|
|
|
Overview |
|
|
Definition |
|
Amenorrhea is the absence of menses. Primary amenorrhea is defined as the
failure of menses to begin once a woman reaches 16 years of age, whether or not
other pubertal changes such as breast development/pubic or axillary hair are
present. Secondary amenorrhea is the absence of menses for the length of time
equal to three consecutive normal menstrual cycles in a woman who has previously
experienced cyclical menses. Interference with hypothalamic/pituitary
functioning plays a major role in the disorder, and the resultant
"hypoestrogenemic amenorrhea" may play a role in the development of
cardiovascular disease, osteoporosis, and infertility. Amenorrhea may be present
with other conditions or abnormalities, including hirsutism, obesity, and
galactorrhea. Incidence of primary amenorrhea in U.S. is 2.5% of female
population.
|
|
|
Etiology |
|
Generally, the causes of amenorrhea include certain genetic defects, anatomic
abnormalities, ovarian failure, or hypothalamic, pituitary, or other endocrine
dysfunction.
- Pregnancy—high hCG:
(Primary—even in denial of
intercourse/Secondary)
- Hypothalamic/pituitary
dysfunction—low-normal follicle-stimulating hormone
(FSH): Interferes with GnRH production, therefore pituitary gonadotropin
secretion (Primary/Secondary)
- Ovarian—high FSH: Dysfunction/dysgenesis of
ovaries (Primary); premature ovarian failure (before the age of 40)
(Secondary)
- Hyperandrogenism—low-normal FSH: Secretion
of excessive testosterone (Primary/Secondary)
- Pseudohermaphroditism—high luteinizing
hormone (LH): Defective testosterone synthesis with excessive testosterone
levels (Primary)
- Uterine—normal FSH: Absent or malformed
uterus (Primary); intrauterine infection, endometritis (Secondary)
- Menopause—high FSH: Beginning as early as
age 40 (Secondary)
- Normal delayed onset (Primary)
Related causes:
- Breast-feeding
- After stopping oral contraceptive use
- Diabetes mellitus
- Tuberculosis
- Stress
- Psychological disorders
- Brain disease
- Genetic defect
- Testicular Feminization Syndrome
- Malnutrition/extreme weight loss (anorexia)
- Strenuous exercise of long duration
- Extreme obesity
- Drug abuse
- Cyanotic congenital heart disease
- Drug therapies—steroids, danazol
- Turner's Syndrome
|
|
|
Risk Factors |
|
- Genetic deficiencies
- Endocrine system disorders
- Extreme athletic training
- Psychological stresses
|
|
|
Signs and Symptoms |
|
In addition to the obvious absence of menses, there may be other symptoms
related to the particular cause of the amenorrhea. They include:
- Primary: Headaches, blood pressure/visual field abnormalities, acne,
short stature (Turner's syndrome), tall stature
(eunuchoidism/gigantism)
- Secondary: Nausea, breast enlargement, hot flushes, headaches, visual
field abnormalities, thirst, polyuria, goiter, skin darkening, anorexia,
alcoholism, Cushing's syndrome, cirrhosis, renal
failure
|
|
|
Differential
Diagnosis |
|
- Primary and/or sexual infantilism: Differentiate between gonadal
dysgenesis and hypopituitarism.
- Rule out pregnancy.
- Anatomical variants or tumor mass through
examination
|
|
|
Diagnosis |
|
|
Physical Examination |
|
- Breasts may or may not be developed; pubic and axillary hair may or
may not be present; external genitalia/reproductive organs may be abnormal or
absent.
- History and physical examination should determine the cause of
amenorrhea.
|
|
|
Laboratory Tests |
|
- Pregnancy test (serum or urine hCG)
- Cervical mucus/endometrium analysis
- Serum analysis: GnRH, LH, FSH, thyroid-stimulating hormone (TSH), T3,
T4, prolactin, estrogen, testosterone levels
- Renal/hepatic function
- Plasma potassium
|
|
|
Pathology/Pathophysiology |
|
- Dependent upon underlying
disorder
|
|
|
Imaging |
|
Frequently not necessary. Imaging studies could include:
- CT/MRI of head for brain/pituitary disease
- MRI of hypothalamus if high prolactin levels
- Pelvic ultrasound
|
|
|
Other Diagnostic
Procedures |
|
- Detailed medical history, including prior menstrual cycles
- Physical examination to determine degree of breast development;
presence of pubic and axillary hair in pubescent girls
- Examine external genitalia/reproductive organs: presence of
uterus
- Chromosome analysis
- Trial period—usually 10
days—with progesterone and/or MPA or estrogen. If
bleeding follows withdrawal, reproductive system is
functional.
|
|
|
Treatment Options |
|
|
Treatment Strategy |
|
Treat according to underlying cause.
- Pituitary tumors: Bromocriptine to inhibit prolactin secretion;
surgical removal; radiation therapy
- Developmental abnormalities: Hormone therapy; surgery; psychosocial
counseling and support
- Oral contraceptives or hormones to artificially induce
menses
- Estrogen replacement therapy for hypogonadism/hysterectomy/post
menopause
|
|
|
Drug Therapies |
|
- Estrogen replacement therapy: Greatly reduces risk of cardiovascular
disease and inhibits osteoporosis. Conjugated estrogens 0.625 to 1.25 mg/day; or
on days 1 to 25 of calendar month (0.3 mg/day prevents bone loss). Women with
intact uterus should receive progestin to reduce risk of estrogen-induced
endometrial carcinoma.
- Medroxyprogesterone acetate (MPA)—progestin
of choice—is given at 5 to 10 mg/day on days 16 to 25
of calendar month
- Alternative estrogen replacement: Includes ethinyl estradiol (20 or
50 mcg); estradiol (0.5, 1, 2 mg); Selective Estrogen Receptor Modulators
(SERMs) such as raloxifene and Evista for patients refusing estrogen but at-risk
for osteoporosis
- Progesterone: For ovarian cysts or some intrauterine disorders (if no
pregnancy desired)
- Pulsatile GnRH: To stimulate reproductive function
- Long-acting GnRH analogs: To suppress reproductive
function
- Specific drugs to treat underlying
disorders
|
|
|
Complementary and Alternative
Therapies |
|
Treating amenorrhea with alternative therapies may be effective in aiding the
body to metabolize hormones efficiently while ensuring that the nutritional
requirements for hormone production are met. Begin with nutritional support,
vitamins and minerals, and essential fatty acids. Herbal treatment should begin
with Vitex alone. Other herbs may be added according to underlying
etiology. Minimum length of treatment is three months. |
|
|
Nutrition |
|
Minimize refined foods, as they deplete the body of magnesium and other
essential nutrients which are needed for normal hormone production. Limit animal
products, as they are a source of saturated fats and exogenous estrogens. Limit
the Brassica family of vegetables (cabbage, broccoli, brussel sprouts,
cauliflower, kale) because they inhibit thyroid function. Eliminate
methylxanthines (coffee, chocolate), as they place a burden on the liver and may
compromise appropriate hormone ratios. Include whole grains, organic vegetables,
and omega-3 fats (cold-water fish, nuts, and seeds).
- Calcium (1,000 mg/day), magnesium (600 mg/day), vitamin D (200 to 400
IU/day), vitamin K (1 mg/day), and boron (1 to 3 mg/day) help to optimize bone
density and are needed for hormone production.
- Iodine (up to 600 mcg/day), tyrosine (200 mg one to two times/day),
zinc (30 mg/day), vitamin E (800 IU/day), vitamin A (10,000 to 15,000 IU/day),
vitamin C (1,000 mg tid), and selenium (200 mcg/day) are needed for thyroid
health and hormone balance.
- B6 (200 mg/day) is a specific therapy which may reduce high prolactin
levels caused by pituitary tumors.
- Essential fatty acids: Flaxseed, evening primrose, or borage oil
(1,000 to 1,500 mg one to two times/day) to enhance hormone
production
|
|
|
Herbs |
|
Herbs are generally a safe way to strengthen and tone the body's systems. As
with any therapy, it is important to ascertain a diagnosis before pursuing
treatment. Herbs may be used as dried extracts (capsules, powders, teas),
glycerites (glycerine extracts), or tinctures (alcohol extracts). Unless
otherwise indicated, teas should be made with 1 tsp. herb per cup of hot water.
Steep covered 5 to 10 minutes for leaf or flowers, and 10 to 20 minutes for
roots. Drink 2 to 4 cups/day. Tinctures may be used singly or in combination as
noted.
Amenorrhea needs to be treated with a well-balanced formula that supports
pituitary function and hormone activity, as well as addressing the underlying
cause. Balancing hormones should be undertaken with the supervision of a
qualified practitioner.
- Chaste tree (Vitex agnus cactus) helps to normalize pituitary
function but must be taken long term (12 to 18 months) for maximum
effectiveness. To be used only under physician supervision with hormone
therapy.
- Black cohosh (Cimicifuga racemosa), licorice (Glycyrrhiza
glabra), and squaw vine (Mitchella repens) help to balance estrogen
levels. Licorice is contraindicated in hypertension.
- Chaste tree, wild yam (Dioscorea villosa), and lady's mantle
(Alchemilla vulgaris) help to balance progesterone levels.
- Kelp (Laminaria hyperborea), bladderwrack (Fucus
vesiculosus), oatstraw (Avena sativa), and horsetail (Equisetum
arvense) are rich in minerals that support the thyroid.
- Milk thistle (Silybum marianum), dandelion root (Taraxacum
officinale), and vervain (Verbena hastata) support the liver and may
help restore hormone ratios.
- Sage (Salvia officinalis) is a specific herb for reducing high
prolactin levels due to pituitary
tumors.
|
|
|
Homeopathy |
|
Constitutional homeopathic support can be very effective in addressing
underlying causes of amenorrhea. This should be done by an experienced
homeopathic practitioner. |
|
|
Physical Medicine |
|
The following methods help to increase circulation and relieve pelvic
congestion.
- Castor oil pack. Used externally, castor oil is a powerful
anti-inflammatory. Apply oil directly to skin, cover with a clean soft cloth
(e.g., flannel) and plastic wrap. Place a heat source (hot water bottle or
heating pad) over the pack and let sit for 30 to 60 minutes. For best results,
use for three consecutive days.
- Contrast sitz baths. Use two basins that can be comfortably sat in.
Fill one with hot water, one with cold water. Sit in hot water for three
minutes, then in cold water for one minute. Repeat this three times to complete
one set. Do one to two sets per day three to four days per
week.
|
|
|
Acupuncture |
|
Treatment of amenorrhea with acupuncture may be beneficial for normalizing
hormone production and endocrine function. In some cases it may restore regular
menstrual cycles. |
|
|
Massage |
|
Therapeutic massage may be helpful in relieving the effects of stress and
improving endocrine function. |
|
|
Patient Monitoring |
|
Track progress of therapy. |
|
|
Other
Considerations |
|
Although the mechanism is not known, the fat cell hormone, "leptin," is
necessary for a healthy reproductive system. |
|
|
Prevention |
|
- When cause is unknown, prevention is not possible
- Attention to nutrition/appropriate body weight/alcohol and drug
abuse
- Stress-relieving techniques
- Avoid extreme exercise
regimens
|
|
|
Complications/Sequelae |
|
- Emotional and psychological distress, particularly in congenital
defects and if pregnancy is desired and unattainable
- Hot flushes, mood changes, depression, and vaginal dryness in
estrogen deficiency
- Long-term estrogen replacement increases risk of breast cancer,
melanoma, seizures; 10-fold increased risk of endometrial carcinoma if unopposed
with progestin. May cause weight gain, tender breasts, edema,
and—rarely—venous thrombosis,
and hypertriglyceridemia
|
|
|
Prognosis |
|
- Not detrimental to overall health
- Prognosis is good where underlying disorders are correctly diagnosed
and treated (normal delay of onset, weight issues, chronic illnesses, benign
tumors, ovarian cysts, hormone imbalances, and similar causes; poor for
congenital abnormalities, testicular feminization syndrome, true
hermaphroditism, cystic fibrosis, Prader-Willi syndrome, and similar
disorders
- After pregnancy and breast-feeding cease: Menses usually return
spontaneously
- Discontinuation of oral contraceptives: Menses usually rectify
spontaneously within 24 months
- Post-menopause/hysterectomy: Menses cease
- Irreversible amenorrhea: Where this causes emotional distress,
induction of pseudo-menstruation may be possible through drug therapy if uterus
is present
|
|
|
Pregnancy |
|
- Impossible in certain congenital abnormalities
- Fertility may be affected
- Complications such as incomplete spontaneous abortion, ectopic
pregnancy, trophoblastic
disease
|
|
|
References |
|
Mowrey DB. The Scientific Validation of Herbal Medicine. New Canaan,
Conn: Keats Publishing; 1988.
National Institutes of Health: Accessed at www.nih.gov on January 16,
1999.
Tierney LM, McPhee SJ, Papadakis MA, eds. Current Medical Diagnosis &
Treatment 1999. 38th ed. Stamford, Conn: Appleton & Lange; 1999.
Tyler VE. Herbs of Choice: The Therapeutic Use of Phytomedicinals.
Binghamton, NY: Pharmaceutical Products Press; 1994.
Ullman D. Discovering Homeopathy. Berkeley, Calif: North Atlantic
Books; 1991. |
|
Copyright © 2000 Integrative Medicine
Communications This publication contains
information relating to general principles
of medical care that should not in any event be construed as specific
instructions for individual patients. The publisher does not accept any
responsibility for the accuracy of the information or the consequences arising
from the application, use, or misuse of any of the information contained herein,
including any injury and/or damage to any person or property as a matter of
product liability, negligence, or otherwise. No warranty, expressed or implied,
is made in regard to the contents of this material. No claims or endorsements
are made for any drugs or compounds currently marketed or in investigative use.
The reader is advised to check product information (including package inserts)
for changes and new information regarding dosage, precautions, warnings,
interactions, and contraindications before administering any drug, herb, or
supplement discussed herein. | |