Amenorrhea is a disorder of menstrual function in which women of childbearing age (16-45 years) do not menstruate for six months or more. Amenorrhea, as a rule, is not an independent disease, but serves as a symptom of genetic, biochemical, physiological, psycho-emotional disorders in the body. To identify the causes of amenorrhea, a gynecological history is evaluated, an ultrasound of the pelvic organs is performed, and a hormonal status study is performed. Treatment is aimed at eliminating the root cause of menstrual dysfunction: it can be conservative or surgical.
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Amenorrhea is a disorder of menstrual function in which women of reproductive age (16-45 years) do not menstruate for six months or more. Disease, as a rule, is not an independent disease, but serves as a symptom of genetic, biochemical, physiological, psycho-emotional disorders in the body. With false amenorrhea, cyclic and hormonal changes in the ovaries and uterus are preserved, but menstrual discharge from the genital tract is absent due to any anatomical obstacle. With true amenorrhea, there is no ovulation, and pregnancy becomes impossible.
The causes of primary form can be genetically determined (hereditary), anatomical and psycho-emotional factors:
- Heredity. Many patients have a family history of menstruation later (after 17 years) in the mother or older sisters. In such cases, they talk about hereditary factors that cause amenorrhea. Primary form is observed in Turner syndrome, a disease characterized by underdevelopment of the sex glands as a result of abnormal development of sex chromosomes.
- Constitutional and anatomical features. These include a general delay in physical development, manifested in the features of the physique (thinness, underweight, undeveloped breasts, narrow pelvis, etc.), as well as abnormalities in the development of the genitals (overgrowth of the vaginal canal or hymen).
- Neuropsychiatric exhaustion. Frequent culprits of primary amenorrhea are stress, severe psycho-emotional shocks, anorexia and debilitating physical exertion. Such factors are extremely dangerous for an undeveloped adolescent organism, because they cause disorders at the stage of formation of menstrual function.
Secondary form occurs in approximately 10% of women aged 17-45 years and is considered a severe violation of menstrual function. The factors most often affecting the cessation of established menstruation and the development of secondary amenorrhea are:
- Anorexia (38%). Most patients with secondary amenorrhea are victims of trendy diets and anorexia, a severe mental and physical disorder characterized by an obsessive desire to lose weight. Purposeful refusal to eat, abuse of laxative procedures, artificially induced vomiting in anorexia lead to a sharp weight loss and the development of psychosexual disorders, depression, constipation and secondary form.
- Polycystic ovaries (26%). Characteristic symptoms that make it possible to suspect polycystic ovarian changes are hirsutism, acne, impaired fat metabolism, amenorrhea and lack of pregnancy.
- Early menopause (22%). Menopause is considered early (premature) if menstruation stops in a woman who has not reached the age of 40 due to insufficient ovarian function. Prolonged stress can provoke premature menopause and amenorrhea.
- Hyperprolactinemia (11%). Hyperprolactinemia is a condition caused by an increase in the level of the hormone prolactin in the blood. It is characterized by lactic secretions from the mammary glands, various disorders of menstrual function, up to the complete cessation of menstruation – amenorrhea.
In some cases, the cessation of menstruation can serve as a temporary reaction to nervous shocks and recover after a certain time independently, without additional interventions. However, in most cases secondary amenorrhea requires qualified medical intervention.
The classification is based on two types of amenorrhea – false and true.
- False. Cyclic and hormonal changes in the ovaries and uterus are preserved, but menstrual discharge from the genital tract is absent due to any anatomical obstacle. Such obstacles can serve as congenital malformations of the structure of the genitals: atresia of the vagina, cervix or hymen. Thus, depending on the anatomical defect with false amenorrhea, menstrual blood can accumulate in the fallopian tubes (hematosalpinx), the uterine cavity (hematometer) or the vagina (hematocolpos).
- True. It is characterized by the absence of menstrual bleeding and cyclical processes in the body that cause them. With true amenorrhea, there is no ovulation, and pregnancy becomes impossible. In turn, depending on the causes causing it, true amenorrhea can be physiological or pathological.
Physiological amenorrhea is not a painful condition and is caused by natural conditions (pregnancy, breast-feeding) or age periods of a woman (childhood, menopause).
Pathological amenorrhea is an alarming symptom indicating functional or organic disorders in the female body. If menstruation does not occur initially in adolescence, they talk about primary form. In cases where regular menstruation stops due to any reason, amenorrhea is considered secondary.
The absence of menstruation and hormone-dependent cyclical changes in the reproductive system, accompanying the period of breastfeeding, is called lactation amenorrhea. Lactation amenorrhea is a physiological method of contraception based on the absence of ovulation and, consequently, the impossibility of pregnancy. However, the method of lactation amenorrhea is effective only for six months from the moment of delivery and exclusively during breastfeeding.
The conditions for the effectiveness of lactation amenorrhea as a method of contraception are compliance with the following rules:
- feeding the child according to each of his requirements at least 6 times a day;
- mandatory night feeding;
- the absence of mixed feeding and complementary foods.
The mechanism of lactation form is based on the suppression of ovulation in a woman with constant sucking of breast milk by a child, and, consequently, the absence of a menstrual cycle and pregnancy. The effectiveness of the contraceptive effect in lactation amenorrhea is close to 98%. Among the undoubted advantages of the lactation amenorrhea method are high reliability, naturalness, benefits for the child, ease of use, absence of side effects, rapid postpartum recovery.
The disadvantages of lactation amenorrhea, as a method of contraception, include the short duration of pregnancy prevention (maximum six months), the mandatory need to comply with all the conditions of its effectiveness. In addition, lactation form does not guarantee protection against sexual infections and sexually transmitted diseases (including HIV and hepatitis B). If it is impossible to use lactation amenorrhea as the main method of contraception, you should choose a more reliable means of protection against unwanted pregnancy together with the gynecologist observing the woman.
At a gynecological appointment with a patient complaining about the cessation of menstruation, pregnancy is first of all excluded and the moments that provoke the development of amenorrhea are found out: the fascination with diets, physical and mental overload, concomitant diseases, the time of menopause in mothers and grandmothers, etc. The gynecologist evaluates the height and weight of the patient, their ratio to each other and the indicators of the norm. In some cases, dystrophy or, on the contrary, obesity can cause secondary amenorrhea due to hormonal and physiological failures in the body.
If amenorrhea is suspected, the examination is aimed at identifying the nature of ovarian dysfunction. For this purpose, a study of the level of hormones (primarily prolactin, progestogens, estrogens, sex chromatin, karyotin), ultrasound of the pelvic organs (to exclude polycystic ovaries and determine the state of the endometrium) is carried out. Additionally, a schedule of changes in rectal temperature is drawn up, a cytological analysis of a smear of the posterior vaginal arch is performed to determine the estrogenic saturation of the patient’s body.
An important diagnostic test criterion for secondary amenorrhea is the “pupil symptom”. During the normal course of the menstrual cycle, in the period from the 6th to the 20th day, the diameter of the external pharynx of the cervix, filled with transparent mucus, increases and resembles a pupil when examined. This disease is characterized by a slight opening of the uterine pharynx and a small amount of mucus. Based on the results obtained, as a rule, the cause of amenorrhea is established and a treatment course is prescribed.
Treatment of amenorrhea
The principles of treatment of primary amenorrhea are aimed at eliminating or correcting the factors that caused it. Patients with Turner syndrome are shown lifelong hormone replacement therapy (estrogenization). With a delay in physical and reproductive development, girls are prescribed a diet aimed at building muscle and fat mass and hormonal treatment that stimulates menstrual function. Hormone therapy should be carried out under the strict supervision of a gynecologist-endocrinologist.
With increased emotional instability, treatment is carried out aimed at strengthening the nervous system. If primary amenorrhea is caused by anatomical causes, surgical removal of obstacles is performed – creating conditions for the normal outflow of menstrual blood from the uterine cavity through the genital tract to the outside.
Amenorrhea, associated with a sharp weight loss or physical exertion, is a consequence of an incorrect lifestyle and requires its change. A critical indicator for the normal course of the menstrual cycle in an adult woman is the loss of 10 or more kilograms of weight, as well as a body weight of less than 50 kg. Progestogenic oral contraceptives that do not contain estrogenic components are usually prescribed until menstrual function is fully normalized. Often, secondary amenorrhea is eliminated without hormone therapy while observing reasonable physical exertion, a rational diet, work and rest, normalization of the psycho-emotional background.
Secondary amenorrhea, which develops in polycystic ovary syndrome, requires treatment of a background disease. To normalize the ovulatory cycle in polycystic ovaries, hormonal contraceptives are prescribed or laparoscopic diathermocoagulation of organ tissue is performed (according to indications).
Hyperprolactinemia, as a factor in the development of amenorrhea, is eliminated by taking dopamine agonist drugs that lower prolactin levels. The effectiveness of treatment is determined by the control of basal temperature, an increase in which indicates the commission of ovulation. In case of tumor lesions of the pituitary gland, neurosurgical intervention is indicated. Secondary amenorrhea caused by premature menopause is corrected with the help of long-term hormone replacement therapy.
Assisted reproductive technologies
ART and the method of in vitro fertilization, which is successfully used by modern gynecology, allows women with premature menopause and untreatable secondary amenorrhea to become pregnant. In such cases, a donor egg or a donor embryo is used for artificial insemination (using ICSI, PIXIE or IMSI methods). Then the embryos are transplanted into the uterus of the expectant mother.
Prognosis and prevention
The sudden cessation of menstruation in women of childbearing age (secondary amenorrhea) is a signal of distress and malfunctions in the body that require attention. Some of them are easily eliminated by lifestyle changes, others need qualified medical care. The danger of amenorrhea is that it is always associated with the female factor of infertility. At a young age, it is especially dangerous to get carried away with various diets: restrictions on self-nutrition lead to insufficient intake of protein, fats, vitamin and mineral compounds into the body, slowing down development, including and sexual and contributing to the development of amenorrhea. One should avoid hobbies in power sports: weightlifting, martial arts, bodybuilding, etc.