HYPOMENORRHEA AND AMENORRHEA
Combining the anatomy of the female genital tract with the
endocrine system will key in on the major sources of absent or diminished
menstrual flow. It is perhaps best to begin at the bottom and work upward to
the head.
-
Female genital tract. Such congenital anomalies as an imperforate
hymen, imperforate vagina, cervical stenosis, double uterus, or the complete
absence of any one or more of these organs would obviously cause amenorrhea.
Radiation therapy may destroy the endometrium so that it cannot respond to
female hormones. Pregnancy is the most common cause of amenorrhea, and it
must be considered the cause of sudden onset of amenorrhea in an apparently
healthy woman until proven otherwise. Excessive blood levels of endogenous
or exogenous estrogen or progesterone will cause amenorrhea. The tubes
should immediately suggest an ectopic pregnancy as the cause, although
spotting and metrorrhagia are frequent in these cases.
- Ovary. The mnemonic MINTS serves well in subdividing the
causes here.
- M—Malformations of the ovary include Turner syndrome (where the
ovaries are reduced to a fibrotic, pea-sized nodule), Stein–Leventhal
syndrome, and other congenital cysts. Acquired malformations suggest the
atrophy of menopause, which may occur as early as the late 20s.
- I—Intoxication includes the ovarian dysfunction of exogenous
hormones, irradiation, chronic alcoholism, or drug addiction. I for
inflammation helps to recall autoimmune oophoritis. I for
idiopathic helps to recall idiopathic ovarian failure.
- N—Neoplasms of the ovary frequently cause amenorrhea, especially if
they secrete hormones or are bilateral. The arrhenoblastomas, granulosa cell
and theca cell tumors, and cystadenocarcinomas must be considered in this
category.
- T—Trauma as a cause of amenorrhea is well known, but this is
generally due to diffuse body
trauma such as an automobile crash, severe burns, or
extensive
surgery.
Direct trauma to the ovary merely reminds one that oophorectomy can cause
amenorrhea. Emotional trauma is probably a more common cause of amenorrhea
than any of the above.
- S—Systemic disease suggests the amenorrhea of leukemia, Hodgkin
lymphoma, chronic nephritis, fever, and severe malnutrition.
- Thyroid. It is well known that hyperthyroidism causes hypomenorrhea
or amenorrhea and hypothyroidism causes hypermenorrhea; however, the exact
reverse may occur.
- Adrenal gland. Visualizing this organ should stimulate the recall
of amenorrhea in the adrenogenital syndrome of adrenal hyperplasia or
carcinomas and in Addison disease.
- Pituitary gland. MINT is a useful mnemonic here also.
- M—Malformations here are Fröhlich syndrome and Chiari–Frommel
syndrome, but perhaps more important is the reduced output of pituitary
hormone in many states of congenital mental retardation and brain damage.
- I—Inflammation suggests the hypopituitarism of sarcoid and TB.
- N—Neoplasm suggests the largest group of causes of hypopituitarism,
including chromophobe adenomas and basophilic adenomas.
- T—Trauma recalls the hypopituitarism of postpartum hemorrhage and
amniotic fluid emboli or Sheehan syndrome.
Approach to the Diagnosis
Obviously the first thing to do is rule out pregnancy both by
examination and a pregnancy test, preferably the serum β -subunit human
chorionic gonadotropin (HCG). One must keep an ectopic pregnancy in mind
even if the examination is normal and plan follow-up examinations and
ultrasonography should the situation warrant. Altered secondary sex
characteristics should be noted. If the examination fails to show evidence
of pregnancy, congenital anomalies, or tumors of the ovaries, the physician should order thyroid
function studies, a Wassermann test, CBC, and sedimentation rate. If these
tests are normal, a gynecologist should be consulted. The gynecologist may
give a test dose of intramuscular progesterone to prove that the endometrium
functions well. He or she may do a D & C first. Then serum or urine FSH,
LH, and prolactin levels are done; if the FSH level is high, the ovary is
probably the site of the trouble. If the levels are low, even after
gonadotropin-releasing factor (GRF) is administered, the pituitary is
responsible. X-rays of the skull, CT scans, culdoscopy, and exploratory
laparotomy all share their place in the workup.
CASE PRESENTATION #52
A 34-year-old white mother of three complained of amenorrhea and weight
loss. A pregnancy test was negative. She has been under a lot of emotional
distress for several months and has lost her appetite.
Pictures
Book Source Details
- Book Title: Differential Diagnosis in Primary Care
- Author(s): R. Douglas Collins MD, FACP
- Year of Publication: 2007
- Copyright Details: Differential Diagnosis in Primary Care, Copyright © 2007 Lippincott Williams & Wilkins.
Other Book Chapters Related to Amenorrhea
Read excerpts from these other book chapters related to Amenorrhea:
Medical Books Excerpts
- AMENORRHEA
- "Algorithmic Diagnosis of Symptoms and Signs" (2003)
- [ read ]
- Amenorrhea
- "Handbook of Signs & Symptoms (Third Edition)" (2006)
- [ read ]
- Amenorrhea
- "A Pocket Manual of Differential Diagnosis" (1999)
- [ read ]
- Amenorrhea
- "Professional Guide to Diseases (Eighth Edition)" (2005)
- [ read ]
- Amenorrhea
- "Professional Guide to Signs & Symptoms (Fifth Edition)" (2006)
- [ read ]
- Amenorrhea
- "The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter" (2000)
- [ read ]
- Amenorrhea
- "Signs & Symptoms: A 2-in-1 Reference for Nurses" (2007)
- [ read ]
Copyright Details: Differential Diagnosis in Primary Care, Copyright © 2008 Williams & Wilkins.
More About Causes of Amenorrhea
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