Amenorrhea

Amenorrhea Overview:

Amenorrhea is defined as the absence of menstrual periods.


Aetiology:

A minimum bodyweight of 48kg, and a fat content of 16-24% are required for menstruation to ocurr. For this reason it is common for women suffering from anorexia nervosa, chronic disease with convalescence, mal nutrition, and long distance runners to experience amenorrhea. 

+ Primary Amenorrhea

Young women who have never had menarche

Causes:

  • Chromosomal
    • Turner's
    • Androgen insufficiency syndrome
    • Congenital adrenal hyperplasia
  • Vaginal agenisis
  • Neuroendocrine disturbance
    • Stress
    • LOW
    • Excessive excercise
    • Chronic illness
    • Post OCP

+ Secondary Amenorrhea

Characterised by the absence of menses for 6 months or for longer. It can be differentiated via FSH levels.

  • FSH low: neuroendocrine stress: eg female athlete triad, prolactinoma
  • FSH normal: comorbid endocrine disease: eg PCOS, hypothyroidism
  • FSH high; premature ovarian insufficiency/failure, menopause

Causes:

  • Physiological
    • Pregnancy/lactation
    • Menopause
  • Endocrine
    • Hyperprolactinemia
    • Thyroid disturbance
    • Premature ovarian syndrome
  • Neruoendocrine
    • Female Athlete Triad
    • Starvation

+ Female Athlete Triad

  • Amenorrhea
  • Low bone mass (osteopenia, psteoporosis)
  • Eating behaviour disorders (low body weight, high excercise levels)

Excessive excercise is a form of chronic stress that the HPA axis then responds by reducing thyroid hormone levels, vitamin D, and increasing ACTRH and GnRH.

Amenorrhea and FSH Levels

FSH Levels Mechanism Examples
FSH Low Neuroendocrine stress (hypothalamus/pituitary) Female athlete triad, Prolactinoma
FSH Normal Comorbid endocrine disease PCOS, Hypothyroidism
FSH High Premature ovarian insufficiency/failure Menopause
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Symptoms:

Symptom

Symptom

Symptom

Symptom

Symptom

Symptom

Symptom


Comorbidities/Associated Conditions:

  • Prolonged amenorrhea reduces bone density
  • Acyclic oestrogen exposure causes hyperplasia of the endometrium
  • Often with concurrent and severe PMS

Diagnostic Considerations:

  • Pregnancy test (beta HCG)
  • Computerized tomography (CT) scan or magnetic resonance imaging (MRI) of pituitary area
  • Thyroid stimulating hormone
  • Plasma hormone levels of FSH & LH
  • Oestradiol
  • Prolactin
  • Testosterone
  • Progesterone withdrawal test: give a progestogen for 5 days. If the woman bleeds afterwards, she has oestrogen in her circulation and a uterus.
  • Ultrasound assessment of:
    • uterine size;
    • pregnancy;
    • ovarian size and morphology
    • follicular function.
  • Examination under anaesthesia if congenital abnormality:
    • assess the pelvic organs;
    • perform a laparoscopy to inspect the pelvic organs and to take a biopsy of the ovaries

Therapeutic Aims:

1. Rule Out Other Conditions First

Such as menopause, PCOS, pregnancy etc.

  • insert

2. Correct Hypothalamic Malfunction

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  • HPO Modulators (Vitex agnus-castus, Asparagus racemosus, Caulophyllum, Paeonia lactiflora, Cimicifuga racemosa)

3. Treat Any Associated Depression Or Anxiety

insert

  • Nervine Tonics ()
  • Thymoleptics (Hypericum perforatum)
  • Adaptogens (Withania somnifera)
  • Anxiolytics (Passiflora incarnata)

4. Treat Any Debility (If Applicable)

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  • Adaptogens (Withania somnifera, Panax ginseng, Angelica sinensis)
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Differential Diagnosis:

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Cautions:

Any woman within childbirth age with amenorrhea should have pregnancy ruled out.

 

Herbs For Amenorrhoea:

  • Asparagus racemosus
  • Vitex agnus-castus
  • Hypericum
  • Caulophyllum 
  • withania
  • angelica sinensis
  • panax ginseng
 

Author:

Justin Cooke

The Sunlight Experiment

Updated: October 2017


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