Amenorrhea

The amenorrhea is defined as a temporary or permanent absence of menstruation.

There are three fundamental types of amenorrhea:

1. Physiological amenorrhea: are those that occur naturally, and appear in the following states: before puberty (the appearance of the first period, or menarche, usually takes place between 10 and 14 years), in pregnancy ( it is the most frequent cause of amenorrhea), in lactation and in menopause (between 45 and 55 years).
2. Primary amenorrhea: it is the absence of the appearance of the rule when the woman has reached the age of 16.
3. Secondary amenorrhea: it is the lack of menstruation for at least 3 months in a woman who had previously had her period, excluding physiological amenorrhea.

Causes of amenorrhea

The main causes of amenorrhea are:

Genetic abnormalities of the genital tract

• Hymen imperforation: it is a rare malformation in which the woman experiences monthly pain coinciding with menstrual desquamation (which is retained within the vagina and uterus).
  Congenital absence of vagina.
• Rokitansky syndrome: it consists of a total or partial agenesis of the vagina associated with a rudimentary non-canalized uterus and frequent renal or urinary malformations.
• Morris syndrome: it is a form of intersex that is characterized by a female external appearance with the absence of axillary and pubic hair, a blind vagina (because the uterus is usually missing) and well-shaped testicles (although they are usually intra-abdominal).
• Adrenogenital syndrome: It is another form of intersex that is characterized by masculine external appearance with hypertrophy of the clitoris, normal vagina and existing uterus and ovaries.
• Gonadal dysgenesis: it is a malformation of the ovaries. The external genitalia are female but childlike in appearance. It presents in three forms: gonadal dysgenesis with dwarfism and extragenital malformations (Turner syndrome); pure gonadal dysgenesis, without malformations or dwarfism (Swyer’s syndrome); and gonadal dysgenesis with dwarfism (Rösle syndrome).

Amenorrhea of ​​uterine origin

They are mainly due to endometrial lesions due to multiple causes and that cause secondary amenorrhea. Among these causes we find uterine curettage, radiation injuries, cauterizations, infections (especially tuberculosis ), etc. Sometimes these destructive processes produce uterine synechiae, which is known as Asherman’s syndrome.

Amenorrhea of ​​ovarian origin

• Primary ovarian failure: it is due to a failure in the function of the ovary, which can be produced by many causes, and which alters the hormonal regulation of menstruation.
• Some ovarian tumors.
• Polycystic ovary or Stein-Leventhal syndrome: it is defined as the association of large and bulky ovaries, menstrual alterations (mainly amenorrhea), sterility, hirsutism and obesity, accompanied by certain hormonal alterations.
• Some ovarian cysts.

Amenorrhea of ​​pituitary origin

The main cause of amenorrhea due to alteration of the pituitary gland are pituitary tumors: prolactinomas, ACTH-producing tumors, growth hormone-producing tumors, and craniopharyngiomas. All of them cause an alteration in the hormonal regulation of menstruation.

Amenorrhea of ​​hypothalamic origin

All of them entail an alteration of the hormonal regulation of the menstrual cycle, which can end up producing amenorrhea:

• Amenorrhoea psychic: occurs in situations of stress , internment (in schools, prisons, concentration camps, etc.), or fear of pregnancy or sexuality.
• Amenorrhea due to malnutrition: it is fundamentally associated with anorexia nervosa .
• Obesity.
• Sports amenorrhea: occurs in women who practice intense and competitive exercise (athletics, ballet, gymnastics, etc).
• Non-tumor lesions: which can secondarily affect the hypothalamus, for example: hydrocephalus, meningitis , brain trauma, etc. Among these injuries we find Sheehan’s syndrome, which consists of a total pituitary failure due to ischemia or an infarction of the pituitary, which occurs after significant bleeding after childbirth.
• Genetic defects: these are very rare lesions, including the Laurence-Moon-Bield syndrome, which is characterized by sexual infantilism, obesity, mental deficit, retinitis pigmentosa, polydactyly and hypertrichosis.
• Drug amenorrhea: contraceptives, phenothiazines, reserpine, digoxin, etc.
• Kallman syndrome: it is a lack of development of the central nervous system characterized by sexual infantilism, primary amenorrhea and alterations in smell.

Amenorrhea of ​​adrenal and thyroid origin

Both the excess or the defect of the hormonal function of the adrenal glands or of the thyroid can cause amenorrhea.

Amenorrhea occurs because any of the aforementioned causes alter the normal functioning of the menstrual cycle, preventing the appearance of the rule, either by an alteration of its hormonal regulation or by an anatomical alteration of the various structures that intervene in it. cycle (uterus, ovaries, pituitary and hypothalamus).

Symptoms of amenorrhea

The only symptom of amenorrhea, as its name suggests, is the lack of menstruation.

The rest of the symptoms that may appear will be related to the cause that produces amenorrhea, so they can be very varied:

• Hypothalamic / pituitary involvement: vision alteration, hormonal and nutritional alterations, …
• Thyroid involvement: hyperthyroidism , hypothyroidism, …
• Ovarian involvement: ascites , hirsutism, …
• Uterine involvement: infertility, …
• External genitalia involvement: dyspareunia, dwarfism, …
• Others: picological alterations,….

How is it diagnosed?

The study of an amenorrhea is different depending on whether it is primary or secondary.

Primary amenorrhea

In the study of these amenorrhea, a detailed medical history and a general and gynecological examination must be carried out as complete as possible, and depending on the findings we find, various complementary tests will have to be performed to determine the exact cause of the amenorrhea.

Secondary amenorrhea

The first thing to rule out is a pregnancy, performing a pregnancy test and / or an ultrasound.

If they are positive, it will be necessary to think about a pregnancy, although it could also be an ovarian tumor that produces HCG (which is a much less frequent disease).

If they are negative, the study is continued with hormonal tests, to determine the exact location of the alteration:

• Hypothalamic and / or Pituitary Diseases: Stress, Athletes, Prolactinomas …
• Thyroid Diseases: Hyperthyroidism, Hypothyroidism …
• Ovarian Diseases: Polycystic Ovarian Syndrome, Ovarian Tumors …
• Diseases of the Uterus (Endometrium): Synechiae, Uterine curettage …
• External Genital Diseases.

Treatment of amenorrhea

Ovulation-triggering drugs such as clomiphene citrate, gonadotropins, and medroxyprogesterone acetate can be used in women with persistent lack of ovulation.

In gonadal dysgenesis, in testicular feminization, in early menopause, in ovarian failure and in certain pituitary and hypothalamic insufficiencies, the use of a replacement therapy with estrogens and associated gestagens is indicated.

In cases of gonadal dysgenesis associated with dwarfism, it is necessary to treat first with growth hormone and later with hormone replacement therapy.

In cases of amenorrhea accompanied by high prolactin levels, the treatment of choice is bromocriptine.

In pituitary tumors there are two alternatives:

1. medical treatment with bromocriptine, which shrinks the tumor
2. surgical treatment with microsurgery.

Amenorrhea associated with obesity usually subsides with a hypocaloric diet.

In psychic amenorrhea, before starting any hormonal treatment, it is convenient to try to solve the psychological problem.