• Medical Treatment of Some ‘Specific’ Causes of Secondary Amenorrhoea.
• Causes of Secondary Amenorrhoea ‘Common with Primary Amenorrhoea’ and their Medical Management • Medical Management of Non-organic Causes of Secondary Amenorrhoea • Causes of Secondary Amenorrhoea which Cannot be Treated by Drugs | |
DEFINITION
Past 15 years, not menstruated yet (Beiber, 2006). Bone age is a better guide than the chronological age for allocating age.
‘AT A GLANCE CHART’
For Management of Primary Amenorrhoea
I | II | III |
|---|---|---|
Diagnosis (Cause) | Diagnostic Test | Drugs to be used |
1. Hyperprolactinaemia with or without galactorrhoea | • Serum prolactin- Elevated • CT/MRI- To spot/exclude Microadenoma | Bromocriptine 2.5 mg od or bd or cabergoline 0.5 mg weekly-titrated by Prolactin level (see chapter 34 and 35). |
2. Hypothyroidism | Elevated TSH | Thyroxine (Thyronorm 25, 50, 100 mcg) daily-to be titrated by TSH level |
3. Hypogonadotrophic hypogonadism | Low FSH, Low LH Low oestrogen (All 3 low) | Oestrogen replacement therapy for sexual development e.g. Oestrogen patch |
4. Adrenal hyperplasia | Elevated plasma 17-hydroxy progesterone and DHEAS | Dexamethasone 0.5 mg -1/2 or 1 tab daily to suppress Adrenals (see chapter 36) |
5. Peripubertal PCOD | Elevated LH and high LH/FSH ratio-more than 3: 1 | 1. Weight reduction 2. OC Pill Duoluton L cyclically 3. Recurrent Medroxy Progesterone withdrawal bleeding 4. Clomiphene 50-150 mg/day for 5 days-for few cycles 5. Treatment of hirsutism (see chapter 20, PCOD) |
6. Cushing's syndrome | Elevated urinary free cortisol and plasma cortisol | Refer to Physician |
7. Anorexia Nervosa (see chapter 32) | Weight loss, BMI <10th percentile (Beiber, 2006) under weight– > 25%, poor intake, low FSH, LH and E2 in some cases | Appetite stimulant, Anti-depressant, dietrary supplement; in severe cases admission and psychiatric consultation. |
8. Exercise induced amenorrhoea | No significant abnormality. History of heavy physical exercise-Athlete, keen dancer | Cutting down physical activity where possible |
9. Pituitary microadenoma, Prolactinoma | Very high level of Prolactin, Microadenoma on CT/MRI | Bromocriptine in high doses. Refer to Neurosurgeon |
10 Turner's syndrome and other forms of gonadal agenesis | High FSH and LH and very low oestrogen, Karyotype-XO, short stature | Oestrogen, Progestogen and Growth hormone (see chapter 38) |
11 Genital Koch's | Elevated Koch's antibodies, strongly positive Mantoux, high ESR, tubercles in curetted endometrium or on pelvic organs on Laparoscopy, +ve Koch's PCR of endometrium | Anti Koch's drugs (see Chapter 54). |
* In rare case primary amenorrhoea may be caused by pregnancy and hence this also has to be excluded by urine hCG test. | ||
* Malnutrition, under nutrition and chronic debilitating disease must be corrected. | ||
Note: This chart applies also for ‘secondary amenorrhoea’ and ‘infrequent menstruation’. | ||
THE CAUSES OF PRIMARY AMENORRHOEA THAT HAVE NO MEDICAL TREATMENT
• | Imperforate hymen | – | Needs surgery |
• | Transverse vaginal septum | – | Needs surgery |
• | Absent uterus | – | Not treatable |
In the cases of absent uterus the following two causes are to be kept in mind.
- Mullerian agenesis
- Testicular feminisation-(Testes are to be removed)
• | Hypothalamic and pituitary tumour | – | Needs surgery/ Radiotherapy |
• | Adrenal tumour | – | Needs surgery |
Basic non-invasive investigations for primary amenorrhoea
- Hb, TC,DC, ESR—For general health
- US scan of pelvis—To confirm or exclude the presence of uterus and ovaries and if present their size.
- TSH—To exclude hypothyroidism.
- PRL— To exclude hyperprolactinaemia.FSH:Low—HypogonadotrophismHigh—Turner's syndrome or gonadal agenesis.
Special Test —Karyotype
This is required only where history, clinical examination and the above investigations suggest the possibility of Turner's syndrome (XO) or Testicular feminisation (XY).
FURTHER READING
- Bieber EJ, Sanfilippo JS and Horowitz IR: In Clinical Gynecology, Elsevier, 2006;469-79, 818.
- Speroff L & Firtz MA. In Clinical Gynecologic Endocrinology and Infertility. 7th edition, Lippincott, 2005;401–63.
- Whitfield R. Dewhursts' Textbook of Obstetrics & Gynaecology for postgraduates, 5th edition, Blackwell Science, Oxford, 1995;24-63 Also see under the following chapters–32, 33, 34, 35, 36, 37 and 38.