Secondary Amenorrhea Causes And Diagnosis
Temporary cessation of menses is extremely common and usually does not require extensive endocrine investigation. In the childbearing age, pregnancy must be ruled out. In women beyond the childbearing age, menopause should be considered first. States of emotional stress, malnutrition, anemia, and similar disorders may be associated with temporary amenorrhea and correction of the primary disorder will usually also reestablish menstruation. Some women fail to menstruate regularly for prolonged intervals after stopping oral contraceptive pills. Lactation may be associated with amenorrhea, either physiologically or for abnormally prolonged periods after delivery. An increasing number of small pituitary tumors causing secondary amenorrhea and often lactation have been discovered by means of prolactin assays and pituitary tomography.
By the use of the dilation and curettage, the administration of progesterone with subsequent withdrawal, these amenorrhea can be arbitrarily divided into amenorrhea with negative dilation and curettage and amenorrhea with positive dilation and curettage. The former (with the exception of pregnancy) show an atrophic or type of endometrium; the latter show an endometrium of the proliferative type but lacking progesterone.
Secondary amenorrhea with negative medical dilation and curettage may be due to the following causes: premature ovarian failure, pituitary tumor, pituitary infarction (Sheehan's syndrome). The measurement of serum FSH and LH is extremely helpful in separating ovarian causes (high gonadotropins) from hypothalamic-pituitary origin (low gonadotropins). Serum prolactin levels must be measured. Less common causes include virilizing syndromes such as arrhenoblastoma, Cushing's disease, Addison's disease, and miscellaneous causes such as anorexia nervosa, profound myxedema, and irradiation of the uterine lining.
Secondary amenorrhea with positive medical dilation and curettage may be due to metropathia hemorrhagica, Stein-Leventhal syndrome, estrogen medication, estrogenic tumors, like granulosa cell tumors (rare), hyperthyroidism, and perhaps liver disease. A common cause is psychogenic amenorrhea related to emotional trauma (divorce, going to college, stressful new job and so on). Menstruation usually returns in a few months without any specific therapy. Tonic elevation of serum LH with normal FSH is helpful in the diagnosis of polycystic ovary syndrome. Amenorrhea or oligomenorrhea is also often found in athletes (long-distance runners, dedicated ballet dancers, etc). Depletion of body fat due to strenuous exercise may play a role in the pathogenesis of this problem.
Some degree of overlap in these 2 groups is sometimes found.
Secondary Amenorrhea Treatment
The aim of therapy is not only to reestablish menses (although this is valuable for psychologic reasons) but also to attempt to establish the cause (eg. pituitary tumor) of the amenorrhea and to restore productive function.Treatment depends upon the underlying disease. It is not necessary to treat all cases, especially temporary amenorrhea or irregular menses in unmarried girls or women. These cases usually are corrected spontaneously after marriage or the first pregnancy
In patients whose are response to progesterone is normal, the administration of this hormone during the las 5-10 days of each month, can correct the amenorrhea. In patients who are unresponsive to progesterone and whose urinary gonadotropin levels are low treatment of the pituitary lesion may restore menstruation
A commonly used schedule is the oral administration of 1.2 mg of conjugated estrogens from days 1 to 20 of each month and 10 mg of medroxyprogesterone daily during days 21 to 25. Corticosteroids may restore menstruation in virilizing disorders that are due to enzymatic abnormalities in cortisol biosynthesis. Wedge resection of the ovaries often restores regular menstruation in the polycystic ovary syndrome) Transsphenoidal resection of small prolactin-produc-ing pituitary adenomas likewise has resulted in restoration of fertility.
General measures include dietary management as required to correct overweight or underweight; psychotherapy in cases due to emotional disturbance; and correction of anemia and any other metabolic abnormality that may be present (eg, mild hypothyroidism).