Amenorrhea
Amenorrhea: Excerpt from Professional Guide to Signs & Symptoms (Fifth Edition)
The absence of menstrual flow, amenorrhea can be classified as primary or secondary. In primary amenorrhea, menstruation fails to begin before age 16. In secondary amenorrhea, it begins at an appropriate age but later ceases for 3 or more months in the absence of normal physiologic causes, such as pregnancy, lactation, or menopause.
Pathologic amenorrhea results from anovulation or physical obstruction of menstrual outflow, such as from an imperforate hymen, cervical stenosis, or intrauterine adhesions. Anovulation itself may result from hormonal imbalance, debilitating disease, stress or emotional disturbances, strenuous exercise, malnutrition, obesity, or anatomic abnormalities, such as congenital absence of the ovaries or uterus. Amenorrhea may also result from drug or hormonal treatments. (See How amenorrhea develops, pages 40 and 41.)
History and physical examination
Begin by determining whether the amenorrhea is primary or secondary. If it’s primary, ask the patient at what age her mother first menstruated because age of menarche is fairly consistent in families. Form an overall impression of the patient’s physical, mental, and emotional development because these factors as well as heredity and climate may delay menarche until after age 16.
If menstruation began at an appropriate age but has since ceased, determine the frequency and duration of the patient’s previous menstrual cycles. Ask her about the onset and nature of any changes in her normal menstrual pattern, and determine the date of her last menses. Find out if she has noticed any related signs, such as breast swelling or weight changes.
Determine when the patient last had a physical examination. Review her health history, noting especially any long-term illnesses, such as anemia, or use of hormonal contraceptives. Ask about exercise habits, especially running, and whether she experiences stress on the job or at home. Probe the patient’s eating habits, including number and size of daily meals and snacks, and ask if she has gained weight recently.
Observe her appearance for secondary sex characteristics or signs of virilization. If you’re responsible for performing a pelvic examination, check for anatomic aberrations of the outflow tract, such as cervical adhesions, fibroids, or an imperforate hymen.
Medical causes
Adrenal tumor
Amenorrhea may be accompanied by acne, thinning scalp hair, hirsutism, increased blood pressure, truncal obesity, and psychotic changes. Asymmetrical ovarian enlargement in conjunction with rapid onset of virilizing signs is usually indicative.
Adrenocortical hyperplasia
Amenorrhea precedes characteristic cushingoid signs, such as truncal obesity, moon face, buffalo hump, bruises, purple striae, hypertension, renal calculi, psychiatric disturbances, and widened pulse pressure. Acne, thinning scalp hair, and hirsutism also typically appear.
Adrenocortical hypofunction
Besides amenorrhea, adrenocortical hypofunction may cause fatigue, irritability, weight loss, increased pigmentation (including bluish black discoloration of the areolas and mucous membranes of the lips, mouth, rectum, and vagina), nausea, vomiting, and orthostatic hypotension.
Amenorrhea-lactation disorders
Amenorrhea-lactation disorders, such as Forbes-Albright and Chiari-Frommel syndromes, produce secondary amenorrhea accompanied by lactation in the absence of breast-feeding. Associated features include hot flashes, dyspareunia, vaginal atrophy, and large, engorged breasts.
Anorexia nervosa
Anorexia nervosa is a psychological disorder that can cause either primary or secondary amenorrhea. Related findings include significant weight loss, a thin or emaciated appearance, compulsive behavior patterns, blotchy or sallow complexion, constipation, reduced libido, decreased pleasure in once-enjoyable activities, dry skin, loss of scalp hair, lanugo on the face and arms, skeletal muscle atrophy, and sleep disturbances.
Congenital absence of the ovaries
Congenital absence of the ovaries results in primary amenorrhea and absence of secondary sex characteristics.
Congenital absence of the uterus
Primary amenorrhea occurs with congenital absence of the uterus. The patient also may fail to develop breasts.
Corpus luteum cysts
Corpus luteum cysts may cause sudden amenorrhea as well as acute abdominal pain and breast swelling. Examination may reveal a tender adnexal mass and vaginal and cervical hyperemia.
Hypothalamic tumor
In addition to amenorrhea, a hypothalamic tumor can cause endocrine and visual field defects, gonadal underdevelopment or dysfunction, and short stature.
Hypothyroidism
Deficient thyroid hormone levels can cause primary or secondary amenorrhea. Typically vague, early findings include fatigue, forgetfulness, cold intolerance, unexplained weight gain, and constipation. Subsequent signs include bradycardia; decreased mental acuity; dry, flaky, inelastic skin; puffy face, hands, and feet; hoarseness; periorbital edema; ptosis; dry, sparse hair; and thick, brittle nails. Other common findings include anorexia, abdominal distention, decreased libido, ataxia, intention tremor, nystagmus, and delayed reflex relaxation time, especially in the Achilles tendon.
Mosaicism
Mosaicism is a genetic disorder that results in primary amenorrhea and absence of secondary sex characteristics.
Ovarian insensitivity to gonadotropins
Ovarian insensitivity to gonadotropins is a hormonal disturbance that leads to amenorrhea and absence of secondary sex characteristics.
Pituitary infarction
Pituitary infarction usually causes postpartum failure to lactate and to resume menses. Although associated signs and symptoms depend on the infarction’s severity, they include headaches, visual field defects, oculomotor palsies, and an altered level of consciousness. The patient may also lose pubic and axillary hair.
Pituitary tumor
Amenorrhea may be the first sign of a pituitary tumor. Associated findings include headache, visual disturbances such as bitemporal hemianopia, and acromegaly. Cushingoid signs include moon face, buffalo hump, hirsutism, hypertension, truncal obesity, bruises, purple striae, widened pulse pressure, and psychiatric disturbances.
Polycystic ovary syndrome
Typically, menarche occurs at a normal age, followed by irregular menstrual cycles, oligomenorrhea, and secondary amenorrhea. Alternatively, periods of profuse bleeding may alternate with periods of amenorrhea. Obesity, hirsutism, slight deepening of the voice, and enlarged, “oysterlike” ovaries may also accompany polycystic ovary syndrome.
Pseudoamenorrhea
An anatomic anomaly, such as imperforate hymen, obstructs menstrual flow, causing primary amenorrhea and, possibly, cyclic episodes of abdominal pain. Examination may reveal a pink or blue bulging hymen.
Pseudocyesis
In pseudocyesis, amenorrhea may be accompanied by lordosis, abdominal distention, nausea, and breast enlargement.
Sertoli-Leydig cell tumor
Sertoli-Leydig cell tumor is an ovarian tumor that may produce amenorrhea along with acne, hirsutism, deepening of the voice, balding, muscle mass development, and clitoral enlargement.
Testicular feminization
Primary amenorrhea may signal this form of male pseudohermaphroditism. The patient, outwardly female but genetically male, exhibits breasts and external genitalia but scant or absent pubic hair.
Thyrotoxicosis
Thyroid hormone overproduction may result in amenorrhea. Classic signs and symptoms include an enlarged thyroid (goiter), nervousness, heat intolerance, diaphoresis, tremors, palpitations, tachycardia, dyspnea, weakness, and weight loss despite increased appetite.
Turner’s syndrome
Primary amenorrhea and failure to develop secondary sex characteristics may signal this syndrome of genetic ovarian dysgenesis. Typical features include short stature, webbing of the neck, low nuchal hairline, a broad chest with widely spaced nipples and poor breast development, underdeveloped genitalia, and edema of the legs and feet.
Uterine hypoplasia
Primary amenorrhea results from underdevelopment of the uterus, which is detectable on physical examination.
Other causes
Drugs
Busulfan, chlorambucil, injectable or implanted contraceptives, cyclophosphamide, and phenothiazines may cause amenorrhea. Hormonal contraceptives may cause anovulation and amenorrhea after they’re discontinued.
Radiation therapy
Irradiation of the abdomen may destroy the endometrium or ovaries, causing amenorrhea.
Surgery
Surgical removal of both ovaries or the uterus produces amenorrhea.
Special considerations
In patients with secondary amenorrhea, physical and pelvic examinations must rule out pregnancy before diagnostic testing begins. Typical tests include progestin withdrawal, serum hormone and thyroid function studies, and endometrial biopsy.
Pediatric pointers
Adolescent girls are especially prone to amenorrhea caused by emotional upsets, typically stemming from school, social, or family problems.
Geriatric pointers
In women older than age 50, amenorrhea usually represents the onset of menopause.
Patient counseling
After diagnosis, answer the patient’s questions about the type of treatment that will be provided and its expected outcome. Because amenorrhea can cause severe emotional distress, provide emotional support. Be sure to encourage the patient to discuss her fears and, if necessary, refer her for psychological counseling.
Pictures
Book Source Details
- Book Title: Professional Guide to Signs & Symptoms (Fifth Edition)
- Author(s): Springhouse
- Year of Publication: 2006
- Copyright Details: Professional Guide to Signs & Symptoms (Fifth Edition), Copyright © 2006 Lippincott Williams & Wilkins.
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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