SECONDARY AMENORRHEA

By

Dr. Maryam B. Mahmmud

College of medicine – university of sulaimania

AMENORRHEA IS DIVIDED INTO EITHER:

Primary: faiuler to establish menstruation by age 16.

Secondary: cessation of menstruation for 6 consecutive months in a woman who has previously had regular period.

Woman with secondary amenorrhea must have an intact hypothalamic-pituitary-ovarian-uterine axis.

CAUSES:1. Physiological: pregnancy-lactation-

menopause.2. Pathological: this is subdivided into: Hypothalamic causes e.g. weight

loss,exercise,irradiation,TB, head injury, chronic illness, psychological,

sarcoidosis. Pituitary; e.g.hyperprolactinaemia, Sheehan

syndrome, tumors (crainopharangioma, glioma).

Ovarian; e.g. PCOS, premature ovarian failure (genetic, autoimmune, infective, radio/chemotherapy).

Uterine; e.g. Ashermans syndrome, cervical stenosis.

Systemic causes; e.g. chronic illness,wt.loss,thyroid disorder

Drugs; e.g. post pill amenorrhea , GnRH analogue.

PREMATURE OVARIAN FAILURE Is defined as cessation of periods

accompanied by raised gonadotrophin level prior to age of 49 years. The true incidence is not known but is about 5-10%. Onset before puberty is mainly due to either chromosomal anomaly or childhood radio/chemotherapy. The main concern with this problem is impaired fertility and risk of osteoporosis, so HRT is indicated.

ASHERMANS SYNDROME Results from acquired scarring and

adhesion of endometrial lining secondary to postpartum hemorrhage or endometrial infection, followed by instrumentation (i.e. D & C).

DIAGNOSIS: Is suggested by absence of normal

uterine stripe on pelvic ultrasound, absence of withdrawal bleeding after administration of estrogen, then progestin for several weeks or by HSG OR Hysteroscopy evaluation of the endometrium.

ASHERMAN’S SYNDROME

POST PILL AMENORRHEAIs defined as absence of menstruation for 6 months following cessation of the combined oral contraceptive pill. It probably results from A transient inhibition of gonadotrophin-releasing hormone.

ASSESSMENT: In any woman in reproductive age group

and secondary amenorrhea pregnancy should be ruled out at first; this can be achieved by serum B-hCG testing which is most sensitive.

• Detailed history should search for the above causes like recent wt.loss, history of head injury, abnormality in visual field, previous history of PPH, uterine instrumentation, drug administration, and

history of galactorrhea. Symptoms of estrogen deficiency? Hot flashes,Vaginal dryness ,Poor sleep.

INVESTIGATION:Following could be helpful Pregnancy test. Serum prolactin. Serum FSH and LH if FSH is high this may indicate ovarian

failure and further investigation may be needed like karyotyping.

Serum androgen. Ultrasonography may show PCOS. If suspected, Asherman syndrome can be ruled out by doing

progesterone challenge test(10 mg medroxy progesterone acetate for 10 days) if bleeding does not occur, combined estrogen and progesterone should be given if still no bleeding adhesion may be suspected and HSG or hysteroscopy may be indicated.

TREATMENT: It somewhat depend on the cause; e.g. dietary

counseling in wt. related amenorrhea reduction of exercise, HRT in those with ovarian failure. Asherman syndrome can be treated with adhisolysis using hysteroscopy. Long-term estrogen administration to stimulate regrowth of endometrial tissue.

COMPLICATION: Infertility: usually they do not ovulate. Endometrial hyperplasia: women with

amenorrhea but no associated estrogen deficiency are at increased risk of endometrial hyperplasia and endometrial carcinoma

Osteoporosis: women with amenorrhea associated with estrogen deficiency are at significant risk of developing osteoporosis.

HYPERPROLACTINAEMIA

Is the commonest cause of amenorrhea, the causes including:

Mild elevation: (prolactin level less than 1000 mu/l e.g. stress, recent physical or breast examination.

Moderate elevation: (prolactin level up to 2500mu/l e.g. hypothyroidism, PCOS , drugs like dopamine antagonist phenothiazines , metoclopramide.

Sever elevation: with up to 8000mu/l may be due to pituitary tumors which could be non-functioning, producing only disruption of inhibitory factor; or functioning prolactin secreting adenoma (micro adenoma less than 1cm size or macro adenoma more than 1 cm size which may cause pressure symptom like disturbed visual field and asymmetrically enlarged pituitary fossa with double contour of its floor and erosion of clinoid process. Other investigations may be required in sever elevation like CT scan or MRI.

TREATMENT:If it’s due to drugs; discontinue it.Medical treatment inform of dopamine agonist like Bromocriptine (parlodel) starting with 1.5mg and increasing gradually every 5 days. the drawback of parlodel is associated side effects like nausea, vomiting, headache and postural hypotension. Newer drug are available like Cabargolin (dostinex) which can be given twice weekly with lower side effects.

These drugs cause fall in prolactin level within few days of starting the treatment, and reduction in size of tumor within 6 weeks.

Surgical treatment in the form of trans sphenoidal adenectomy indicated for cases of drug resistance, failure to shrink macro adenoma .

Patients with micro adenoma who want to conceive have of only less than 2% of tumor expansion on the other hand if macro adenoma not treated has 25% risk of tumor expansion during pregnancy. Bromocreptin can be discontinued during pregnancy but if symptoms reoccur like visual field defect CT or MRI are indicated and treatment should be recommenced.

Thanks