From a clinical point of view, a general practitioner must first eliminate pregnancy and ensure that he is dealing with secondary rather than primary amenorrhea. The main reason is one of four: PCOS, hypothalamic amenorrhea, hyperprolactinemia, or ovarian failure.
PCOS is detected in approximately 30% of women with amenorrhea, but by itself it most often causes oligomenorrhea (76%) than amenorrhea (24%).
Up to 1/3 of cases of secondary amenorrhea are caused by prolactinoma. In women with amenorrhea, accompanied by hyperprolactinemia, the main manifestations of the disease, as a rule, are due to a lack of estrogen. Galactorrhea is observed in only 1/3 of patients with hyperprolactinemia, and its appearance does not correlate with either the level of prolactin or the presence of a tumor.
Ovarian failure or menopause is considered premature if they occur before the age of 40 years. In 20-40% of cases, premature menopause is caused by autoantibodies, and other causes include mumps, surgery, radiation, and chemotherapy.
To maintain a normal menstrual cycle, a woman’s body mass index should exceed 19 kg / m 2 (normally 20–25 kg / m 2). Amenorrhea develops when a woman loses 10-15% of her body weight, normal for her height. This loss of body weight can occur due to various reasons: from serious diseases to anorexia and exercise. Amenorrhea occurs on the background of physical activity that requires endurance (for example, long-distance running) or a certain appearance (ballet and gymnastics).
Causes of secondary amenorrhea without signs of excess androgens
- Sheehan syndrome
Causes of lesion at the pituitary / hypothalamus level
- Radiotherapy to the skull area
- Head injuries
- Cervical constriction
- Asherman syndrome (intrauterine adhesions after instrumental interventions)
- Premature ovarian exhaustion
- Resistant ovary syndrome
- Severe chronic disease
- Hypo or hyperthyroidism
- Due to COC or Depo Provera injection (temporary)
- Radiation therapy
- Weight loss
- Physical exercise
- Psychological shocks
- Severe chronic disease
Causes of secondary amenorrhea in the presence of an excess of androgens
- Androgen-producing tumors of the adrenal glands or ovaries.
- Congenital adrenal hyperplasia with late onset.
What data history should be clarified with secondary amenorrhea?
- Menstrual, obstetric and gynecological history.
- Has a woman recently used contraceptives, in particular progestins or COCs?
- The possibility of pregnancy.
- Additional symptoms, such as galactorrhea, hirsutism, hot flashes and / or vaginal dryness, signs of thyroid disease.
- A history of eating disorders, recent changes in body weight or emotional shocks.
- The severity of physical exertion.
- Radiotherapy on the abdomen, pelvis or skull, as well as chemotherapy
- Presence in the family of cases of early menopause.
What are the important aspects in the examination of patients with secondary amenorrhea?
- Measurement of height and body weight.
- Examination for hirsutism, acne, or signs of virilization, such as a low voice or an enlarged clitoris.
- Symptoms of thyroid disease or galactorrhea.
- Acanthosis nigricans (hyperpigmentation and thickening of skin folds in the armpits and neck), which is the result of pronounced insulin resistance and occurs in PCOS.
- If a pituitary tumor is suspected, a fundus examination and evaluation of visual fields is necessary.
- Gynecological examination for enlarged polycystic ovaries.
What additional survey methods are needed?
Since pregnancy is the most common cause of amenorrhea, always perform a pregnancy test before moving on to other studies. If the test is negative, then to identify the most common causes of amenorrhea, it is necessary to measure the levels of follicle-stimulating (FSH) and thyroid-stimulating hormones, as well as prolactin.
Determining thyroid function will help identify hyper- and hypothyroidism. Under stress, examination of the mammary glands and vein puncture, there may be a moderate transient increase in prolactin levels returning to normal (700 mIU / l may result from PCOS or severe hypothyroidism (thyrotropin-releasing hormone stimulates prolactin secretion). Prolactin levels are greater than 1000 mIU / l when two consecutive measurements require further examination (for example, CT or MRI of the pituitary fossa) and may indicate microadenoma. A level above 5000 mIU / L usually accompanies the macroadenoma.
The third stage is the assessment of the estrogenic status of a woman. Determining the level of estradiol in serum is unreliable and is not recommended. More indicative of the evaluation of estrogenic status test with progesterone load. During this test, a woman is given medroxyprogesterone acetate orally at a dose of 5-10 mg for 5-7 days. Women with adequate levels of circulating estrogen and intact sexual ways develop withdrawal bleeding (positive test). If withdrawal bleeding does not occur, then most likely the level of circulating estrogen is low. A negative test can also result from endometrial abnormalities (Asherman syndrome) or genital tract obstruction. The reasons described above can be suspected on the basis of anamnesis and confirmed using a cyclic load with estrogen and progesterone (administration of COC for 1-2 months) or during hysteroscopy.
In order to distinguish hypothalamic or pituitary insufficiency from gonadal (ovarian) deficiency, an assessment of gonadotropin levels is used. As a result, you can get four conclusions. Low levels of FSH and LH on the background of a negative result of progesterone loading indicate amenorrhea due to physical exertion, weight loss and / or stress. Normal or slightly increased levels of gonadotropins, especially with an increased LH / FSH ratio, amid a positive test result with a progesterone load and a slightly increased level of androgens indicate PCOS.
What do you pay attention to when treating patients with secondary amenorrhea in general practice?
If a woman develops secondary amenorrhea, the general practitioner should:
- whenever possible to influence any probable reasons) ',
- to prevent complications of long-term estrogen deficiency,
- suspect, identify, and treat increased estrogen production (for example, endometrial or neoplastic hyperplasia),
- give advice on the ability to fertilize in the future and reduce psycho-emotional stress.
How should patients with hyperprolactinemia be treated?
In the presence of hyperprolactinemia, it is best to consult a specialist endocrinologist. MRI is recommended for the detection of prolactinomas. Bromocriptine is very effective in therapy: a decrease in the tumor is observed already after 6 months. after the start of the reception. Cabergoline is more expensive and easier to use than bromocriptine. The drug is usually well tolerated and effective in patients who do not respond to bromocriptine. In the case of drug resistance, surgical treatment is carried out.
What can a general practitioner advise a patient with premature ovarian depletion?
The diagnosis of premature ovarian depletion is established with amenorrhea, persistent estrogen deficiency and an increased level of FSH in a woman younger than 40 years old. The causes may be genetic, for example, carrier of the fragile chromosome X, and iatrogenic, for example, radiation or chemotherapy for a malignant disease (in both cases there is a certain potential to restore ovarian function). It is important to realize that before the final disappearance of oocytes and the development of persistent ovarian failure, ovarian function may fluctuate with a gradual increase in the irregularity of the menstrual cycles.
When should a general practitioner refer a patient to a specialist?
With secondary amenorrhea, the general practitioner should send for further examination:
- patients with hyperprolactinemia on CT or MRI,
- patients with premature ovarian depletion for screening for autoimmune diseases (for example, primary adrenal insufficiency in the presence of clinical indications). In patients younger than 30 years old, the need for chromosomal analysis should be considered,
- patients with low levels of gonadotropins, which cannot be explained by stress, exercise or weight loss.
What is the risk for a woman with secondary amenorrhea?
The combination of normal estrogenic status with anovulation increases the risk of endometrial hyperplasia (due to the relative excess of estrogens). Reception of gestagens within 10-14 days of each cycle or COC reduces this risk.
If a woman has hypoestrogenism (when amenorrhea develops as a result of hyperprolactinemia, premature ovarian depletion, weight loss, or increased exercise), other problems arise, primarily the risk of osteoporosis, and then cardiovascular diseases.
In women with secondary amenorrhea, prolonged estrogen deficiency can lead to infertility.
In women with hypoestrogenic amenorrhea, regardless of the cause that caused it, there is a decrease in the density of the lumbar vertebrae by 10-20% compared with women with a normal menstrual cycle. Therefore, all women with amenorrhea lasting more than 6 months. should receive estrogen replacement therapy. The most reasonable and convenient to prescribe such therapy in the form of COCs. Additional calcium supplementation (1500 mg / day) and maintaining normal vitamin D levels are also recommended.
The question of the risk of cardiovascular diseases in women with hypoestrogenic remains controversial. Little has been done to evaluate this risk. In one small paper that studied lipid levels in women with hypothalamic amenorrhea, it was shown that, unlike estrogen deficiency, menopause in young women with hypothalamic amenorrhea did not change high-density lipoprotein levels, and the amount of total cholesterol, low-density lipoproteins and triglycerides did not change.
What advice can be given about the possibility of conception in the future?
For a woman, amenorrhea is a sign that something is wrong in the body. Therefore, this condition can often be accompanied by significant anxiety, a violation of self-esteem. It is important for a woman with secondary amenorrhea to make it clear that if there is sporadic ovulation, pregnancy is still possible. For the same reason, if pregnancy is not planned, you should use contraception. Most women are usually concerned about whether they can become pregnant. Usually, treatment of the cause of amenorrhea is necessary to restore the ability to conceive.
Secondary amenorrhea - menstrual disorders, characterized by the absence of menstruation for 6 months or longer. Unlike primary amenorrhea, the secondary form develops in previously menstruating women. At the age of 16-45 years, the incidence of secondary amenorrhea, not associated with physiological causes (pregnancy, lactation, menopause), is 3-10% of cases. Secondary amenorrhea is one of the most difficult reproductive health problems, since women with such a disorder always suffer from infertility. Spontaneous cessation of menstruation indicates a serious dysfunction of the body, which may be in the plane of gynecology, endocrinology, psychiatry.
Classification of secondary amenorrhea
Among the secondary amenorrhea, its true and false forms are distinguished. At the heart of true amenorrhea is a violation of the neuroendocrine regulation of the menstrual cycle. False amenorrhea is diagnosed with the preservation of hormonal function of the ovaries and cyclic changes in the uterus, in this case, the absence of menstruation is associated with anatomical obstacles to the outflow of blood from the uterus and genital tract. With a false amenorrhea, blood can accumulate in the fallopian tubes (hematosalpinx), uterus (hematometra) or in the vagina (hematocolpos).
Depending on the level of gonadotropic hormones that regulate menstrual function, amenorrhea is divided into:
- hypogonadotropiccaused by organic lesions of the pituitary or hypothalamus,
- hypergonadotropiccaused by impaired ovarian function of genetic, enzyme, autoimmune or other etiology,
- normogonadotropicdue to uterus pathology, PCOS, psychogenic factors, malnutrition, debilitating physical exertion, hyperprolactinemia.
Forms of secondary amenorrhea
Regardless of the cause of secondary amenorrhea, common to all forms is the cessation of menstrual bleeding, which previously occurred more or less regularly, and infertility. The criterion is considered to be the absence of menstruation for 6 months or more in a row. The remaining symptoms are variable and depend on the form of secondary amenorrhea.
Psychogenic amenorrhea is additionally accompanied by asthenoneurotic, depressive or hypochondriacal syndromes. Patients noted increased fatigue, anxiety, sleep disturbances, a tendency to depression, decreased libido. Tachycardia, dry skin, and constipation may disturb. Menstruation stops suddenly, there is no oligomenorrhea period.
Amenorrhea on the background of weight loss is accompanied by a noticeable lack of weight, during a medical examination revealed hypoplasia of the mammary glands and genitals. Other signs of malnutrition include hypotension, bradycardia, hypothermia, hypoglycemia, and constipation. Appetite is reduced, persistent aversion to food and cachexia may occur, indicating the onset of anorexia.
Secondary amenorrhea in hypothalamic syndrome is combined with early puberty, obesity, hirsutism, the presence of acne and stretch marks on the skin, vegetative-vascular dystonia. Amenorrhea associated with hyperprolactinemia is characterized by spontaneous galactorrhea. Frequent complaints of cephalgia, dizziness, arterial hypertension. There are psycho-emotional disorders: mood variability, irritability, depressive reactions.
In ovarian forms of secondary amenorrhea, the disappearance of menstruation is often preceded by a period of oligomenorrhea. In patients with a history of early menarche, and often normal menstrual function. In resistant ovarian syndrome, menstruation stops at the age of up to 35 years, but the vegetative-vascular disorders characteristic of premature menopause are absent. Amenorrhea associated with ovarian exhaustion syndrome, in contrast, is accompanied by flushes, facial flushing, sweating, and headaches.
The defining symptom of false amenorrhea are spastic abdominal pain caused by the violation of the flow of menstrual blood. In chronic endometritis, menstrual irregularity develops gradually: with the passage of time, the intensity and duration of menstruation decreases until complete cessation.
Diagnosis of secondary amenorrhea
Secondary amenorrhea is diagnosed based on history and clinical presentation. However, a more difficult task for gynecologists, endocrinologists, neurologists, psychotherapists and other specialists is the differential diagnosis of the form of amenorrhea and the determination of its causes. When clarifying the gynecological status of the patient, the age of menarche, the nature of menstruation in the past, obstetric history, transferred gynecological and extragenital diseases, operations and injuries, heredity, nutrition, susceptibility to stress and other factors affecting menstrual function are taken into account.
In case of secondary amenorrhea, examination on a chair, functional tests (pupil symptom, basal temperature measurement, colpocytology), colposcopy, and pelvic ultrasound are required. As part of the differential diagnosis, pharmacological tests are widely used: with progesterone, estrogen and gestagens, clomiphene, gonadotropins. Hysterosalpingography and hysteroscopy are performed to detect intrauterine pathology. For ovarian forms of secondary amenorrhea, diagnostic laparoscopy is informative.
In order to identify hormonal disorders, a study of TSH, T4, insulin, LH and FSH, estradiol, progesterone, testosterone, prolactin, ACTH, cortisol, and other hormones is shown, taking into account the proposed option of secondary amenorrhea. If the pathology of the pituitary gland is suspected, a roentgenography of the Turkish saddle is performed, if indicated, a CT scan or MRI of the pituitary is performed. Consultation of an ophthalmologist with fundus examination (ophthalmoscopy) and visual field examination are included in the survey plan.
Treatment of secondary amenorrhea
Treatment options for secondary amenorrhea are closely related to its form. Therapy is aimed at eliminating the causes of amenorrhea, and if possible, restoring menstrual and reproductive functions.
Secondary amenorrhea caused by weight deficiency or anorexia is treated in conjunction with psychotherapists and nutritionists. Patients are prescribed a high-calorie diet with frequent fractional meals, sedatives, multivitamins, and psychotherapy. If on this background there is no spontaneous recovery of the menstrual cycle, hormone therapy is prescribed for 4-6 months. Patients with a psychogenic form of amenorrhea are recommended to exclude provocative factors, to normalize working and rest conditions. Physiotherapy courses are shown: endonasal electrophoresis, ShVZ massage, balneotherapy.
If the cause of amenorrhea is hypothyroidism, thyroid hormones are used in long courses. Patients with hyperprolactinemia have been shown to take bromocriptine, cabergoline and their analogues. Detection of the pituitary macroadenoma on the results of the examination is the basis for surgical or radiation treatment.
Therapy of ovarian forms of secondary amenorrhea is the appointment of cyclic hormone therapy, low-dose COCs. When an ovarian tumor is found, oophorectomy or adnexectomy (removal of appendages) is required. When atresia of the cervical canal produce his bougienage. Treatment of uterine cavity synechiae is surgical, using hysteroresectoscopy. In infectious processes, etiotropic antibiotic therapy is indicated. In the future, to improve the metabolic processes in the uterus, it is advisable to conduct physiotherapeutic procedures - ultrasound, electrophoresis, diathermy on the pelvic area.
In most cases, with the help of properly organized treatment, it is possible to achieve the resumption of menstruation. The prognosis for the restoration of reproductive function depends on the form of secondary amenorrhea. With persistent infertility, a fertility specialist consultation is recommended. Modern reproductive technologies allow in vitro fertilization (according to the method of IMSI or ICSI), if necessary using donor sperm, a donor egg or a donor embryo. To increase the chances of pregnancy after artificial insemination and the successful embryological stage, cryopreservation of embryos is performed with their subsequent thawing and replanting into the patient's uterus. Chronic miscarriage is an indication for the use of surrogate motherhood.
Types and features
Puberty is a stepwise process. At the first stage, the girls begin to change the bookmarks of the mammary glands (the areolar region swells and darkens). After that, body hair appears in the genital and axillary areas, and whites begin to stand out from the genital tract. In parallel with this, the psyche of the child, the perception of others, etc., are changing. The final stage of puberty is the establishment of menstrual function.
The first periods are normal should go to the girl not earlier than at 9, but not later than 16 years. Also, these parameters may slightly shift due to constitutional and national characteristics.
In the case when there are no monthly periods after reaching the age of 16, one should speak of primary amenorrhea. The reasons for the development of this state are many - from malformations to the pathology of the central nervous system.
It is important to know that for two years from the beginning of the menstrual function, the girl may experience various irregularities in the menstrual cycle, it does not always immediately determine the frequency from 21 to 35 days and the normal duration of critical days up to 3-5 days. Both delays and shortening of the period are possible - the body becomes accustomed to new conditions. But any such failures should not be present after two years from the beginning of menarche.
Causes of Amenorrhea
The final determination of why the girl had irregularities in the menstrual cycle can only be done by a specialist after at least a minimal examination. But the sooner the problem is fixed, the more likely it is to solve it in the most favorable way, with the possibility of further birth of healthy children.
The following four groups of causes for amenorrhea can be distinguished:
- Various kinds of functional disorders, which are not always easy to handle. But the main thing is that in this case there are no problems in the structure and main work of the sex glands and the structures associated with them.
- Disruption of the pituitary or hypothalamus. These can be either acquired problems or congenital ones.
- Disruption of the development of the gonads. In this case, the appearance of a practically healthy girl is observed with a serious change in her genetic material.
- Detection of malformations of the genitals themselves.
Look at the video about the symptoms and causes of amenorrhea:
Especially in girls during the period of formation of sexual function, the work of all organs depends on her lifestyle and the genetic material obtained. Amenorrhea can be caused by the following:
- The constitution of the girl. So, if a delay in sexual development was observed in one of the closest relatives, both in the female and in the male line, and without disturbing the reproductive function and any other deviations, the likelihood of the child is high. During the examination, no deviations are observed. In this case, the first menstruation often occurs at the age of 18. Such girls differ from their peers by some infantilism, although the genitals are developed in accordance with age. This is always the primary amenorrhea in adolescents.
- Against anorexia. It is known that when there is a shortage of nutrients, the body tries to reduce all its functions, including the reproductive system, because it takes a lot of strength and energy to bear and give birth to a healthy baby. It should also be borne in mind that adipose tissue is involved in the metabolism of estrogen, and its deficiency leads in addition to various disorders. As a result, there is a functional amenorrhea.
Disruption of the pituitary and hypothalamus
The pituitary and hypothalamus secrete a large number of active substances that regulate the functions of many organs. As for the ovaries, these are gonadotropins. Also, the pituitary gland secretes prolactin, which is responsible for the transformation of the mammary glands during breastfeeding. Disruption in the formation of these substances and changes in the sensitivity of tissues lead to disruptions of the menstrual cycle:
Changing the genetic material of girls
Often, before the onset of puberty, it is difficult to notice any abnormalities in the genetic material. Adolescent amenorrhea becomes a reason for in-depth examination, as a result, pathology is determined. Normally, the set should be XX. Changes may be as follows:
- Shereshevsky-Turner syndrome is due to the presence of only one X chromosome. This pathology occurs in one of 2,000 to 4,000 newborn girls. This is characterized by a low growth of girls, a thick neck with winged folds. Sexual signs are not expressed or weakly visible, the mammary glands are not developed. This is due to the fact that instead of the ovaries there is only their imitation of connective tissue, and, accordingly, there are no necessary hormones.
- Svayer syndrome and testicular feminization are characterized by the fact that, according to external signs, the girl is defined as having a lag in sexual development, and in the study of genetic material - male data, i.e. Xy. But while there are no sex hormones in the blood. Most often, prior to the period of the pubertal, pathology is not defined due to the absence of specific symptoms. After clarification of self-determination and sensation, hormone replacement therapy and sometimes surgery are necessary.
- The syndrome of resistant ovaries is caused by a sharp decrease in the sensitivity of the latter to the pituitary LH. This is due to gene mutation. As a result, girls with normal development of the external and internal genital organs have problems with menstruation - primary or secondary amenorrhea in adolescence. These changes lead to infertility due to the lack of ovulation.
- Defect in the work of some enzymes leads to impaired formation of sex hormones and corresponding clinical changes. Normally, estrogens are formed from androgens, and if this does not occur, then signs of virilization appear - increased male type hair growth, an increase in the clitoris, and others.
- Polycystic ovary syndrome (Stein-Leventhal) also leads to varying severity of amenorrhea. But the true nature of the pathology is not clear. The disease is multifaceted, manifested by varying degrees of cystic changes in the ovaries, hormonal disturbances and infertility.
Malformations of the genitals
With normal general well-being and good ovarian function in girls, various genital malformations can be observed, and therefore secondary amenorrhea will be observed. The main defects associated with the following changes:
- Underdevelopment of the upper part of the vagina and uterus. In this case, the lower third allows you to even lead a normal sex life. Pregnancy in such cases is possible only with the use of IVF, in particular, surrogate motherhood.
- Atresia (contraction and fusion) of the cervical canal, vagina, as well as an excessively dense hymen. In such situations, the girl's menstrual blood is formed, but can not leave the uterus or vagina. Monthly accumulations of discharge cause pulling pain in the lower abdomen in girls, sometimes with very intense temperament. During examination, including ultrasound, these changes are clearly visible and do not cause any particular difficulties.
Treatment of amenorrhea in adolescents directly depends on the cause of it.
Combined therapy in some cases can restore menstrual function and even normalize reproductive potential. But some variants with genetic changes, violation of the development of the genitals, sometimes require serious surgical interventions.
The main directions of conservative treatment are as follows:
- Cyclic vitamin therapy, as well as homeopathy and herbal remedies. For example, cyclodinone, time factor, cyclovite and others are often used. They are especially effective in functional disorders caused by stress, changes in nutrition, constitutional features and in the presence of metabolic pathology, for example, diabetes, etc.
- Parents should organize the most comfortable conditions for a girl’s life: if necessary, reduce physical and mental stress, balance nutrition, etc.
- Sedatives, ranging from plant fees to antidepressants, help to overcome functional impairment caused by anorexia and other diseases. It is important for the normalization of connections between the pituitary, hypothalamus and genital organs mental balance. Adaptogens (Eleutherococcus, Ginseng, and the like) are prescribed for the same purpose.
- Preparations to stimulate the proper function of the ovaries, for example, methionine, glutamic acid and others.
- Often, hormone replacement therapy with regular oral contraceptives is prescribed on an ongoing basis. Such treatment is necessary to imitate menstrual function and preserve health in case of ovarian failure or anomalies associated with it.
Amenorrhea in adolescence is a serious pathology, which must be immediately paid attention to and try to identify the cause of the violations. The sooner the treatment is started, the higher the chances of maximum social adaptation for genetic and other serious defects. Saving or recreating reproductive function is possible, unfortunately, not always.
The main causes of amenorrhea 
- Functional delayed sexual development.
- Congenital or acquired anomalies of the central nervous system and hypothalamic-pituitary structures that cause impaired secretion of luteinizing releasing hormone (LH-RG) and / or gonadotropins (FSH and LH).
- Malformations of the gonads.
- Malformations of the external and internal genitalia.
In the clinic, constitutional and functional forms of amenorrhea are more common.
Functional delayed sexual development
Constitutional delayed sexual development (CPRD). Primary amenorrhea can be one of the symptoms of a PDR. In this case, later menarche could be the mother, late sexual development in the father and other immediate relatives.
The nature of the functional delay in puberty remains unclear. The key condition for the start of puberty is the pulsed nature of the secretion of LH-WG, which activates the release of gonadotropins. An important role in this is taken by the central nervous system and subcortical structures, which can lead to late activation of this mechanism.
Girls are stunted behind their peers. Pubertal leap extended over time (from 14 to 18 years). Body weight corresponds to the actual height. Appearance - infantile. The bone age lags behind the passport by 2–3 years. External and internal genitalia correspond to biological age.
With a long delay in puberty, eunuchoid body proportions can form. Especially often this is observed in adolescents with obesity.
An extremely important symptom, accompanied by the CPR, is a decrease in bone density and a decrease in its mineralization. Later menarche in adolescent girls is a risk factor for osteoporosis.
Anorexia nervosa. One of the symptoms of anorexia nervosa is primary amenorrhea. Anorexia nervosa is predominantly found in girls of puberty and in the postpubertal period. Patients refuse to eat or, after eating, artificially induce vomiting, take laxatives and enemas. They form a pathological conviction of overweight and an obsessive desire to lose weight. Refusal to eat leads to pronounced weight loss, including cachexia and various somatoendocrine disorders. From clinical symptoms can be noted bouts of hypoglycemia. The skin is dry, turgor reduced, abdominal pain, quick mood changes .
Anorexia nervosa is characterized by a sharp decrease in the secretion of gonadotropic hormones by reducing the frequency and amplitude of the pulsed LH secretion, as well as by weakening the activity of gonadotropic releasing hormone, which leads to menstrual dysfunction. Along with a decrease in the secretion of gonadotropic hormones, a violation of the metabolism of sex hormones occurs, which is manifested by hypoestrogenemia. Changes in estrogen metabolism during anorexia nervosa are likely to be non-specific and are associated with changes in body weight or diet. It is the hypoestrogenic condition in patients with anorexia nervosa that underlies their susceptibility to osteoporosis. Its severity is determined by the duration of hypoestrogenemia. In connection with disorders of the metabolism of gonadotropic and sex hormones, patients with hormonal anorexia nervosa return to the prepubertal state. In this case, a violation of reproductive function should be considered as a defensive reaction in the conditions of food deficiency and mental stress. Therefore, to restore the age-related secretion of gonadotropic releasing hormone, it is necessary to achieve ideal body weight and eliminate mental stress. Along with hypoestrogenemia, anorexia nervosa is characterized by an increase in blood cortisol (adrenal hormone) with the release of its excess amount with urine, as well as a decrease in thyroid hormone thyroxine (T4) and triiodothyronine (T3). The lack of caloric intake in anorexia nervosa can cause an increase in growth hormone (GH) levels. The disease is associated with the pathological formation of the personality, or it is one of the manifestations of schizophrenia.
Most patients go to the doctor before the development of severe eating disorders. In such cases, the cure can occur spontaneously, without medical intervention. If, nevertheless, patients need medical care, then it traditionally includes psychoanalysis, psychotherapy, instructing family members and forced feeding of girls. Regardless of the applied methods of treatment, the condition of the majority of patients improves and their body weight increases. Regular physical activity dramatically increases the level of estrogen, which has a positive effect not only on menstrual function, but also on bone density .
However, there are situations when anorexia nervosa threatens the lives of patients. In severe cases, when body weight is reduced by 40% or more, immediate forced parenteral feeding is required (intravenous administration of glucose and protein-fat solutions).
Amenorrhea can occur in girls also with high physical exertion that does not correspond to physical abilities: sports, dancing, etc.
Hyperprolactinemia. The cause of amenorrhea may be hyperprolactinemia. Prolactin secretion is regulated by the hypothalamus, which produces prolactoliberin and prolactostatin (dopamine). In addition, thyroid stimulating hormone (TSH) and vasoactive intestinal peptide stimulate the secretion of prolactin.
Патогенез гипогонадизма при гиперпролактинемии обусловлен, прежде всего, подавлением импульсной секреции ЛГ-РГ, избытком пролактина и отрицательным влиянием на процессы стероидогенеза в гонадах. Нарушение гипоталамической регуляции секреции пролактина — снижение дофаминергического влияния или усиление продукции пролактолиберина — приводит к гиперплазии лактофоров гипофиза с возможным развитием микро- и макроаденом.
The earliest symptom of hyperprolactinemia is a violation of the menstrual function, which is the reason for the treatment of patients to the doctor. Examination allows in some cases to identify a pituitary adenoma at the stage of microadenomas. According to the data of the Pediatric Clinic of the Endocrinological Research Center of the Russian Academy of Medical Sciences (Moscow), prolactinomas account for 22% of the pituitary adenomas diagnosed . More often, they were detected in girls during puberty and manifested as a syndrome of primary amenorrhea.
Hyperprolactinemia is found in tumor diseases of the hypothalamus and pituitary, damage to the pituitary stalk, the syndrome of "empty Turkish saddle", as well as injuries and inflammatory processes of the skull base.
Primary amenorrhea as a consequence of hyperprolactinemia occurs in some endocrine diseases: primary hypothyroidism, gigantism, congenital dysfunction of the adrenal cortex (VDCH). Hyperprolactinemia on the background of hypothyroidism develops in response to a decrease in the level of thyroid hormones and an increase in the secretion of thyroliberin. Given that thyroliberin is one of the main factors stimulating both secretion of prolactin and TSH, increasing its concentration leads to hypersecretion of these two hormones. The cause of gigantism can be mixed adenoma, which secretes not only the somatotropic hormone, but also prolactin.
Therapy of this group of patients should be directed to the adequate treatment of the underlying disease, which normalizes the secretion of prolactin, and therefore leads to the normalization of the menstrual cycle .
Congenital or acquired anomalies of the central nervous system and hypothalamic-pituitary structures that cause impaired secretion of LH-WG or gonadotropins
Kalman syndrome, First described in 1944, it is characterized by hypogonadotropic hypogonadism and anosmia (lack of smell). It occurs in the form of sporadic and familial cases. It was found that the disease is due to selective deficiency of GnRH. A gene responsible for the translocation of neurons secreting GnRH has now been identified.
In girls, there is minimal development of secondary sexual characteristics and primary amenorrhea. The body type is usually of eunuchoid type, the arm span exceeds the height of the patient by 5 cm or more. Despite the delayed maturation of the skeleton, the rate of linear growth is usually normal (except for the absence of a distinct “pubertal jerk”). The final growth of patients does not suffer, since the growth zones remain open up to 18 years or more. As for anosmia, patients may not even be aware that they have it. Anosmia is a consequence of hypoplasia or aplasia of the olfactory bulbs and the olfactory tract. Other congenital malformations can also be combined with this syndrome (sensory deafness, brachydactyly, optic nerve atrophy, horseshoe kidney).
The content of the pituitary hormones, with the exception of gonadotropins, is normal. The basal level of FSH and LH is reduced. Most have no pulsating secretion of LH. Gonadotrophs do not respond to the introduction of lyulberin with LH release, and it remains at the pre-pubertal level, as well as sex steroids.
Adipose-genital dystrophy (Pehrants – Babinsky – Fröhlich syndrome). The disease is associated with damage to the hypothalamic-pituitary system of various origins, resulting in uncontrolled obesity at 6–7 years of age and hypogonadotropic hypogonadism during puberty. In addition to obesity, girls at the age of 14 lack menstruation. External and internal genitalia have pre-pubertal size. Bone age lags behind the passport.
Adolescent girls do not develop enough mammary glands. The pubic and axillary coat is scanty.
Intellect is age appropriate.
Lawrence – Munay – Bardé – Beadle Syndrome. Hereditary disease characterized by hypogenitalism, obesity, retinal pigment degeneration, mental retardation and polydactyly. The type of inheritance is autosomal recessive. Currently, 18 genes are known, the mutation of which can lead to the development of the syndrome. The basic sign of this disease is retinitis pigmentosa, polydactyly. There are also abnormalities in the development of internal organs: heart defects, kidneys. In the gonads reveal sclerosis, hyalinosis.
Obesity, appearing in the 1-2 years of life, is progressing rapidly. Organic signs of damage to the central nervous system manifest themselves in the form of extrapyramidal disorders, seizures, and severe mental retardation.
The prognosis is unfavorable. Patients die from concomitant diseases or renal failure. The probability of re-birth of a sick child is 25%. It is assumed that in Lawrence-Mune-Bardé-Bidley syndrome, primary amenorrhea is associated with impaired production of gonadotropin-releasing hormone .
Malformations of the gonads
Shereshevsky – Turner syndrome (SShT) is a chromosomal disease caused by complete or partial X-monosomy. It occurs with a frequency of 1: 2000–1: 4000 newborn girls. The absence of one X chromosome leads to disruption of the transformation of the primary gonads into the ovaries. It has been proven that two X chromosomes are necessary for the normal development of the ovaries and the formation of primordial follicles.
Gonads with this syndrome are undifferentiated connective tissue strands. In this regard, 95% of adolescents revealed sexual infantilism. Dysgenetic ovaries insufficiently produce sex steroids. In patients with UWD, the uterus and vagina are formed correctly, but hypoplasia of the small and large labia is possible. During puberty, secondary sexual characteristics are absent: the mammary glands are not developed. Pubic and axillary pilosis scarce. Characterized by primary amenorrhea. Ovarian insufficiency is accompanied by increased levels of FSH and LH.
Typical for UWD is short stature (height does not exceed 135–145 cm) and a short neck with winged folds. Changes in the skeleton are manifested in the form of valgus limb deformities, shortening of the cervical vertebrae, underdevelopment of the facial skeleton and high palate.
More than 30% of patients detect heart defects, kidneys, organs of vision.
The diagnosis of SShT is based on the detection of the 45 XO karyotype or the 45 X / 46 ХХ mosaic variant.
Swan Syndrome - “pure” gonadal dysgenesis. This syndrome is characterized by a female phenotype in individuals with a 46XU karyotype. Mutations in the SRY gene (an English sex-determining region on Y-chromosome), which determines sex at 4–6 weeks of gestation, cause the formation of dysgenetic gonads. The latter do not synthesize testosterone and the anti-Mullerian factor according to the genotype. Internal genitals are formed by the female type (uterus, fallopian tubes).
Most often, pathology before puberty is not diagnosed.
During puberty, adolescents lag behind in sexual development: the mammary glands do not develop, menstruation is absent, but these patients have normal or slightly increased final growth. Hair growth, pubic and axillary, which depends on the hormones of the adrenal glands, is weakly expressed. The examination revealed an increase in LH and FSH, a decrease in the level of sex steroids in the blood serum .
During puberty, estrogen replacement therapy is recommended. Dysgenetic gonad should be removed.
Resistant ovary syndrome (defect of LH receptors). An inactivating mutation of the LH receptor gene leads to a blockade of LH exposure to the cell. The disease is inherited in an autosomal recessive manner.
The formation of internal and external genitalia corresponds to the female type. Puberty can begin at the usual time. But menstruation comes late and scanty. Some girls may experience primary amenorrhea. The main symptom of resistant ovaries is the lack of ovulation and infertility.
During the examination, a sharp increase in the level of LH is registered, moderate hypoestrogenesis (in girls, the main stimulator of estrogen secretion is FSH, and in ovulation LH plays the main role). Ultrasound does not reveal any specific changes.
Enzyme deficiency P450s17. This enzyme is necessary for the synthesis of cortisol and androgens (dehydroepiandrosterone and androstenedione). Enzyme P450s17 is encoded by the CYP17 gene. Mutation of this gene leads to blockade of the biosynthesis of cortisol in the adrenal glands and sex steroids in the adrenal glands, ovaries and testicles. In individuals with a male karyotype, the inactivating mutation of this gene leads to pronounced manifestations of hermaphroditism, i.e., the absence of sex steroids leads to feminization of the structure of the external genitalia, glucocorticoid insufficiency, increased blood pressure caused by excessive secretion of mineralcorticoids. Internal genitals are not differentiated.
The defect of this enzyme system in the pubertal period is manifested by a picture of hypogonadism, and therefore, adolescent girls lack menarche.
Testicular feminization syndrome (Morris syndrome). The frequency of occurrence is 1: 5000. The disease is caused by a violation of the action of testosterone in target tissues, which, above all, include urogenital sinus tissue. All patients with this syndrome have a male genotype (46 XY) and a female phenotype.
In patients during the embryonic period, the gonads do not transform into normal testes producing testosterone, but Sertoli cells secrete a sufficient amount of an anti-Mullean hormone that promotes the regression of the Mullerian ducts.
The external genitalia are formed according to the female type. The gonads are located in the abdominal cavity or in the inguinal canals. Before puberty, the diagnosis is made by chance, in connection with an operation for an inguinal hernia, where undeveloped atrophic testicles are found.
In the pubertal period, the female phenotype is formed, the mammary glands are well developed, hair growth in the pubic and axillary regions is absent. At this time, the reason for the survey is "primary amenorrhea."
The final growth in these patients is above average. Internal "female" genitals - the uterus, fallopian tubes, the upper part of the vagina - absent.
In the blood, high testosterone and estradiol levels are detected. The increase in estradiol, sufficient for the realization of the female phenotype, is associated with the peripheral conversion of testosterone into estrogens.
Atrophic testicles that are prone to malignancy should be removed. Starting from puberty, substitution therapy with female sex hormones is performed.
Aromatase deficiency. Aromatase is an enzyme necessary for the conversion of testosterone to estradiol (E2) and androstenedione to estrone (E1).
The lack of aromatase in girls leads to a lack of estrogen-dependent signs of puberty and the emergence of androgenization symptoms.
In newborn girls (XX) symptoms of virilization of the external genitalia are noted (clitoral hypertrophy, labial suture fusion).
In the pubertal period, girls with aromatase deficiency lack breast augmentation and menstrual function. Symptoms of virilization increase. Polycystic changes are observed in the ovaries.
In laboratory studies, high levels of testosterone, androstenedione, dehydroepiandrosterone and its sulfate are detected. Estrogen levels are significantly reduced. Gonadotropic hormones are elevated. In genetic studies, a mutation of the CYP19 aromatase gene is detected.
Estrogen therapy has a positive effect on the development of the mammary glands and the appearance of menarche.
Stein – Leventhal Syndrome (sclerocystic ovary, polycystic ovary). The disease, which is based on the process of cystic degeneration of the ovaries. It is characterized by oligo- or amenorrhea, overweight, hirsutism, acne, alopecia, enlarged, polycystic ovaries and anovulatory cycles .
The pathogenesis of the syndrome is not fully understood. It occurs in 1.4–2.5% of girls surveyed for amenorrhea. Current evidence suggests that several factors are involved in the formation of polycystic ovary syndrome (PCOS). This is a violation of the secretion of sex steroids in the ovaries, a violation of the hypothalamus – pituitary – ovaries, a violation of the synthesis of androgens in the adrenal glands, ovaries, receptor disorders in the cells of the effectors for these hormones involved in the implementation of biological effects. A certain contribution to the development of PCOS is made by insulin resistance, which is associated with a violation of the action of insulin at both receptor and post-receptor levels, as well as with hyperprolactinemia.
The disease is detected during puberty in connection with irregular menstruation (primary or secondary amenorrhea). At the same time, hirsutism of varying severity develops. Hair growth can be over the upper lip, around the nipples of the mammary glands, along the white line of the abdomen, on the thighs. Most patients have varying degrees of obesity. The external genitalia are formed according to the female type. Only in some patients, elevated androgens cause an increase in the clitoris.
The diagnosis is confirmed by an increase of almost 2 times LH, with a normal or even reduced level of FSH. The ratio of LH / FSH is always increased. Half of the patients increased testosterone and dehydroepiandrosterone sulfate, in one third - prolactin. Conducting a test with gonadoliberin causes a hyperergic reaction with a sharp increase in LH and a lack of response from FSH. A dynamic study of the hormones LH, FSH, estrogen, progesterone reveals monotonous indicators, which confirms the absence of an increase in rectal temperature. This is indicative of anovulatory cycles.
With ultrasound (ultrasound), the ovaries are enlarged, the capsule is dense, the stroma is well defined, and numerous cysts are found.
Malformations of the external and internal genitalia
Mayer – Rokitansky – Kyustner syndrome meets with a frequency of 1: 4500 newborn girls. There are sporadic and familial cases. The type of inheritance is autosomal dominant.
For the first time, the disease can be detected during the examination of mature girls in connection with primary amenorrhea. The syndrome is characterized by congenital aplasia of the uterus and the upper third of the vagina in patients with a female phenotype and with a 46XX karyotype. A study using ultrasound determines the absence of the uterus and its appendages or their rudiments. Ovaries of normal size. The content of sex steroids and gonadotropic hormones in the blood is normal. This syndrome can be combined with congenital defects of the kidneys, heart, skeletal abnormalities.
False amenorrhea is associated with abnormal development of the internal and external genitalia.
Amenorrhea can develop in the presence of well-developed ovaries, uterus and normally occurring changes in them. This type of amenorrhea is observed with atresia of the vagina, overgrowth of the uterine pharynx as a result of inflammatory changes, completely overgrown virginal membrane. The clinic noted cyclic pain in the lower abdomen, lower back. With rectal examination, hematocolpos, hematometer can be detected. These changes can dissolve before the next menstruation. Surgical treatment.
So, the complex of diagnostic measures for juvenile amenorrhea should include the measurement of height, body weight, the ratio of the upper and lower body segments, X-ray of the skull, computed tomography or magnetic resonance imaging of the brain, bone marrow examination (X-ray of the hand to assess ossification and growth zones ), karyotype determination, blood test for hormones: levels of cortisol, testosterone, dehydroepiandrosterone sulfate, estradiol, prolactin, progesterone, LH, FSH, TSH, T3, T4, GH.
Ultrasound of the pelvic organs is necessary: determination of the degree of development of the uterus, ovaries, the presence of cavity follicles in them. The study of the fundus, visual fields is carried out to clarify the state of the optical-chiasmatic region.
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- Osvyannikova T.V., Makarov I.O., Kamilova D.P., Khachatryan A.M. Hyperprolactinemia: modern approaches to diagnosis and treatment // Gynecology. Journal for medical practitioners. 2011, No. 6, T. 13, p. 4–7.
- Lilin E. T., Bogomazov E. A., Goman-Kadoshnikov P. B. Genetics for doctors. M .: Medicine, 1990.
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V.V. Smirnov,doctor of medicine, professor
A. G. Zubovskaya
GBOU VPO RNIMU them. N.I. Pirogov, Moscow
Causes of primary amenorrhea in adolescents
Complaints about the absence of menstruation during puberty are not a frequent reason for going to the gynecologist, although they can be a manifestation of serious diseases. Causes of primary amenorrhea are divided into three main groups:
- отсутствие менструаций вызвано анатомическими особенностями подростка,
- патология обусловлена наследственными факторами,
- problems with the menstrual cycle were the result of emotional and psychological disorders.
The anatomical causes of primary amenorrhea often occur even in the prenatal period, when the girl's genitals begin to form.
In some cases, during the first gynecological examination, the adolescent is found to have a very narrow or completely closed entrance to the vagina. Such anatomical features do not allow menstrual blood to come out, so it accumulates in the uterus, which is fraught with the emergence and development of inflammatory processes in the organs of the genitourinary system. Also such a development of pathology can cause inflammation of the peritoneum and other dangerous consequences.
Primary anatomical type of anatomical type is usually peculiar to girls with a lack of weight and insufficiently developed secondary sexual characteristics. For accurate diagnosis it is necessary to make an ultrasound of the pelvic organs.
Genetic causes of primary amenorrhea are also often identified at the first visit to the gynecologist. Sometimes when collecting the history, it turns out that the adolescent’s family has the same deviations from close relatives, for example, the mother or older sister had a late onset of menstruation.
Genetic abnormalities in amenorrhea are associated with damage or inferiority in the 23rd pair of X chromosomes, which are responsible for the functioning of the ovaries.
In recent years, gynecologists are increasingly confronted with cases in which adolescents who complain about the absence of menstruation do not show any hereditary or anatomical factors in the occurrence of amenorrhea.
During the examination, about a third of all girls with menstrual disorders reveal psycho-emotional problems, constant stress, excessive physical exertion, for example, playing professional sports, anorexia, excessively strict diets for weight loss. Many of them cycle back over time without medical intervention, but sometimes they require skilled medical care.
This form of amenorrhea is called “central”; it is caused by problems in the hypothalamus, one of the functions of which is to control menstrual function. In rare cases, a brain tumor can be a factor in the occurrence of central amenorrhea.
In general, the causes of primary amenorrhea can be formulated as follows:
- abnormalities in the development of the uterus and gonads (gonadal dysgenesis),
- genetic pathology in which girls have one X chromosome is missing or damaged (Shereshevsky-Turner syndrome),
- lack of sensitivity of tissues to male sex hormones, when the set of chromosomes in girls corresponds to the male (textual feminization syndrome),
- problems with the hypothalamus,
- pathologies of prenatal development that caused vaginal fusion,
- anorexia, wrong diet,
- excessive exercise
- constant stress, nervous tension.
To determine the cause of primary amenorrhea will allow a thorough comprehensive examination of a teenager.
And here more about ovarian dysfunction.
Symptoms of pathology
The main difference between amenorrhea and other female diseases is the absence of menstruation for six months or more, but against the background of this there are always signs of the pathologies that caused the development of this phenomenon:
- If the primary amenorrhea is caused by anatomical problems, blood accumulates in the uterus, which causes severe cramping in the lower abdomen. These pains appear cyclically in those days when menstruation should begin, and last an average of 2 to 3 days. Accompanying symptoms are headache, nausea, an increase in the mammary glands and an increase in their sensitivity.
- If the absence of menstruation is associated with neoplasms in the pituitary gland, girls have increased irritability, an unstable emotional state, mood swings, headache and other psycho-emotional disorders.
- At primary amenorrhea of a genetic nature, underdevelopment of genital organs is found in girls of puberty. Often, adolescents are different from peers too tall, long limbs with a rather short body.
- If the pathology is caused by disorders in the ovaries, its symptoms may be overweight, acne, too noticeable hair on the body and face, elevated levels of insulin in the blood. This form of primary amenorrhea is fraught with the development of osteoporosis.
The complex of identified symptoms of primary amenorrhea allows the doctor to determine the tactics of treatment depending on the nature of the disease that caused this pathology.
For the causes of primary amenorrhea, see this video:
Treatment of primary ovarian amenorrhea and others
The complexity of the therapy of this pathology depends on the reasons for it. So, if amenorrhea is associated with a lag in the development of the reproductive system, the girl needs to adjust her lifestyle and diet. Assigned to a special diet rich in nutrients, in order to increase muscle mass and build fat tissue.
At the same time, the doctor prescribes a course of hormone replacement therapy to stimulate the development of secondary female sexual characteristics. Correction of hormonal background allows you to stimulate the onset of menstruation and normalize the cycle. Assign hormones and develop a treatment regimen can only be a doctor based on the analysis of hormones.
If menstruation is absent due to congestion of the vagina or hymen, as well as caused by other anomalies in the anatomical structure of the adolescent, surgical intervention is shown.
Dissection of the hymen
This operation is simple, carried out on an outpatient basis, is usually performed without anesthesia and does not pose any danger to the girl. The surgeon must make a small incision of the tissue that closes the entrance to the vagina; menstrual blood will subsequently be released through this opening.
Sometimes for complete recovery of the genital organs may require plastic vagina.
In other forms of primary pathology, the so-called true amenorrhea, the treatment is much more complex and long, and the prognosis is rarely favorable. So, in the absence of an ovary or uterus in the girl's body, she will forever be fruitless, since it is impossible to restore these organs.
In other cases of true amenorrhea, the success of therapy depends on how timely the pathology is detected, how appropriate the treatment is prescribed.
Almost all disorders in the reproductive system that caused the absence of menstruation in adolescents require long-term and systemic complex hormonal therapy. For example, if amenorrhea is caused by chromosomal abnormalities (Turner syndrome), the girl will have to take female sex hormones, estrogens, for life.
This pathology minimizes the likelihood of natural conception, although systemic therapy allows for the normal development and functioning of the genital organs. Pregnancy is most often possible with the use of a donor egg after the IVF procedure.
If there are problems with the pituitary and hypothalamus, as well as with Kallman's syndrome, hormone replacement therapy is also shown to the girl, and when the standard climax age is reached, the woman is removed the ovaries from the abdominal cavity. This form of primary amenorrhea is one of the most severe, since pregnancy is in principle impossible due to the absence of a uterus.
The complex treatment of primary amenorrhea necessarily includes drugs to strengthen the nervous system, recommendations for proper and balanced nutrition, vitamin complexes and fortifying agents.
And here more about genital herpes in women.
Primary amenorrhea is not considered a separate disease, but is a consequence of various anomalies of the development of the female body and requires close attention from parents and doctors.
Many of the symptoms of pathology occur in girls at an early age. If parents notice any deviation in the development of sexual characteristics in a teenager, they should immediately consult a doctor, since early diagnosis gives a chance for recovery and the possibility of having children in the future.
On the links of the regulation of the menstrual cycle, see this video:
Vulvitis develops, the symptoms and treatment of which can often be determined only by a physician, due to improper hygiene, viruses and bacteria. Causes of acute condition can be found in the sexual partner. The treatment is carried out with ointments, drugs, at home apply douching.
If algodysmenorrhea is detected in girls, treatment should be started as soon as possible. It is primary and secondary, adolescents are often diagnosed with “NMC-type syndrome”, women are secondary. Symptoms - acute pain during menstruation, changes in emotional background. Help drugs, pills, exercise therapy.
Because of unprotected and active sex with different partners, you can get STD infections. Their list is quite extensive, and the symptoms at the beginning are invisible to many. What are the hidden infections in men and women? How to treat, if it does not work out?
Vaginal candidiasis is quite common among adult women, but can also occur in girls. The reasons are quite extensive, it is not always possible to establish the source. The symptoms of thrush are the discharge of curd consistency and smell. Drugs than to treat the infection in an acute condition are selected by a doctor. But diet will help avoid complications.
Amenorrhea in adolescents
The complete absence of menstruation over several cycles is defined as amenorrhea. Its development is not associated with the onset of pregnancy, lactation, or physiological menopause. This pathological condition is a signal of health about the presence of disorders in it.
Amenorrhea in adolescents suggests that the genital system of girls of this age has not reached its maturity. The beginning of the reproductive age of a woman falls on 9-16 years, during this period is the first menstruation (menarche). Girls with low weight have their first menstruations at 13-14 years old, and their full contemporaries earlier - at 9-12. Talk about amenorrhea is, if a teenager in 16 years of menstruation does not occur. It is the elucidation of the cause that prevents the onset of the menstrual cycle, the gynecologist is engaged in during the diagnosis and, on the basis of the factor that influenced the disease, he prescribes treatment. They are divided into several categories and are anatomical, endocrine, neurosurgical, so it is important to emphasize that amenorrhea is not a separate disease, but acts as a manifestation of an existing pathology.
There are common causes of amenorrhea in adolescents:
- Postponed surgery on the reproductive organs.
- Chromosome abnormality.
- Violation of the structure of the genitals.
- The impact of harmful factors on a woman's body during her pregnancy (if the expectant mother did not give up bad habits or was subjected to other intoxications during pregnancy, it is likely that the maturation of her daughter’s sexual system will be delayed).
Primary amenorrhea in adolescents rarely serves as the main complaint of seeking medical help. To a greater extent, the mothers of girls are concerned when the first menstrual flow of the daughter has stopped, after a certain period of time after the onset. This phenomenon in gynecology is called “secondary amenorrhea in adolescents” and it develops if there is a constant effect of stress, malnutrition and the associated weight loss, if a brain injury or brain pathology was previously transferred. One of the accompanying symptoms in this case is the acquisition by the girl of a male body type, as well as the presence of obesity in the face and neck.
The treatment of amenorrhea in adolescents consists of conducting hormone therapy, drawing up an optimal nutritional program, normalizing sleep and rest, and weight correction. Since this is not a disease, it’s not necessary to talk about the consequences of amenorrhea in adolescents: the main thing is not to self-medicate and follow a doctor’s prescription.
Careful gynecological examination on the chair is always carried out with amenorrhea, even among virgins. Sometimes the exit from the vagina is narrowed or completely closed.
Causes of amenorrhea in adolescents
Amenorrhea in girls - the causes of its development at different stages of life.
Amenorrhea in adolescence develops most often and is characterized by the absence of menstruation in general after reaching the age of sixteen or the cessation of menstruation for six months or more, provided that there have been bleeding from the genital tract at least once or the menstrual cycle has already been formulated. Amenorrhea is associated at this age, most often as a result of a disruption of the body’s work at the genetic level or as a result of a number of reasons that will be discussed further. Depending on the time of occurrence and the diagnosis of the absence of menstruation, it is customary to divide it into primary and secondary forms. The most favorable outcome of treatment will be to identify it in the period from 11 to 16 years of age, when it is possible to treat and stabilize the hormones without having serious consequences.
The reasons for amenorrhea in girls can be determined only by a doctor based on the results of the examination. The timely treatment of amenorrhea is important, since early detection of its cause increases the likelihood of a favorable outcome in terms of the performance of reproductive function by the girl.
The causes of amenorrhea in adolescents can be very diverse, making it difficult to diagnose and treat. Primary amenorrhea is associated, in most cases, with genetic or congenital pathologies in which the pathology is hidden in the chromosomes or is associated with disruption of the normal structure and functioning of the reproductive system of the fetus when exposed to adverse environmental factors, chronic maternal diseases, exposure to harmful habits, drugs and intoxication. And with a secondary form of amenorrhea in adolescents, the causes are associated primarily with stress, starvation or diets, and heavy physical or mental stress. Sometimes it occurs as a result of diseases of the brain or the consequences of TBI.
Primary amenorrhea: the causes of adolescents are very diverse, but the first place among them is anomaly of the uterus, while the development of the girl is no different from girls without such a pathology, but when clarifying complaints it is possible to identify painful feelings in the lower abdomen once a month.
Diseases of the hypothalamic - pituitary system, in which amenorrhea is one of the symptoms of diseases of the neurohumoral system, also have an important place in its development. The most famous and well-studied is Itsenko-Cushing syndrome, which develops on the background of injuries, operations or infections. When this happens, hyperproduction of glucocorticoids and androgens occurs, leading to the appearance in the girl of non-female signs of sexual development, obesity on the face, neck and upper body.
Anorexia also causes amenorrhea, since with insufficient intake of nutrients into the body, he tries to reduce his work, including the function of the reproductive system, which is extinguished, which is associated with a large amount of effort and energy to bear and give birth to a child. All this leads to metabolic disorders in the body of a girl with the launch of anorexia nervosa, which is very difficult to treat.
Amenorrhea is secondary in adolescents - the causes of its appearance are also often associated with a violation in the formation of prolactin by the pituitary gland and a change in the sensitivity of tissue receptors to it, which leads to menstrual disorders. Most often it occurs with pituitary tumors and then it produces a hormone in excess, which does not carry any symptoms, in most cases, but then there is amenorrhea.
The causes of amenorrhea in adolescents and their identification are the main task among parents of adolescents, which requires them to take the adolescent to the pediatric gynecologist in a timely manner, since timely treatment during puberty allows for correct and better correction of the pathology.
Primary amenorrhea in adolescents
Primary amenorrhea in adolescents is a condition between the ages of 10 and 16 years, when menstruation does not occur in the absence of developmental delay or without delaying it.
The main diagnostic points of primary amenorrhea are considered to be:
- the onset of menstruation does not occur until the age of 14, along with the lack of growth and signs of puberty
- there is no menstruation before the age of 16, regardless of the development of signs of sexual differentiation, or if there are no menses for 4 years from the beginning of the growth of the mammary glands.
Аменорея первичная у подростков возникает при генетических илврождённых аномалиях, и только генетический анализ и повышенный уровень гонадотропинов даёт возможность выяснить причину аменореи. К аномалиям относят целую девственную плеву, перегородку во влагалище, агенезию его или атрезию, агенезию матки и тестикулярную феминизацию.
Among the violations of target organs, they distinguish agenesis of the ovaries, gonads and their insufficiency.
Hypothalamus disorders are associated with the development of a tumor in it, tuberculosis, sarcoidosis, exposure to radiation.
Pituitary amenorrhea occurs with injuries, operations in this area, radiation, and the accumulation of hemosiderosis in it.
Treatment of primary amenorrhea in adolescents
Let us now consider how to treat amenorrhea in adolescents depending on its form, what methods of treatment exist and their effectiveness in each particular case.
Treatment of primary amenorrhea in adolescents is primarily due to its cause. When overgrowing the hymen, surgical treatment is used, which is aimed at carrying out its arcuate incision in order to restore the flow of menstrual blood. For other anomalies of the reproductive system, plastic surgery is used. In the presence of genetic defects, treatment with hormones is indicated in order to correct the appearance of the girl, and when karyotyping and identifying the XY karyotype, gonads should be removed, which can be transformed and transformed into a gonoblastoma. After such a situation, if a woman wants to have a child, you should use the donation of eggs with the help of modern reproductive technologies.
For the purpose of hormone replacement therapy, natural estrogens and gonadotropin-releasing hormone agonists are used, and only a qualified specialist can select the dose and drug, the duration of its administration, after a full examination of the adolescent girl's body.
Secondary amenorrhea in adolescents - treatment as well as in primary amenorrhea depends on the cause that caused it. In most cases, the development of secondary amenorrhea in adolescents is associated with abnormal diet, as most adolescent girls tend to follow a variety of diets to achieve the perfect figure, physical and mental stress, psycho-emotional experiences. And in most cases, the normalization of nutrition with amenorrhea in adolescent girls, exercise regime, mental work and the emotional state of the body leads to the restoration of the menstrual cycle without any drugs.
Treatment of secondary amenorrhea in adolescents on the background of a hormonal disruption in the body is aimed at restoring it on the basis of hormonal preparations - gestagens. After the course of treatment, the cycle is restored and the woman can exercise her reproductive function. It is often used in combination with hormones and drugs to normalize the nervous system and stabilize lean body mass.
Secondary amenorrhea: treatment in adolescents may be surgical. If a girl is diagnosed with a pituitary tumor, then she should be removed, with polycystic use, laparoscopic techniques are most often used, with the help of which ovarian fenestration is performed with simultaneous diagnostics of tubal patency, but for uterine diseases, one has to resort to hysteroscopy.
Amenorrhea is secondary in adolescents, treatment is started without waiting for the absence of six months, as the proper treatment started in a timely manner is the key to the results of treatment and the effectiveness will be much higher, which increases the chances of the girl's reproductive function in the future.
Therefore, if a teenage girl is diagnosing hypothalamic puberty syndrome, then herbal non-hormonal drugs and vitamin groups are used to normalize menstrual function.
If the reason for the absence of menstruation is established, and it is the stress and feelings of the adolescent, then it is worth eliminating these factors and establishing proper sleep and rest, how exactly eliminating the cause in this case contributes to the appearance of menstruation.
With reduced production of gonadotropins by the pituitary gland and their cyclic secretion, cyclic hormone replacement therapy with a duration of 3-6 months in compliance with the daily regimen, compliance with a balanced diet, physical therapy and vitamin therapy
Amenorrhea in adolescents: how to treat with non-aggressive methods - vitamin therapy, herbal preparations, physiotherapy and stabilization of work and rest, we will try to make out just these treatment methods in 40% of cases are able to restore the menstrual cycle without the use of hormonal preparations.
Treatment of amenorrhea in adolescents folk remedies should not be independent, because not always traditional medicine has a good result. Only after consulting with a doctor dealing with the treatment of your pathology, it is possible to use traditional medicine, as it is not always possible to combine folk remedies with a course of medical treatment aimed at restoring the teenager’s hormonal background in order to restore menstruation.
Amenorrhea in adolescents: treatment of folk remedies is quite widespread. Let's stop on a few of them. The most popular are the following folk methods:
- take 2 tablespoons of the root of the cuff and chop, pour boiling water with 1 liter and insist for two hours. Then boil it for 20 minutes and strain it well. Use for baths for two weeks no more than 20 minutes.
- Take 4 tablespoons of the bird-mountaineer, 2 tablespoons of stinging nettle, 1 tablespoon of shepherd's bag and the same amount of Amur velvet and grind everything to a homogeneous mass and pour 1 liter of water and put in a water bath and cook until it boils 1 32 part of the content, the next step is to insist on for 30 minutes and take 1 tablespoon. 3 times a day for 2 weeks.
- Take 2 kg of onion and peel off, then boil it in 3 liters of water and take this broth in the morning and evening.
- 3 tablespoons parsley pour 3 cups boiling water and leave for 12 hours. Then drink half a glass 4 times a day for half an hour before meals for 3 weeks with a seven-day break.
Amenorrhea primary in adolescents
Amenorrhea is considered primary if menstruation does not occur after 16 years. As a rule, menstruation begins at the age of 12 - 13 years and during the year their frequency becomes regular. Amenorrhea primary in adolescents manifested in the absence of menstruation and hormonal disruptions, as well as in children's form of the body, lack of development or lack of breast, in the wrong hair growth, etc.
One of the causes of amenorrhea of the first type are uterine malformations. At the same time, a teenage girl often grows normally, but once a month she may experience pain in her stomach.
Amenorrhea secondary in adolescents
With secondary amenorrhea, menstruation in girls disappears for a period of more than 6 months. The reasons for this phenomenon can be many. Most often, amenorrhea of this type is caused by stress, feelings, etc. Here is the psychogenic nature of amenorrhea. Amenorrhea secondary in adolescents often accompanied by changeable mood, aggressiveness, unreasonable fears, etc.
Second fairly common the cause long absence of menstruation in modern girls is the desire for weight loss and exhausting diets. In this case, malnutrition leads to impaired metabolism, the functioning of the pituitary and hypothalamus. Malfunctions of this system lead to nervous amenorrhea, which is quite difficult to stop. At the same time, there are failures in the functioning of the human reproductive system, which is not always possible to correct.
Diseases of the hypothalamus or pituitary gland
Another source of amenorrhea of the second type are diseases of the hypothalamus or pituitary. In addition to the absence of menstruation, the body also has symptoms that are caused by diseases of the neurohormonal system. A rather common disease in this case is Itsenko-Cushing syndrome. It develops due to injuries, tumors, and infections. In this case, adolescent girls have an increased level of glucocorticoid and male hormones.
As can be seen from the above, effects of amenorrhea enough serious. Therefore, the main task of parents in the period of puberty of the girl is timely visits to the gynecologist. As a rule, in adolescence there is a chance to correct the consequences of this disease.
In adolescent girls, secondary amenorrhea may be due to abnormalities in the hormonal status.
According to studies conducted in the last 20 years, the following deviations are observed in girls with secondary amenorrhea:
- 32% of hypoestrogenism, that is, a decrease in estrogen synthesis below the reference norm,
- 60% - low levels of leptin, a hormone that regulates energy metabolism. Its deficiency causes obesity,
- 50% - low insulin-like growth factor, which leads to a delay in the development of organs,
- 83.3% - a critically low level of insulin, which in turn dramatically increases the concentration of sex-steroid-binding globulin.
These changes provoke uterine hypoplasia, which leads to amenorrhea and other changes that impede reproductive functions.
The physiological reason for the above is, first of all, a sharp weight loss - more than 10–15%. In a more mature age, even a rigid diet does not lead to such a rapid weight loss, new adolescence against the background of accelerated metabolism, such a situation is quite possible. This is the main cause of the hormonal disorder and all the ensuing consequences.
Signs of amenorrhea, in addition to the actual absence of menstruation, are very diverse.
Symptoms related to the cause of the disease:
- Uterine form - with intrauterine fusion, menstruation simply stops, because adhesions do not allow to increase the functional layer of the organ. If tuberculosis was the cause of splices, then amenorrhea begins otherwise: menstruation passes on time, but the amount of discharge and the duration of this period gradually decrease until they stop altogether. When atresia observed spastic abdominal pain.
- The psychogenic form is accompanied by high fatigue, sleep disorders, depression, anorexia. and the emergence of vegetative syndrome.
If amenorrhea occurs due to weight loss, its symptoms coincide with anorexia: weakness, aversion to food, low temperature and pressure.
- Against the background of neuroexchange endocrine syndrome, there is an increase in temperature and pressure, headaches, obesity, the formation of pigment spots. Special feature: constant thirst and the formation of a large amount of urine.
- Simmons syndrome - accompanies infections, tumors and injuries. In this case, amenorrhea is combined with vomiting, constipation, exhaustion. Dystrophy develops in all tissues of the body.
- Sheehan syndrome - develops on the background of bleeding or extensive purulent processes. In this state, the work of the adrenal glands and the thyroid gland is suppressed, which leads to amenorrhea.
- Hyperprolactinemia - the disease on this background is combined with an increase in the uterus and mammary glands, while the libido is markedly reduced due to lack of sex hormones.
- Thyroid dysfunction - amenorrhea develops in combination with a decrease in temperature, fatigue, weight loss, high fragility of nails and hair. A characteristic sign of hypothyroidism is cold intolerance.
- Polycystic ovaries - in addition to the absence of menstruation causes obesity and infertility, accompanied by the appearance of acne and stretch marks.
- Ovarian exhaustion syndrome - the exhaustion of follicles. It is combined with the usual signs of menopause: hot flashes, fatigue, emotional drops.
- Resistant ovarian syndrome is the result of radiation or chemotherapy, as well as the use of certain medications. In this case, changes in the genitals are not observed, but there is a weakness and autonomic disorders.
How to cure?
Treatment of pathology depends on the cause that caused it. The course includes not only drugs, but also recommendations, which are in fact mandatory conditions for restoring the cycle.
- Physical overload - when it comes to sports, after achieving a result, you should restore normal nutrition and alternate the load with rest. If it comes to hard work, then it definitely needs to be changed.
- Weight loss or obesity, if they are not caused by organic changes, but by diet and improper eating habits, is treated by adjusting the diet. Amenorrhea after the normalization of body weight in most cases passes on its own.
If the cause is disruption of the hormonal background, whatever they are caused, the therapeutic course includes hormonal preparations:
- with thyroid insufficiency, synthetic thyroid hormones are appointed - thyroxin, triiodothyronine,
- in hyperthyroidism, it is necessary to suppress the excessive synthesis of hormones; therefore, thyreostatic drugs are taken - tiamazol, propylthiouracil,
- in polycystic ovaries, the course includes metformin in stage 1 - it improves the susceptibility of the ovaries to glucose, then clomiphene, a synthetic antiestrogen that prepares the follicular apparatus for ovulation. The second stage is prescribed if the patient wants to get pregnant,
- adrenal hypoplascics are treated with reserpine. If the result is unsatisfactory, prescribe chloditan. Before treatment, the pituitary region is irradiated,
- early menopause, also accompanied by amenorrhea, is treated with synthetic estrogens - clemena, cleonorm,
- in Sheehan's syndrome, glucocorticoids are prescribed - prednisone, for example.
The dosage of hormonal drugs, the duration of treatment and the regimen are selected individually.
Treatment of adolescents is performed according to a slightly different scheme. In this case, it is especially important to establish the true cause and prevent infertility.
Hormonal drugs are usually prescribed in 2 cases:
- abnormalities in the development of the ovaries, which leads to insufficient production of sex hormones. For the correction of the background prescribe drugs that combine estrogen and progestin - femoston, for example,
- disorders in the hypothalamic-pituitary system - is treated with the same drugs - synthetic estrogen and progestin, but in a different proportion and in a different way. In most cases, it is possible to manage only estrogen.
It should be noted that the correction of hormonal background in a teenage girl with gonadal dysgenesis is performed only after determining the complete set of chromosomes - the karyotype. The fact is that if with amenorrhea it turns out that the karyotype includes the male chromosome, the ovaries are removed before the onset of 20-22 years. Such a combination in most cases leads to ovarian cancer, so they try to prevent the disease.
Prevention and prognosis
Prevention of amenorrhea is reduced to maintaining a healthy lifestyle. The absence of excessive overloads of any plan - physical, emotional, nervous, guarantees women's health until the onset of this menopause.
It is very important to keep body weight within the limits of age and type of physical activity. And excessive thinness, and excessive completeness equally badly affects the hormonal background and leads to the appearance of amenorrhea, among other things.
Regular sex is also one of the factors that prevent dysfunction of the uterus and ovaries.
If amenorrhea is still observed, it is imperative to visit a gynecologist and get tested. If untreated, the risk of osteoporosis, heart disease, tumors of the uterus and ovaries, etc., increases dramatically. Infertility is the hardest consequence.
Many wonder if it is possible to get pregnant with secondary amenorrhea. With timely treatment, projections depend on the severity of the disease and its nature. In general, the restoration of menstrual function is quite possible. Often there is the opportunity to conceive a child.
Secondary amenorrhea appears for a variety of reasons: due to loss of body weight, due to abnormalities in the thyroid gland, with hyperplasia of the adrenal cortex. The disease can lead to the most serious complications and requires immediate treatment.
In the video about the causes of delayed menstruation:
When is amenorrhea normal?
- Age before puberty
Usually menstruation begins at the age of 12-16; at the age of 12-13, the absence of menstruation is the absolute norm.
The normal age of menopause is 49-52 years. These are very averaged numbers, it is necessary to focus on the age of menopause in women in the family.
Lack of menstruation during the lactation period is lactational amenorrhea. Here is the time of lactational amenorrhea, a very special balance of hormones, high levels of prolactin and egg cells do not mature. But as a method of contraception, we do not recommend it, since it is enough to take a break in feeding for more than two hours and some egg can mature. And if sex life is regular, then you can not see the monthly, and immediately get pregnant.
The absence of menstruation during pregnancy - this is natural. The function of the egg is completed, you are carrying the baby, other eggs are not needed.
Amenorrhea - diagnosis and examination
- Medical history and external examination
It is always very important to interview the patient and her relatives. Как обстоят дела с менструальным циклом у матери, как проходили роды, не было ли серьезных заболеваний у девочки в детстве, было ли воздействие радиации или химических веществ, какие есть другие проблемы со здоровьем (сердечные проблемы, лишний вес, заболевания суставов).
External examination is also important, we assess the height and weight of the patient, body type, the degree of development of the mammary glands, the presence and type of hair distribution, skin type. Often, genetic syndromes have characteristic signs and can be suspected when they are first taken.
- Examination of an obstetrician-gynecologist on a chair
The condition of the small pelvis, external genitals, in girls - the type of hymen is assessed.
- Ultrasound of the genitals and mammary glands
According to the result of ultrasound, we get a lot of useful information: the presence and size of the uterus and ovaries, the functioning of the ovaries (maturation of follicles in them), the state of the walls of the uterus, the presence of cysts and tumors.
- Hormonal profile:
- thyroid hormones (minimum is T4 free and TSH)
- sex hormones (FSH, LH, DHEAS, testosterone, prolactin, AMH and others according to indications)
- Additional studies:
- genetics consultation,
- a neurologist and / or a neurosurgeon,
- Ultrasound of the thyroid gland and adrenal glands,
- radiography of the skull,
- computed or magnetic resonance imaging of the brain, pelvis and adrenal glands.
Forms of amenorrhea
Amenorrhea is divided into primary and secondary forms. The forms and causes of amenorrhea are of fundamental importance in the choice of treatment method. And the diagnosis of the causes of amenorrhea should deal only with a specialist. As a rule, with complaints of lack of menstruation go to the obstetrician-gynecologist. But in some cases, you may need the help of an endocrinologist, and even genetics.
Testicular feminization syndrome (STF)
Under the scientific name lies a state when the metabolism of hormones is disrupted intrauterinely in the fetus. First of all, there are problems with the production and exchange of testosterone. As a result, the girl looks normal, her appearance is developed according to the female type. Someone worried about the lack of pigmentation around the nipples and the lack of hair in the armpits and pubic hair, and someone does not pay attention to it.
But with in-depth examination revealed that she has a vagina, but it is short and ends blindly. Uterus and cervix no ovaries, too. In the pelvis there are underdeveloped testes (male genital organs), in which germ cells are not produced. Since there are no ovaries and a uterus, then there is no menstruation, and subsequently there are no pregnancies. The frequency of occurrence is approximately 1 in 15 thousand newborns.
Treatment after the diagnosis necessarily includes the removal of male organs, as they often develop cancer. The operation is shown after 16 years, after the breast has developed, and a female physique has formed. Then female hormones (femoston) are prescribed for life and make vaginal plastics to allow the girl to live a normal sex life.
Impaired function of the hypothalamic-pituitary system (HGS)
HGS is a system of regulatory organs in the brain; hormones and other stimulating-inhibiting substances are produced here that regulate not only the menstrual functions, but also the metabolism as a whole.
Functional dysfunction of HHS occurs against the background of a child’s inadequate nutrition, with chronic, long-term current infections and intoxications. Amenorrhea in adolescent girls is often observed with low hemoglobin (anemia).
When a girl is cured of the underlying disease, she gains enough weight, then the menstrual function is regulated by itself.
Sometimes we may encounter a constitutional form of delayed sexual development, when the sexual age lags slightly behind the passport age. This happens in women of the northern peoples (Khanty, Aleuts, Koryaks, Nenets, Chukchi and others, smaller). In these cases, the absence of menstruation at age 16 and slightly older is normal with the exclusion of other causes of amenorrhea. As a rule, in such cases they do not only study hormones and ultrasound of the genitals, but perform an X-ray of the bones of the hand, wrist, and forearm. If there are normal growth zones in these bones, then there are no genetic features of the development and delay of puberty.
Primary amenorrhea without delayed development of secondary sexual characteristics
Ginatresia and aplasia of the uterus are most common in this group of conditions.
Ginatresia is the fusion of a part of the vagina or the complete fusion of the hymen (hymen). It is also formed in utero, but fortunately, it is surgically corrected quite well. Usually, in this case, the ovaries are functioning fully, but the menstrual blood has nowhere to pour out. After surgery, both the normal menstrual cycle and pregnancy are quite possible.
Aplasia of the uterus is a congenital absence of the uterus. Often combined with the underdevelopment of the vagina and the defects of the kidneys and urinary tract. Ovaries often work normally, hormonal profile is also normal. But the uterus is a small dense formation without a cavity inside, or is not defined at all. In this case, the menstrual cycle and pregnancy are impossible. But after surgical correction, sex life has no significant limitations.
Many of these pathologies are the result of intrauterine mutations, already observed in adolescents. Therefore, medical interventions often help a girl to adapt to her body and live a full life. But it is impossible to completely cure congenital conditions.
Sometimes after intrauterine interventions, such as instrumental abortion, separate therapeutic and diagnostic curettage, hysteroscopy, removal of polyps, the consequences remain.
The type of damage depends on the type of operation, the instruments used, and the qualifications of the operating gynecologist. Sometimes parts of the inner wall of the uterus become so thin that they cease to function as they should. Endometrium does not increase during the cycle and, accordingly, during menstruation there is nothing to reject. As a rule, such a pathology develops gradually, menstruation becomes poorer and shorter, and then stops altogether. Such complications of the procedure, which are performed on the background of inflammation, are especially dangerous.
Also in this case, atresia (fusion) of the cervical canal may develop. Atresia is treated surgically, the duct is restored.
Intrauterine adhesions (synechiae) or Asherman's syndrome can also be a consequence of abortion or any other curettage. The uterus inside is filled with adhesions, its cavity almost disappears.
Both of these complications significantly reduce the chances of pregnancy.
Treatment consists of therapeutic hysteroscopy, the separation of adhesions and the introduction of solutions to prevent the formation of new adhesions. Often used gel preparations of hyaluronic acid (antiadhesin).
Ovarian Hypermotility Syndrome (HTPS)
FAT is the absence of menstruation after prolonged use of certain hormonal drugs. Combined oral contraceptives (COCs), gonadalizing hormone agonists (buserelin, goserelin), gestagens (Vizanna) inhibit certain hormonal processes. For most patients, this is a reversible effect when the cycle is adjusted, the course of treatment is completed, they cancel pills / injections and the cycle is restored by itself. But in some girls, menstruation does not begin within 2-3 months after discontinuation of the drug. Girls of asthenic physique (thin, tall, in small breasts), having a violation of the cycle in the past by the type of scarce menstruation or infertility, are more at risk.
If for 3 months the monthly has not recovered, then you should contact your gynecologist. The doctor examines the patient, often in such cases, an analysis of prolactin is prescribed. If prolactin is normal, then clomiphene citrate may be prescribed (a drug to stimulate ovulation) for 1 to 4 menstrual cycles. During treatment, ultrasound of the genitals should be monitored, when we see that the eggs are maturing, and the inner layer of the uterus is growing as it should, then we cancel the preparation.
If the level of the hormone prolactin is increased to 1000 mIU or more, then bromocriptine preparations are prescribed until the prolactin numbers normalize (to 540 mIU or less).
Organic Violation of GHS
This is a rare cause of amenorrhea, here we are talking about tumors and cysts in the brain. Cysts or tumors (most often benign) squeeze the hypothalamus and pituitary (organs in the brain that regulate almost all hormonal processes in the body). Because of this, the whole chain of hormonal processes is disturbed, and menstruation disappears. Surgical treatment here, after removal of a cyst / tumor for 6-12 months, the menstrual cycle is gradually restored.
There are 2 more conditions that disrupt the menstrual cycle. Most often they are associated with childbirth. Amenorrhea develops after a severe pregnancy and / or complicated labor.
Sheehan's syndrome (Shiena) is a vasospasm or hemorrhage in the pituitary gland. Most often, this syndrome develops after pregnancy, occurring on the background of preeclampsia (high blood pressure, edema, protein in the urine) and after childbirth, complicated by massive bleeding.
At first, the problem is not visible, lactational amenorrhea masks it. But even after the cessation of breastfeeding, the periods do not come. In this case, you should not wait longer than 2-3 months, and immediately consult a gynecologist. The gynecologist asks you about the course of pregnancy and childbirth (you need to tell her the details, what the pressure was, whether you have had much blood swelling, if there has been a blood transfusion after the birth), looks at the chair and prescribes additional examination (sex hormones, thyroid hormones).
After further examination, you may be prescribed steroid hormones (prednisone, metipred), thyroid hormones (thyroxin) and / or hormone replacement therapy with sex hormones (femoston, divina, angelica). Assign yourself the hormones is extremely unwise, you can not restore the cycle, but add weight or finally suppress their own hormones. Only the exact and minimum dosage in each case can be useful and safe.
In this case, the hormonal system as a whole functions normally, but the ovaries either do not respond to hormonal signals or are damaged.
Resistant Ovary Syndrome (FRY) is a disease in which the ovaries for some reason stop responding to stimulation by sex hormones (from the pituitary, hypothalamus, and adrenal glands). It develops up to 36 years, it often happens that there are several such cases in a family. The treatment here is carried out using the combined sex hormones (femoston). Independent pregnancies are rare. But it is possible to give birth to a child with the help of IVF with a donor egg.
Premature ovarian depletion syndrome (SPIA) is a condition where the ovaries stop producing eggs, and early menopause occurs. Unlike the physiological early menopause (it is laid genetically and in the family of all women, menopause occurs, for example, at the age of 37-43 years old, or 45-47 years old), SPIA is provoked by external factors. Such factors are: serious infections (measles, rubella, parotitis, severe flu), multiple exposures, chemotherapy.
The treatment of each type of amenorrhea is briefly described when describing these types. Here we will summarize the methods and drugs, hormones and antihormones that we use to treat amenorrhea.
These include Divigel, Estrogel, Folliculin and others, are used to replace the lack of estrogen.
Duphaston, urozhestan or pradzhisan, norethisterone are used with a lack of second-phase hormones or gestagens.
Clomiphene citrate is a drug to stimulate ovulation, it is used strictly under the supervision of a physician.
- Combined drugs for hormone replacement therapy
This femoston in various dosages (1/5, 1/10, 2/10), Angelica, Divina. It is used when we want to give the ovaries to recover, or for life in certain congenital conditions.
- Thyroid Hormones
Levothyroxine (L - thyroxin, eutirox) is needed to replace the lack of thyroid function.
- Steroid (glucocorticoid) hormones
Prednisolone, metipred appointed with insufficient adrenal function, which can be in violation of the functions of the pituitary and hypothalamus.
Bromkriptin reduces prolactin. A high level of prolactin causes in the body a condition similar to feeding a baby and the cycle is broken.
In this group, and gynecological operations (removal of the rudimentary male organs, the separation of adhesions, etc.), and neurosurgical (complete or partial removal of tumors, cysts).
Thus, we see that the problem of the absence or termination of monthly is not as simple as it seems. Self-medication, and even more treatment with folk remedies only exacerbate the problem. You will lose precious time, and amenorrhea will become more resistant. Follow the recommendations of the attending physician, look after yourself and be healthy!
Causes of primary amenorrhea
Primary type amenorrhea tends to manifest itself in young girls - 14-25 years. The main symptoms of this disorder - the complete absence of menstrual flow. Almost always the phenomenon is associated with a violation of sexual development, namely, with its delay.
Disruption of sexual development is not the only cause of amenorrhea, other diseases can also be factors for the emergence of this pathology.
Anomaly of ovarian development
According to statistics, almost 40% of diagnoses are due to ovarian abnormalities. This anomaly is congenital and leads to chromosomal abnormalities. Pathology is the absence in the ovaries of special cells responsible for the production of estrogen. It is estrogen that is responsible for the timely puberty in girls and, accordingly, for the onset of the menstrual cycle.
Diagram of the female reproductive system, menstrual cycle
Endocrine disorders as the cause of amenorrhea
Most of the organs that produce hormones are functionally connected to the brain, and the thyroid gland is no exception. The production of thyroid hormones is controlled by two brain centers known as the hypothalamus and pituitary.
The hypothalamus produces a substance known as TRH (thyrotropin-releasing hormone), which acts on the pituitary gland, which in turn releases an additional substance TSH, which directly affects the thyroid gland. Thanks to such a chain reaction, the body, while standing, produces the T3 and T4 hormones that are indispensable for the body.
Pathological changes in the thyroid gland, a violation of the production of its hormones negatively wag on normal puberty, as a result, there is a delay, manifested by the absence of menarche and subsequent menstrual periods. An appropriate method of treatment will be the regular use of thyroid hormones.
The manifestation of stress - the response of the body to the effects of physical and mental nature. Stress, in turn, is divided into several subspecies: eustress - an adequate response of the body to stimulus and distress - the inability to cope with the situation, which provokes a number of pathological changes.
Primary amenorrhea on the background of stressful situations often occurs in adolescents, girls aged 14-18 years. As a rule, against the background of distress, there is a decrease in body weight, impaired functioning of the immune system, as well as endocrine. All these disorders together and provoke the development of amenorrhea.
It should be noted that the primary amenorrhea on the background of psychogenic factors occurs suddenly and is accompanied by autonomic disorders.
Primary amenorrhea on the background of stressful situations
Diet as the cause of amenorrhea
If we talk about a diet that provokes the development of amenorrhea, then more often it is anorexia nervosa. The causes of anorexia nervosa are still not well established. This is a psychological condition with some genetic predisposition and some influence of external factors.
Girls try to lose weight by drastically reducing calorie intake and excessive physical exercise. Patients often induce vomiting after eating food, abuse laxatives and drink excessive amounts of water. The disease is manifested by weight loss and a critical decrease in body mass index.
The body feels a colossal deficiency of trace elements and vitamins; there is a disruption in the work not only of the hormonal background, but also of the whole organism. During a dramatic weight loss, ovarian dysfunction develops, estrogen production decreases, which leads to amenorrhea.
In addition, the development of amenorrhea on the background of a diet is accompanied by malfunction of the cardiovascular system and the digestive system.
What is menarche?
Menarche - the first menstrual bleeding occurs 2-2.5 years after the first changes in the mammary glands. Menarche in girls is often observed at 12-16 years, while the age factor of the first bleeding is unknown. However, it is considered that hereditary predisposition and lifestyle, including the diet, play a large role. Так, в странах Европы развитие раннего менархе связано с более сбалансированным питанием и более здоровым образом жизни.
100-150 лет назад, средний возраст наступления первой менструации составлял 15 лет, сегодня отметка снизилась до 13.
Также на менархе влияет процентное соотношение жировой ткани. Так, при жировой ткани менее 20% от общего веса месячные могут и не наступить. This trend is often observed in professional athletes, dancers, models. When menstruation is absent or is scanty due to reduced body weight or anorexia.
For the first time 10-12 months after the onset of menarche, menstruation may be irregular, absent or accompanied by minimal bleeding. During this period, 80% of girls do not ovulate.
In gynecology, menarche is defined as the culmination of a number of physiological changes:
- Starts the process of making ovarian estrogen.
- In the next few years, the uterus increases in size, the mammary glands grow, external genitals are formed.
- Cyclic changes in the uterine cavity occur, an endometrium and mucosa are formed, and local blood circulation is improved by the action of estrogen.
The first signs of menarche do not differ from the beginning of menstruation, as a rule, complaints of nagging pain in the lower abdomen, weakness, fatigue, and mood swings.