Amenorrhea

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Overview

Amenorrhea is defined as the absence of menstruation during the reproductive years of a woman's life. Physiological states of amenorrhea are seen, most commonly during pregnancy and lactation (breastfeeding). It can be classified as primary and secondary amenorrhea. The causes of amenorrhea are diverse. This activity outlines the evaluation and management of amenorrhea and highlights the role of the interprofessional team in managing and improving care for patients with this condition. This activity examines when this condition should be considered on a differential diagnosis and how to evaluate it properly.

Female menstrual cycle normally comprises a 28 to 30-day cycle, which contains 2 phases, the proliferative phase and the secretory phase. At the end of the cycle, the uterine lining starts shedding off, which is a normal phenomenon of female menstruation.

The absence of menstruation during the female during the reproductive ages of approximately 12 to 49 years is known as amenorrhea.

There are primary and secondary causes of amenorrhea.

The most common cause of amenorrhea is pregnancy, and it is the first thing that needs to be ruled out when investigating such a patient. In general, if a female does not have menses for 6 months, she has amenorrhea.

Symptoms

The main symptom of amenorrhea is the absence of your monthly period. It often signifies a larger health problem or condition. Related symptoms can include:


Headache.

Vision changes.

Nausea.

Extra facial hair.

Hair loss.

Changes in breast size.

Milky fluid, or discharge, from breasts.

Causes

The main causes of primary amenorrhea include family history, genetics, and lifestyle. Women with the following factors are more at risk:


A family history of amenorrhea or early menopause.

A genetic or chromosomal defect. These can affect your ovary function and menstrual cycle. Turner syndrome is one example.

Severely overweight or underweight.

An eating disorder.

An extreme exercise pattern.

A poor diet.

Stress.

Pregnancy, breastfeeding, and menopause can cause secondary amenorrhea. Other possible causes include:


Some birth controls, such as pills, injections, or intrauterine devices. These can affect your menstrual cycle during and after use.

Some medicines for depression and blood pressure.

Chemotherapy and radiation treatment.

Polycystic ovary syndrome (PCOS).

Fragile X syndrome (caused by the FMR1 gene) or fragile X-associated primary ovarian insufficiency (FXPOI).

Problems with your thyroid or pituitary gland.

Hypothalamic disease.

Uterine scar tissue.

Risk factors

There are various factors that can put one at the risk of developing amenorrhea. Some of the risk factors are:

Eating disorder: People with eating disorders such as anorexia nervosa or bulimia are more prone to amenorrhea due to lack of body fat and other problems.

Family history: If a woman has cases of amenorrhea or early menopause, then there are chances that she may get amenorrhea too.

Excessive exercise: Strenuous exercises and rigorous athletic training can easily put one at amenorrhea risk.

Genetics: Change in the FMR1 gene, which also causes Fragile X syndrome

Ovarian failure: Due to receiving chemotherapy and radiotherapy

Structural abnormalities: Girls who have congenital abnormalities such as poorly developed genital and pelvic organs can be at the risk of developing amenorrhea

Other risk factors include:

Obesity

Chromosomal disorders

Use of contraceptives

Tumor and its treatments

Psychiatric disorders

Impact of Amenorrhea on Fertility

Amenorrhea is a symptom of an underlying causes and the causes of amenorrhea can be varied depending on the cause. Amenorrhea can be caused due to the disorders of the outflow tract (uterus and vagina), ovary and ovulatory disorders, disorder of the pituitary and hypothalamus.

Each of the causes has a different implication in the realm of infertility. In case of the disorders of the outflow tract - these women can have normal or abnormal genital anatomy. In normal genital tract anatomy - the causes include cervical stenosis, ashrams syndrome and endometrial damage. The fertility prospects depends on the extent of the disease as this affects the site of implantation.

In women with abnormal genital tract anatomy - it can be associated with obstruction at the level of the vagina which is amenable to treatment and fertility is restored. In women with absent uterus, surrogacy/ adoption is the only fertility option available. Uterine transplantation is another option which may be available in the future- It is still in the early stages of development.

Ovarian disorders can be further divided into chronic anovulation (where ovulation does not occur regularly and cyclically) and ovarian failure.

In women with chronic anovulation (eg. PCOS, Thyroid disorders) - treatment of the underlying disorder establishes ovulation and then pregnancy.

In women with ovarian failure (Causes- ovarian dysgenesis, premature ovarian failure, chemotherapy, radiotherapy) - in these women natural conception is difficult as the ovarian reserve is very low or non-existent - donor gametes is an option for pregnancy.

In pituitary and hypothalamic causes, the ovarian reserve is not affected, fertility is restored upon treatment of the cause of amenorrhea. Hence probability of pregnancy in amenorrhea is dependent on the underlying cause and each individual is evaluated and treated for fertility as per the same.


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Complications

The causes of amenorrhea can cause other problems as well. These include:

Infertility and problems with pregnancy. If you don't ovulate and don't have menstrual periods, you can't become pregnant. When hormone imbalance is the cause of amenorrhea, this can also cause miscarriage or other problems with pregnancy.

Psychological stress. Not having periods when your peers are having theirs can be stressful, especially for young people who are transitioning into adulthood.

Osteoporosis and cardiovascular disease. These two problems can be caused by not having enough estrogen. Osteoporosis is a weakening of the bones. Cardiovascular disease includes heart attack and problems with the blood vessels and heart muscle.

Pelvic pain. If an anatomical problem is causing the amenorrhea, it may also cause pain in the pelvic area.

Prevention

Living a healthy lifestyle can help prevent some causes of secondary amenorrhea. Try to: Maintain a healthy weight and eat a healthy diet. Be aware of your menstrual cycle (so you'll know if you miss a period).

Practice yoga. Yoga has been shown to be an effective treatment for different menstrual issues. ...

Maintain a healthy weight. ...

Maintain a healthy weight. ...

Spice things up with ginger. ...

Exercise regularly. ...

Spice things up with ginger. ...

Add some cinnamon. ...

Eat pineapple.