Secondary Amenorrhoea
A normal menstrual cycle averages around 28 days with a range of 24-32 days.a
menstrual cycle of 6 weeks to 6 months is called oligomenorrhea. Amenorrehoea of
six months and beyond during reproductive age following establishment of normal
menstruation is called secondary amenorrhoea. It is generally recommended that
the investigation should start once the duration of secondary amenorrhoea is 12 months,
as most of the physiology course will be evident by that time and there are more
chances to find a pathological cause.
Management
HISTORY
the first step of management of secondary amenorrhoea is to establish that it is a
true secondary and not wrongly treated primary amenorrhoea. It is seen in practice
that patients with primary amenorrhoea are often treated with the hormones for the
induction of menstruation and later on these patients present with complaints of
secondary amenorrhoea, when an unwary clinic may start investigating the case
of lines of secondary amenorrhoea. Therefore a detailed history about the pattern
of previous mensuration particularly in relation with hormone intake should be taken
from these patients.
Secondary amenorrhoea due to pregnancy will be associated with general
symptoms of pregnancy like morning sickness, breast tenderness etc and the patients
undergoing menopause will complain of hot flashes, night sweat and psychological
disturbances. Lactation is often associated with amenorrhoea and relevant inquiry
must be included in the history.
Social factors like separation in family , migration to different countries or cities
, or shifting to hostel and stress of university examination can all result in secondary
amenorrhoea. Secondary amenorrhoea is quite common in marathon runners.
Sudden weight change i.e. gain/loss, crash diet or anorexia nervosa are all known
for their association with amenorrhoea. An inquiry about all these factors should be
made.
Sheehan’s syndrome is a condition associated with acute pituitary necrosis
caused by massive postpartum hemorrhage resulting in hypopituitarism which
causes failure of all pituitary depends organ including menstruation and lactation
.therefore a history of massive postpartum haemorrhage followed by failed lactation
should be taken from all patients presenting with secondary amenorrhoea.
Asherman’s syndrome is characterized by secondary amenorrhoea and
infertility due to intrauterine adhesions. The intrauterine adhesions result from
vigorous endometrial curettage when the basal layer of endometrium is also
removed.this condition is more likely to occur when curettage is performed repeatedly
on a pregnant uterus (post abortal, postpartum), particularly in the presence of
infection the patient should therefore be asked about the outcome of previous
pregnancies.
The patients must be asked about the history of any surgery on uterus and ovaries.
History of medication prior to the onset of secondary amenorrhoea is also relevant .
The patients of endometriosis treated with Denzel often develop amenorrhoea.
GnRH analogues with the hypothalmicpituatiry ovarien axis and causes
pseudomenopause. Patients taking oral contraceptive pills for longer
duration often experience amenorrhoea on discontinuation (post pill amenorrhoea ) .
Pelvic irradiation causes ovarian ablation resulting in premature menopause.
Other drugs mentioned above cause secondary amenorrhoea by causing
hyperprolactinemia.
Polycystic ovarian disease is characterized by obesity, hirsutism ,
infertility and oligomenorrhea which may sometimes take the form of secondary
amenorrhoea . Adrenal and virilizing ovarian tumors produced testosterone in
excessive amount when secondary amenorrhoea 9s associated with feature of
virilization (hirsutism, hoarseness of voice, clitoral hypertrophy) Congenital adrenal
hyperplasia is more common a cause of primary than secondary amenorrhoea, and
must be excluded by the measurement of 17∝ hydroxyprogesterone if no other cause
of androgen excess is found.
A history of symptomatology of hyper and hypothyroidism should be taken.
Cushing syndrome is associated with obesity, moon face and buffalo hump.
Pituitary adenoma is associated with galactorrhoea, headache and visual field
disturbance . genital tuberculosis is nearly always secondary to pulmonary tuberculosis
. a relevant history should therefore be taken.
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