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Diseases » Infertility » Causes
 

Causes of Infertility

Contents

List of causes of Infertility

Following is a list of causes or underlying conditions (see also Misdiagnosis of underlying causes of Infertility) that could possibly cause Infertility includes:

More causes: see full list of causes for Infertility

Causes of Infertility (Diseases Database):

The follow list shows some of the possible medical causes of Infertility that are listed by the Diseases Database:

Source: Diseases Database

Infertility as a complication of other conditions:

Other conditions that might have Infertility as a complication may, potentially, be an underlying cause of Infertility. Our database lists the following as having Infertility as a complication of that condition:

Infertility as a symptom:

Conditions listing Infertility as a symptom may also be potential underlying causes of Infertility. Our database lists the following as having Infertility as a symptom of that condition:

Medications or substances causing Infertility:

The following drugs, medications, substances or toxins are some of the possible causes of Infertility as a symptom. This list is incomplete and various other drugs or substances may cause your symptoms. Always advise your doctor of any medications or treatments you are using, including prescription, over-the-counter, supplements, herbal or alternative treatments.

See full list of 36 medications causing Infertility


Medical news summaries relating to Infertility:

The following medical news items are relevant to causes of Infertility:

Cause statistics for Infertility:

The following are statistics from various sources about the causes of Infertility:

  • About 25% of infertility cases due to STDs in the US (American Society of Reproductive Medicine)
  • 30-40% of cases are reportedly due to male infertility compared to female infertility
  • 15% of infertilities due to Pelvic Inflammatory Disease in the US (American Social Health Association)
  • more statistics...»

Related information on causes of Infertility:

As with all medical conditions, there may be many causal factors. Further relevant information on causes of Infertility may be found in:

Causes of Infertility: Online Medical Books

16 MEDICAL BOOKS ONLINE! Review excerpts from medical books online, free, without registration, for more information about the causes of Infertility.

Amenorrhea: Differential Diagnosis
(In a Page: Signs and Symptoms)

Secondary amenorrhea

  • More common than primary
  • Hypothyroidism
  • Pregnancy
    • Polycystic ovarian syndrome
      –Peripubertal onset of menstrual irregularities with hyperandrogenism (hirsutism) and obesity
    • Functional hypothalamic amenorrhea due to stress, eating disorders, weight loss, or excessive exercise
    • Hyperprolactinemia
      –Galactorrhea
      –Secondary to medications (e.g., OCP, phenothiazines) or primary due to pituitary adenoma
      Primary amenorrhea
      • Constitutional delay of puberty
        –Family history of late puberty
        –Normal development at later age
        • Outflow tract disorders
          –Transverse vaginal septum
          –Imperforate hymen
          –Pelvic or lower abdominal pain are common presenting symptoms
        • Complete androgen insensitivity syndrome
          –X-linked recessive disorder (46,XY)
          –Resistance to testosterone due to a defect in the androgen receptor
          –Testes may be palpable in labia or inguinal area
      • Müllerian agenesis (Mayer-Rokitansky-Hauser syndrome)
        –Agenesis of fallopian tubes, uterus, vagina
        –Normally functioning ovaries
        Less common etiologies
        • Turner's syndrome
          –45,X gonadal dysgenesis
          –Ovaries replaced with fibrous tissue
        • Ovarian failure (autoimmune oophoritis or secondary to chemotherapy or radiation injury)
        • 5-αreductase deficiency
        • 17-αhydroxylase deficiency
        • Craniopharyngioma
        • Hypopituitarism
        • Congenital GnRH deficiency (Kallman's syndrome if associated with anosmia)
        • Cushing's syndrome

» READ BOOK EXCERPT ONLINE »

Source: In a Page: Signs and Symptoms, 2004

Amenorrhea – Secondary: Differential Diagnosis
(In A Page: Pediatric Signs and Symptoms)

  • Pregnancy
    –Most common cause
  • Anovulatory cycles
    –Common during first few years after menarche
    • Hyperandrogenism
      –Polycystic ovary syndrome: Problems with fertility are common, LH/FSH ratio is greater than 2.5/1
      –Some adrenal tumors
      –Congenital adrenal hyperplasia
      –Exposure to anabolic steroids
    • Major illness or stress
    • Large changes in weight
      –Anorexia nervosa
    • Hypothyroidism
    • Prolactinoma
    • Other causes of hyperprolactinemia
      –Marijuana
      –Opioids
      –Antidepressants
      –Phenothiazines
    • Hypothalamic-pituitary failure
      –Pituitary tumor
      –Sheehan syndrome
      –Cranial irradiation
    • Ovarian failure
      –Autoimmune destruction
      –Infarction due to gonadal torsion
      –Chemotherapy or radiation
      –Idiopathic
    • Oral contraceptives
      –May delay return to regular menses
    • Cushing syndrome
    • Uterine synechiae (Asherman syndrome)
    • Chiari-Frommel syndrome

» READ BOOK EXCERPT ONLINE »

Source: In A Page: Pediatric Signs and Symptoms, 2007

Amenorrhea – Primary: Differential Diagnosis
(In A Page: Pediatric Signs and Symptoms)

  • Constitutional delay of puberty
    –Most common cause
    • Anatomic causes
      –Uterine aplasia (Mayer-Rokitansky syndrome)
      –Vaginal aplasia
      –Imperforate hymen
  • Hypogonadotropic hypogonadism
    –Decreased FSH
    –Congenital and acquired etiologies
  • Congenital hypogonadotropic hypogonadism
    –Kallmann syndrome
    –Panhypopituitarism
    • Aquired hypogonadotropic hypogonadism
      –Malnutrition
      –Stress
      –Anorexia nervosa
      –Inflammatory bowel disease
      –Celiac disease
      –Excessive exercise
      –Pituitary tumor (e.g., prolactinoma or craniopharyngioma)
  • Hypergonadotropic hypogonadism
    –Increased FSH
    –Gonadal dysgenesis (Turner syndrome is the most common)
    –Ovarian failure: Autoimmune oophoritis, galactosemia, effects of chemotherapy or radiation, FSH or LH receptor mutations (rare)
    • Abnormal thyroid function
    • Androgen insensitivity syndrome
    • Congenital adrenal hyperplasia and other causes of hyperandrogenism
    • Medications
    • Pregnancy

» READ BOOK EXCERPT ONLINE »

Source: In A Page: Pediatric Signs and Symptoms, 2007

Amenorrhea: Medical causes
(Handbook of Signs & Symptoms (Third Edition))

❑ 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 the rapid onset of virilizing signs is usually indicative of an adrenal tumor.

❑ 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 typically appear.

❑ Adrenocortical hypofunction. In addition to 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, a 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 the absence of secondary sex characteristics.

❑ Congenital absence of the uterus. Primary amenorrhea occurs with congenital absence of the uterus. The patient may 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 results in primary amenorrhea and the absence of secondary sex characteristics.

❑ Ovarian insensitivity to gonadotropins. A hormonal disturbance, ovarian insensitivity to gonadotropins leads to amenorrhea and an absence of secondary sex characteristics.

❑ Pituitary tumor. Amenorrhea may be the first sign of a pituitary tumor. Associated findings include headache; visual disturbances, such as bitemporal hemianopsia; 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. Or, periods of profuse bleeding may alternate with periods of amenorrhea. Obesity, hirsutism, slight deepening of the voice, and enlarged, “oysterlike” ovaries may also accompany this disorder.

❑ 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. With pseudocyesis, amenorrhea may be accompanied by lordosis, abdominal distention, nausea, and breast enlargement.

❑ Testicular feminization. Primary amenorrhea may signal this form of male pseudohermaphroditism. The patient, outwardly female but genetically male, shows breast and external genital development 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.

» READ BOOK EXCERPT ONLINE »

Source: Handbook of Signs & Symptoms (Third Edition), 2006

Amenorrhea: Causes and incidence
(Professional Guide to Diseases (Eighth Edition))

Amenorrhea is normal before puberty, after menopause, or during pregnancy and lactation; it’s pathologic at any other time. It usually results from anovulation due to hormonal abnormalities, such as decreased secretion of estrogen, gonadotropins, luteinizing hormone, and follicle-stimulating hormone; lack of ovarian response to gonadotropins; or constant presence of progesterone or other endocrine abnormalities.

Amenorrhea may also result from the absence of a uterus, endometrial damage, or from ovarian, adrenal, or pituitary tumors. It’s also linked to emotional disorders and is common in patients with severe disorders, such as depression and anorexia nervosa. Mild emotional disturbances tend merely to distort the ovulatory cycle, while severe psychic trauma may abruptly change the bleeding pattern or may completely suppress one or more full ovulatory cycles. Amenorrhea may also result from malnutrition, intense exercise, and prolonged hormonal contraceptive use. The incidence of primary amenorrhea in the United States is less than 1%. The incidence of secondary amenorrhea (due to some other cause than pregnancy) is about 4%.

» READ BOOK EXCERPT ONLINE »

Source: Professional Guide to Diseases (Eighth Edition), 2005

Female infertility: Causes and incidence
(Professional Guide to Diseases (Eighth Edition))

The causes of female infertility may be functional, anatomic, or psychosocial:

❑ Functional causes: complex hormonal interactions determine the normal function of the female reproductive tract and require an intact hypothalamic-pituitary-ovarian axis — the system that stimulates and regulates the hormone production necessary for normal sexual development and function. Any defect or malfunction of this axis can cause infertility due to insufficient gonadotropin secretions (both luteinizing hormone [LH] and follicle-stimulating hormone). The ovary controls, and is controlled by, the hypothalamus through a system of negative and positive feedback mediated by estrogen production. Insufficient gonadotropin levels may result from infections, tumors, or neurologic disease of the hypothalamus or pituitary gland. Hypothyroidism also impairs fertility.

❑ Anatomic causes include the following:

– Ovarian factors are related to anovulation and oligo-ovulation (infrequent ovulation) and are a major cause of infertility. Pregnancy or direct visualization provides irrefutable evidence of ovulation. Presumptive signs of ovulation include regular menses, cyclic changes reflected in basal body temperature readings, postovulatory progesterone levels, and endometrial changes due to the presence of progesterone. Absence of presumptive signs suggests anovulation. Ovarian failure, in which no ova are produced by the ovaries, may result from ovarian dysgenesis or premature menopause. Amenorrhea is often associated with ovarian failure. Oligo-ovulation may be due to a mild hormonal imbalance in gonadotropin production and regulation and may be caused by polycystic disease of the ovary or abnormalities in the adrenal or thyroid gland that adversely affect hypothalamic-pituitary functioning.

– Uterine fibroids or uterine abnormalities rarely cause infertility; however, uterine abnormalities may include congenitally absent uterus, bicornuate or double uterus, leiomyomas, or Asherman’s syndrome, in which the anterior and posterior uterine walls adhere because of scar tissue formation.

– Tubal and peritoneal factors are due to faulty tubal transport mechanisms and unfavorable environmental influences affecting the sperm, ova, or recently fertilized ovum. Tubal loss or impairment may occur secondary to ectopic pregnancy.

Frequently, tubal and peritoneal factors result from anatomic abnormalities: bilateral occlusion of the tubes due to salpingitis (resulting from gonorrhea, tuberculosis, or puerperal sepsis), peritubal adhesions (resulting from endometriosis, pelvic inflammatory disease [PID], diverticulosis, or childhood rupture of the appendix), and uterotubal obstruction (due to tubal spasm).

– Cervical factors may include malfunctioning cervix that produces deficient or excessively viscous mucus and is impervious to sperm, preventing entry into the uterus. In cervical infection, viscous mucus may contain spermicidal macrophages. Cervical antibodies have also been found to immobilize sperm.

❑ Psychosocial problems probably account for relatively few cases of infertility. Occasionally, ovulation may stop under stress due to failure of LH release. The frequency of intercourse may be related. More often, however, psychosocial problems result from, rather than cause, infertility.

About 10% to 20% of couples will be unable to conceive after 1 year of attempting to become pregnant. Healthy couples who are younger than age 30 and having intercourse regularly only have a 25% to 30% change of getting pregnant each month. A woman’s peak fertility is in her early 20s. As a woman ages beyond 35 (and particularly beyond 40), the likelihood of conception is less than 10% per month.

» READ BOOK EXCERPT ONLINE »

Source: Professional Guide to Diseases (Eighth Edition), 2005

Male infertility: Causes and incidence
(Professional Guide to Diseases (Eighth Edition))

Some factors associated with male infertility include:

❑ varicocele, a mass of dilated and tortuous varicose veins in the spermatic cord

❑ semen disorders, such as volume or motility disturbances and inadequate sperm density

❑ proliferation of abnormal or immature sperm, with variations in the head’s size and shape

❑ systemic disease, such as diabetes mellitus, neoplasms, hepatic and renal diseases, and viral disturbances, especially mumps-related orchitis

❑ genital infections, such as gonorrhea, tuberculosis, and herpes

❑ disorders of the testes, such as cryptorchidism, Sertoli-cell-only syndrome, and ductal obstruction (caused by absence or ligation of vas deferens or infection)

❑ genetic defects, such as Klinefelter’s and Reifenstein’s syndromes

❑ immunologic disorders, such as autoimmune infertility and allergic orchitis

❑ endocrine imbalances that disrupt pituitary gonadotropins, inhibiting spermatogenesis, testosterone production, or both (as in Kallmann’s syndrome, panhypopituitarism, hypothyroidism, and congenital adrenal hyperplasia)

❑ chemicals and drugs that can inhibit gonadotropins or interfere with spermatogenesis, such as arsenic, methotrexate, medroxyprogesterone, nitrofurantoin, monoamine oxidase inhibitors, and some antihypertensives

❑ sexual problems, such as erectile dysfunction, ejaculatory incompetence, and low libido.

Age, occupation, and traumatic injury to the testes can also contribute to male infertility. Approximately 30% to 40% of infertility problems in the United States are attributed to the male.

» READ BOOK EXCERPT ONLINE »

Source: Professional Guide to Diseases (Eighth Edition), 2005

Amenorrhea: Medical causes
(Professional Guide to Signs & Symptoms (Fifth Edition))

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.

» READ BOOK EXCERPT ONLINE »

Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

Infertility: Differential Overview
(Field Guide to Bedside Diagnosis)

Female Factors

❑ Anovulation

❑ Tubal obstruction

❑ Endometriosis

❑ Polycystic ovary disease

❑ Luteal phase dysfunction

❑ Cervical factors

❑ Uterine leiomyoma

❑ Testicular feminization

Male Factors

❑ Genitourinary infection

❑ Erectile dysfunction

❑ Drugs

❑ Retrograde ejaculation

❑ Varicocele

❑ Germinal compartment failure

❑ Partial androgen resistance

❑ Hypogonadotrophic hypogonadism

❑ Primary hypogonadism

» READ BOOK EXCERPT ONLINE »

Source: Field Guide to Bedside Diagnosis, 2007

Secondary Amenorrhea: Differential Overview
(Field Guide to Bedside Diagnosis)

❑ Pregnancy

❑ Menopause

❑ Functional hypothalamic amenorrhea

❑ Drugs

❑ Anorexia nervosa

❑ Post-contraceptive

❑ Endometrial scarring

❑ Endocrinopathy

❑ Hyperprolactinemia

❑ Premature ovarian failure

❑ Polycystic ovary syndrome

❑ Chromophobe adenoma

❑ Ovarian tumors

❑ Panhypopituitarism

❑ Müllerian dysgenesis

» READ BOOK EXCERPT ONLINE »

Source: Field Guide to Bedside Diagnosis, 2007

Infertility, female: Causes
(Handbook of Diseases)

The causes of female infertility may be functional, anatomic, or psychological.

Functional causes

Complex hormonal interactions determine the normal function of the female reproductive tract and require an intact hypothalamic-pituitary-ovarian axis, a system that stimulates and regulates the production of hormones necessary for normal sexual development and function.

Any defect or malfunction of this system can cause infertility due to insufficient gonadotropin secretions (luteinizing hormone [LH] and follicle-stimulating hormone). The ovary controls and is controlled by the hypothalamus through a system of negative and positive feedback mediated by estrogen production. Insufficient gonadotropin levels may result from infections, tumors, or neurologic disease of the hypothalamus or pituitary gland. Hypothyroidism also impairs fertility.

Anatomic causes

The anatomic causes of female infertility include the following:

❑ Ovarian factors related to anovulation and oligo-ovulation (infrequent ovulation) are a major cause of infertility. Presumptive signs of ovulation include regular menses, cyclic changes reflected in basal body temperature readings, postovulatory progesterone levels, and endometrial changes due to the presence of progesterone. The absence of presumptive signs suggests anovulation.

Ovarian failure, in which the ovaries produce no ova, may result from ovarian dysgenesis or premature menopause. Amenorrhea is commonly associated with ovarian failure. Oligo-ovulation may be due to a mild hormonal imbalance in gonadotropin production and regulation and may be caused by polycystic disease of the ovary or abnormalities in the adrenal or thyroid gland that adversely affect hypothalamic-pituitary functioning.

❑ Uterine abnormalities may include a congenitally absent uterus, bicornuate or double uterus, leiomyomas, or Asherman’s syndrome, in which the anterior and posterior uterine walls adhere because of scar tissue formation.

❑ Tubal and peritoneal factors are due to faulty tubal transport mechanisms and unfavorable environmental influences that affect the sperm, ova, or recently fertilized ovum. Tubal loss or impairment may occur secondary to ectopic pregnancy.

For many patients, tubal and peritoneal factors result from anatomic abnormalities: bilateral occlusion of the tubes due to salpingitis (resulting from gonorrhea, tuberculosis, chlamydia, or other organisms), peritubal adhesions (resulting from endometriosis, pelvic inflammatory disease [PID], or childhood rupture of the appendix), and uterotubal obstruction due to tubal spasm.

❑ Cervical factors may include a malfunctioning cervix that produces deficient or excessively viscous mucus impervious to sperm, preventing entry into the uterus. The cervix may also be stenotic or dilated.

Clinical tip  If the patient’s cervix is dilated, make sure she isn’t pregnant.

With cervical infection, viscous mucus may contain spermicidal macrophages. Some cervical antibodies do immobilize sperm.

Psychological problems

Such problems probably account for relatively few cases of infertility. Occasionally, ovulation may stop because of stress, which results in failure of the body to release LH. Marital discord may affect the frequency of intercourse. Typically, psychological problems result from  —  rather than cause — infertility.

» READ BOOK EXCERPT ONLINE »

Source: Handbook of Diseases, 2003

Infertility, male: Causes
(Handbook of Diseases)

Factors that cause male infertility include:

❑ varicocele, a mass of dilated and tortuous varicose veins in the spermatic cord

❑ semen disorders, such as volume or motility disturbances or inadequate sperm density

❑ proliferation of abnormal or immature sperm, with variations in the size and shape of the head

❑ systemic disease, such as diabetes mellitus, neoplasms, liver or kidney disease, or viral disturbances, especially mumps orchitis

❑ genital infection, such as gonorrhea, tuberculosis, or herpes

❑ disorders of the testes, such as cryptorchidism, Sertoli-cell–only syndrome, varicocele, ductal obstruction (caused by absence or ligation of the vas deferens or infection), hydrocele (collection of fluid in the testes), or infection (orchitis and epididymitis).

❑ genetic defects, such as Klinefelter’s syndrome (chromosomal pattern XXY, eunuchoidal habitus, gynecomastia, and small testes) or Reifenstein’s syndrome (chromosomal pattern 46XY, reduced testosterone, azoospermia, eunuchoid-ism, gynecomastia, and hypospadias)

❑ immune disorders, such as autoimmune infertility and allergic orchitis

❑ endocrine imbalance (rare) that disrupts pituitary gonadotropins, inhibiting spermatogenesis, testosterone production, or both; such imbalances occur with Kallmann’s syndrome, panhypopituitarism, hypothyroidism, and congenital adrenal hyperplasia

❑ chemicals and drugs that can inhibit gonadotropins or interfere with spermatogenesis, such as arsenic, methotrexate, medroxyprogesterone acetate, nitrofurantoin, monoamine oxidase inhibitors, and some antihypertensives

UNDER STUDY: Researchers have found a significant association between abnormally high serum lead levels and low fertilization rates in males and females. Couples with unexplained fertility problems should have their serum lead levels measured as part of an infertility evaluation.

❑ sexual problems, such as erectile dysfunction, ejaculatory incompetence, and low libido.

Other factors include age, occupation, trauma to the testes, and tight-fitting clothing that constricts the scrotum and affects sperm production.

» READ BOOK EXCERPT ONLINE »

Source: Handbook of Diseases, 2003

Amenorrhea: Medical causes
(Signs & Symptoms: A 2-in-1 Reference for Nurses)

Adrenal tumor

In a patient with an 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

In a patient with 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 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.

Anorexia nervosa

Anorexia nervosa, a psychological disorder, 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 and uterus

Congenital absence of the ovaries and uterus results in primary amenorrhea and absence of secondary sex characteristics. Primary amenorrhea occurs with congenital absence of the uterus. The patient may not 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.

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.

Pituitary infarction

Pituitary infarction usually causes postpartum failure to lactate and failure 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, vision 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

In polycystic ovary syndrome, menarche typically occurs at a normal age and is followed by irregular menstrual cycles, oligomenorrhea, and secondary amenorrhea or periods of profuse bleeding may alternate with periods of amenorrhea. Obesity, hirsutism, slight deepening of the voice, and enlarged, “oysterlike” ovaries may also accompany this disorder.

Pseudoamenorrhea

With 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.

Testicular feminization

Primary amenorrhea may signal testicular feminization, a form of male pseudohermaphroditism. The patient, outwardly female but genetically male, shows breast and external genital development 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 Turner’s syndrome, a 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.

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.

» READ BOOK EXCERPT ONLINE »

Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007

Amenorrhea: Medical causes
(Nursing: Interpreting Signs and Symptoms)

Adrenal tumor.Amenorrhea may be accompanied by acne, thinning scalp hair, hirsutism, increased blood pressure, truncal obesity, and psychotic personality changes. Asymmetrical ovarian enlargement in conjunction with the rapid onset of virilizing signs is usually indicative of an adrenal tumor.

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 typically appear.

Adrenocortical hypofunction.In addition to 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-lactationdisorders, 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 can cause either primary or secondary amenorrhea. Related findings include significant weight loss, a thin or emaciated appearance, compulsive behavior patterns, a 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 the absence of secondary sex characteristics.

Congenital absence of the uterus.Primary amenorrhea occurs with congenital absence of the uterus. The patient may 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 results in primary amenorrhea and the absence of secondary sex characteristics.

Ovarian insensitivity to gonadotropins.A hormonal disturbance, ovarian insensitivity to gonadotropins leads to amenorrhea and an absence of secondary sex characteristics.

Pituitary tumor.Amenorrhea may be the first sign of a pituitary tumor. Associated findings include headache; visual disturbances, such as bitemporal hemianopsia; 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. Periods of profuse bleeding may alternate with periods of amenorrhea. Obesity, hirsutism, slight deepening of the voice, and enlarged, “oysterlike” ovaries may also accompany this disorder.

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.With pseudocyesis, amenorrhea may be accompanied by lordosis, abdominal distention, nausea, and breast enlargement.

Testicular feminization.Primary amenorrhea may signal this form of male pseudohermaphroditism. The patient, outwardly female but genetically male, shows breast and external genital development 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.

» READ BOOK EXCERPT ONLINE »

Source: Nursing: Interpreting Signs and Symptoms, 2007

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