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Abnormal Bleeding

  • Amenorrhea is the absence of menstrual periods, it may be either primary (meaning a woman never developed menstrual periods) or secondary (absence of menstrual periods in a woman who was menstruating previously).
  • Genetic  conditions are the most common causes of primary amenorrhea.
  • Amenorrhea may result from disorders of the pituitary,ovaries, hypothalamus, or uterus.
  • Intensive exercising, extreme loss of weight,  physical illnesses  and stress can all result in amenorrhea.
  • Amenorrhea is a symptom and not a disease , so amenorrhea can be prevented only to the extent of the underlying cause  prevented.
  • infertility and  bone loss (osteoporosis) are possible complications of amenorrhea.
  • Treatments to amenorrhea may include surgical correction of anatomical abnormalities, hormone therapies ,medications  and treatment of any underlying conditions which is responsible for amenorrhea.

Primary amenorrhea

Primary amenorrhea is typically the result of a genetic or anatomic condition in younger females who never develop menstrual periods (by the  age 16) and is not Pregnant. Many genetic conditions that are characterized by amenorrhea are circumstances in which few or all of the  internal female organs either fail to develop normally during fetal development or to function properly. Diseases of the pituitary gland and hypothalamus (a region of the brain which  controls  hormone production) can also cause primary amenorrhea since these areas play a critical role in the regulation of ovarian hormones.

Gonadal dysgenesis, is a condition in which the ovaries are prematurely depleted of oocytes and follicles , leads to premature failure of the ovaries. It is one of the most common cases of primary amenorrhea in young women.

Other genetic cause is Turner syndrome, in which women are lacking part of  or all of  one of the 2 X chromosomes normally present in the female. In Turner syndrome  ovaries are replaced by scar tissue and estrogen production is minimal which  results in amenorrhea. Estrogen-induced maturation of the external female genitalia and sex characteristics also fails to occur in Turner syndrome.

Other conditions that may cause  primary amenorrhea include androgen insensitivity (in which individuals have XY male) chromosomes but do not develop the external characteristics of males due to a lack of response to testosterone ), congenital adrenal hyperplasia and polycystic ovarian syndrome .

Secondary amenorrhea

Pregnancy is an obvious and most common cause of secondary amenorrhea. Further causes are varied and may include conditions that affect the ovaries, uterus, hypothalamus, or pituitary gland.

Hypothalamic amenorrhea is caused  by disruption in the regulator hormones which is produced by the hypothalamus in the brain. These hormones influence the pituitary gland, which in turn sends signals to ovaries to produce the characteristic cyclic hormones. A number of conditions can affect the hypothalamus:

  • extreme loss of weight ,,
  • emotional or physical stress,
  • rigorous physical exercise  and
  • severe illnesses.

Other types of medical conditions which can cause secondary amenorrhea:

  • tumors or other diseases of the pituitary gland that lead to elevated levels of  hormone prolactin (which is involved in milk production) also cause amenorrhea
  • hypothyroidism
  • elevated levels of androgens (male hormones), caused by either from outside sources or from disorders that cause the body to produce too high levels of male hormones;
  • ovarian failure (early menopause or premature ovarian syndrome)
  • polycystic ovary syndrome (PCOS)
  • Asherman’s syndrome, a uterine disease caused from scarring of the uterine lining caused due to instrumentation (such as dilation and curettage) of the uterine cavity to manage postpartum bleeding or infection.

When should I seek medical care for amenorrhea?

It is always appropriate to seek medical attention for amenorrhea that is not related to pregnancy or  menopausal transition ( transition is when there is no menstrual periods for 12 consecutive months) and it must  be further investigated to rule out some serious conditions that may result in amenorrhea.

Treatment

Treatment of both primary and secondary amenorrhea is determined by the specific cause. Treatment goals can be to relieve symptoms of hormonal imbalance, establish menstruation, prevent complications, and/or to achieve fertility , although not all of these goals can be achieved in every case.

Cases in which genetic or anatomical abnormalities are the cause of amenorrhea (mostly primary amenorrhea), surgery may be recommended.

Hypothalamic amenorrhea that is related to loss of weight, excessive exercise, physical illnesses or emotional stress can typically be corrected by addressing the underlying cause. For example, weight gaining  and decrease in intensity of exercise can usually restore menstrual periods in women who have developed amenorrhea due to loss of weight or  intensive exercise who do not have additional causes of amenorrhea. In some cases, nutritional counseling may be of benefit.

Women with PCOS (polycystic ovary syndrome) may benefit from treatments that reduce the level or activity of male hormones.

Dopamine agonist medications such as bromocriptine  can reduce elevated prolactin levels, which may be responsible for amenorrhea. Consequently, medication levels may be adjusted by the individual’s  physician if appropriate.

Assisted reproductive technologies and the administration of gonadotropin medications (Drugs that stimulate follicle maturation in the ovaries) which can be appropriate for women with some  types of amenorrhea who wish  to become pregnant.

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