INVESTIGATION
Baseline investigation
i) Pregnancy test
A simple pregnancy test in urine may solve the problem and it must be considered before requesting any expensive investigation.
ii) Hormonal assay
The baseline investigations are serum LH,FSH and prolactin levels, thyroid function tests and pelvic ultrasonography . The results of these investigations when interrupted carefully can diagnose or rule out most of the causes of secondary amenorrhoea. Raised FSH & LH suggest menopause, raised LH/FSH ratio is diagnostic of polycystic ovarian disease , raised prolactin level is either drug related or points to a pituitary adenoma.Low LH & FSH , prolactin and thyroid function test in one patient is suggest suggestive of Sheehan's syndrome. abnormal thyroid function tests alone are seen in thyroid dysfunction.
iii). ultrasonogram
Pelvic ultrasonography is very useful in the diagnosis of ovarian tumors and polycystic ovarian disease.
Further investigation
These investigations are only needed if there is strong clinical suspicion or indicated by baseline investigation . These include X-ray chest and premenstrual endometrial biopsy for the diagnosis of tuberculosis , serum cortisol for Cushing syndrome , thyroid scan for thyroid dysfunction , 17 a hydroxyprogesterone for congenital adrenal hyperplasia and CT scan of adrenal and pituitary glands for tumours. Asherman's syndrome can be diagnosed on hysterosalpingograms but hysteroscopy is the investigation of choice these days.
TREATMENT
Once the underlying cause is detected the further management is straightforward and menstruation is restored by correction of the actiologicale factor.
Adrenal/ovarian tumours would require surgical resection. Cushing syndrome is better referred to the endocrinologist. Congenital adrenal hyperplasia responds and the patients can be made fertile with ovulation induction . Pelvic tuberculosis is treated with anti tuberculosis medication as used for pulmonary tuberculosis , though the fertility outcome is generally poor, pituitary adenoma can be treated with bromocriptine and surgery.
Asherman’s syndrome . Conventional treatment of asherman’s syndrome is to break intrauterine adhesions with uterine sound,Followed by insertion of intrauterine contraceptive devices to prevent further adhesion formation. Mensuration restored with use of oral contraceptive pills. This treatment is now largely replaced with modern technique , in which the intrauterine adhesions are cleared with cautery under direct vision through hysteroscopy. The patient is subsequently prescribed oral contraceptive pills. With this approach menstruation is restored in upto 98% of the cases and fertility is achieved by upto 70% of those who wish to conceive.
In the absence of serious and life threatening condition (i.e pituitary, adrenal and ovarian tumours, pulmonary tuberculosis, Cushing syndrome and thyroid dysfunctions) the patients with secondary amenorrhoea should be thoroughly counselled and reassured that having amenorrhoea does not bear any serious effect on her general health and further fertility. Her desire for immediate conception should also be considered . If she does not want to conceive immediately, she can be given two options, either to leave it as such and menstruation restarts spontaneously in many of them, or if she wants to menstruate she may be prescribed oral contraceptive pills for regular withdrawal bleeding.
Those who want to conceive ovulation induction is the write option for them . Before embarking at ovulation induction , tubal patency and husband semonquilty must be assessed.
Ovulation induction
Non hyperprolactinemia amenorrhoea
Ovulation in non hyperprolactinemia amenorrhoea can be induced with the following drugs.
Clomiphene citrate
It is an anti estrogenic agent available in the form of a 50mg tablet. The treatment is started with 50mg daily from the second day of the menstruation cycle in an oligomenorrhea and on any day in an amenorrhoeic patient and continued for 5 days. If menstruation does not occur after 30 days, the next cycle starts with 100mg daily after ruling out the pregnancy and is continued for 5 days. The dose is increased by 50 mg every month till the menstruation is achieved. The dose on which the patient starts menstruation is then continued as maintenance does. The dose can safely be increased upto 250 mg daily.
Gonadotrophins (LH/FSH)
Gonadotropins are available in the form of injections ( 75i.u. LH / 75i.u. FSH ). The recommended dose is one injection every day starting from day one of the menstruation cycle in oligomenorrhea and on any day in patients with amenorrhoea. Follicular growth is mointerd on ultrasonography done on day 10 and 12 of the cycle. When the dominant follicle reaches 20 mm, injection hGG 5000 i.u. Is given and gonadotropin injections are stopped . The woman ovulates after about 36 hours of hGG injection which is followed by menstruation or pregnancy if desired. This treatment is expensive and carries the risk of ovarian hyperstimulation syndrome.
Hyperprolactinemia amenorrhoea
Bromocriptine
This is the drug of choice in patients with hyperprolactinemia amenorrhoea. It is given indose of 1.25 mg once a day for one week, 1.25 mg twice a day for next week followed by 2.5 mg twice a day. The prolactin level usually falls rapidly and menstruation occurs 3-6 weeks after prolactin level has returned to normal. If there is no response in six weeks, the dose is then doubled. The dose can safely increase upto 20mg a day.The dose at which themenstruration starts is continued as the maintenance therapy. Bromocriptine causes nausea and postural hypotension as a side effect. So it should be taken with meals and bedtime.
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