syndrome (PCOS) is the commonest cause of secondary amenorrhoea. Post pill amenorrhoea and other endocrine disorders such as cushing\'s syndrome and abnormal thyroid functions also lead to pituitary dysfunction
Ovarian causes of secondary amenorrhoe are premature ovarian failure, resistant ovaries syndrome, radiation or surgical damage to ovaries, galacosaemia and mosaic turner\'s syndrome and autoimmune disorders.
Outflow tract abnormalities include endometrial destruction due to infection (Asherman\'s syndrome) or surgery or radiaton. Cervical stenosis secondary to a cone biopsy may also lead to secondary amenorrhoea.
The investigations help in confirming the aetiology so that treatment can be correctly started. Serum Gonadotrophin levels indicate whether it is hypothalamo pituitary failure if they are low. When elevated they indicate ovarian cause and when the ratio of FSH to LH is altered they indicate PCOS.
The serum gonadotrophin levels are repeated in a months time to confirm the results.
Prolactin levels are checked to rule out hyperprolactinaemia.
Thyroid function tests are indicated to rule out hyperthyroidism and hypothyroidism.
Imaging techniques such as ultrasound are used to diagnose PCOS and haematometra. A hysterosalpingogram is indicated if intrauterine adhesions are suspected. Where as a CT scan or MRI of the brain is indicated in cases of hypothalamic-pituitary failure to find the aetiology such as tumor, infection.
Progesterone withdrawal test helps in determining the level of estrogenisation as if there is a bleed there is sufficient estrogenisation commonly seen in PCOS or mild weight loss or exercise.
In case of endometrial destruction microbiological testing for tuberculosis is needed.. In case of ovarian failure at an early age karyotype to rule out Turner\'s mosaic is indicated. Ovarian biopsy is not indicated to confirm premature ovarian failure. In cases of premature menopause, metabolic investigations and autoimmune screen to rule out galactosaemia and autoimmune disorders is indicated.
The treatment is dependant on the cause and desire for fertility and menses.Prevention of osteoporosis due to hypoestrogenism is considered. Conservative management such as weight gain and reassurance are needed in case of weight loss or exercise related amenorrhoea and post pill amenorrhoea. Weight loss is advised in cases of PCOS.
Medical management in the form of Hormone Replacement therapy is indicated for the prevention of osteoporosis in cases of irreversible causes of amenorrhoea until the age of 50 years. The risks HRT such as DVT, breast cancer and stroke must be discussed.
In case, pregnancy is desired, gonadotrophin stimulation is indicated in cases of hypothalamic pituitary failure.
Anti estrogens eg clomiphene are the first line drugs in case of PCOS, but gonadotrophin stimulation may be needed in resistant cases.
Bromocryptine and cabergoline are indicated in cases of hyperprolactinaemia.
In case of premature ovarian failure or irreversible endometrial pathology, ovum donation and surrogacy is an option.
The primary cause must also be addressed such as anti tuberculosis treatment in case of tuberculosis, thyroid dysfunction treatment.
The surgical managent is laparoscopic ovarian drilling for PCOS. Drilling is equally effective to Gonadotrophin stimulation but with risks of laparoscopy. Hysteroscopic adhesiolysis for Ashermann\'s syndrome with intrauterine device to prevent reformation of adhesions.
In cases of intracranial tumors, referral to appropriate speciality and surgery may be needed.
Adoption for infertility is an option to be considered in all cases.
Posted by Farzana N.
Absence of menstruation for six months or for a period equivalent to 3times the previous cycle length in previously normal menstruating women is regarded as secondary amenorrhea. This needs further assessment for identification of underlying cause and its treatment. Causes may be physiological or pathological.
The most common physiological cause of secondary amenorrhea is pregnancy, which should be excluded by taking H/o symptoms suggestive of pregnancy, by doing a preg test or USG.H/o of lactation taken to rule out lactation amenorrhea. Patient?s age and symptoms of menopause may be suggestive of menopause.
Pathological causes may be ovarian-Asherman?s syndrome or cervical stonosis,Ovarian causes include-PCOS,premature ovarian failure(genetic ,autoimmune,infective,radiotherapy or chemotherapy)Hypothalamic ?weight loss, exercise, chronic illness, psychological distress,idiopathic.Pituitary causes include ?hyperprolacinemia,hypopituitarism,Sheehans syndrome. Hypothalamic/pituitary damage as a result of tumours, cranial irradiation, head injuries, sarcoidosis or tuberculosis. Systemic diseases-chronic debilitating illnesses, weight loss, endocrine disorders (thyroid disease, Cushing?s syndrome)
Investigations should include, baseline serum prolactin, TSH, T3, T4, LH, FSH and preg test. Progesterone challenge test is done by giving MPA 10mg orally for 5 days, to assess estrogen status and patency of the outflow tract. If the result is positive, a diagnosis of anovulation can be made with relative security. The test is positive in cases of PCOS moderate stress or exercise or wt loss and hypothalamic ?pituitary dysfunction. .The test is negative in cases of ovarian failure, severe wt loss /stress/anorexia nervosa and pituitary tumors. In case of negative challenge test, endometrium is stimulated with estrogen then progesterone.Absense of bleeding is highly suggestive of outflow tract obstruction.
.Serum LH and FSH is repeated after 1-2 months to ensure that the results are not transient.
Treatment would be directed at the cause. Hysteroscopy is done in case of Asherman?s syndrome for adhesiolysis.patient should be given COCP for three months and .IUCD is inserted to prevent recurrence. Cervical stenosis is corrected by careful cervical dilatation. Cases of PCOS are treated by wt loss, COCP, clomid or metformin according to pt,s requirements. Premature ovarian failure is treated by giving HRT, as these patients are at risk of developing cardiovascular diseases and osteoporosis. They should be warned of the side effects of HRT e.g. VTE, risk of developing breast cancer.Hyperprolactinemia is treated with Bromocriptine or cabergoline.Surgery may be required in resistant cases .Secondary hypogonadorophic gonadism resulting from systemic conditions including sarcoidosis,tuberculosis following head injury or cranial irradiation, can be treated with pulsatile subcutaneous GnRH or gonadotrophins for ovulation induction.The administration of GnRH provides the most physiological correction of infertility caused by hypogonadotrhphic hypogonadism resulting in unifollicular ovulation,while FSH therapy requires close monitoring to prevent multiple pregnancy.
Systemic diseases such as thyroid diseases, Cushing,s syndrome or DM should be optimally treated to correct amenorrhea.
Cases of anorexia nervosa and those with psychological problems should be referred to a psychiatrist. Weight gain in cases of extreme wt loss or excessive exercise will correct amenorrhea. Cyclical estrogen progesterone therapy can also be given to promote regular cycle.