Lecture amenorrhea (no period)

2021-03-18 12:00 AM

Amenorrhea occupies one of the largest chapters in gynaecology, because of its important features not only in the field of reproduction.

General perception

By definition, amenorrhea is a non-period phenomenon for a specified period. That time is 18 years for primary amenorrhea, 3 months if there have been regular periods, or 6 months if there has been irregular periods in history, for secondary amenorrhea. People also differentiate "physiological amenorrhea" and "pathological amenorrhea". Physiological amenorrhea occurs during pregnancy, during howling. Some authors also classify the phenomenon of non-menstrual periods before puberty and after menopause into physiological amenorrhea. All remaining amenorrhea are pathological amenorrhea. In pathological amenorrhea, there is also pseudoamenorrhoea, which is actually menstrual bleeding, but the menstrual blood cannot escape because the cervix is ​​closed, the hymen does not basket or does not have a vagina. So unjustly known as the closing business.

Amenorrhea occupies one of the largest chapters in gynecology, because of its important features not only in the reproductive field but also in the health and life fields of the patient.

Amenorrhea can be distinguished from individual causes such as the lower region, the pituitary gland, the ovary, and the uterus. In addition, there are other causes, even more complicated, such as adrenal gland (Addison's disease, Cushing's disease ...), thyroid disease (mucosal edema, Basedow disease ...), due to disease. mental illness, malnutrition ..., even a combination of many reasons. During World War II, for example, in ancient Europe, up to 50% of women experienced amenorrhea due to fear associated with hunger.

In terms of endocrine, one can quantify sex hormones and gonadotropin hormones for differential diagnosis of the ovary (hypothalamus, pituitary ...). The most accurate and fastest is quantitative in the blood by methods of radioactive immunity (RIA, radio-immuno-assay), or by immunological methods EIA enzymes, enzymes inmuno, assay). If you see low sex hormones, the cause is the egg situation. Because of the lack of ovarian honors, the hypothalamus is not inhibited and the pituitary is stimulated.

To differentiate the causes between the hypothalamus and pituitary gland, it is necessary to quantify the hormone released, a method that has not been widely applied in clinical treatment because it is expensive and complicated. However, it is possible to try treatment with hormones released from the hypothalamus and then re-quantify gonadotropic hormones. If you see this increase, the cause is in the hypothalamus. If the gonadotropin does not increase, the cause is in the pituitary gland. These experimental treatments have not yet been widely applied in Vietnam because the cost of the method is also high.

To distinguish the cause between the ovary and adrenal glands, in addition to the quantitative tests of the specific hormones of the ovary, the adrenal hippocampus, sometimes the test to explore ovarian function and function adrenal stimulation and inhibition. For example, simultaneously by stimulating the ovaries with hCG, FSH inhibits the adrenal cortex with dexamethasone. Compare the results before and after stimulation - inhibition, draw conclusions.

Primary amenorrhea

The reason people distinguish amenorrhea into two types, primary and secondary is because of diagnostic significance. In primary amenorrhea, attention must be paid to all types of causes including endocrine activity abnormalities of the lower hypothalamus - pituitary - ovary, and genital anatomical abnormalities. . Meanwhile, for secondary amenorrhea can ignore the exploration of congenital abnormalities of the genitals. For example, there is no uterus, no vagina, no perforation, no ovaries or atrophic ovaries, etc., because the patient has had a history of menstruation in the past.

Diagnosis: primary amenorrhea conducted step by step:

Question: Pay attention to heredity because up to 0.1 - 0.2% of girls have late menstrual periods after the age of 18.

Examination: See secondary sexual properties such as breast development, pubic hair, armpit hair. Visit the rectum or visit the vagina with one finger, put a small speculum for virgin girls, see if there is anything wrong or missing a part of the genitals. Especially see if there is a uterus. With regard to the ovaries, people do not have much hope in finding out whether or not there are mainly ovarian tumors, especially maleized tumors of the ovaries.

See if there is any abnormality in the body structure. Short-necked dwarfs, short-necked hips, low hair growth characteristic of Tumer's syndrome, etc. Do investigative tests such as quantification of gonadotropic hormones, estrogen, progesterone, endocrine vaginal cytology, mortality index. bow to determine where there is an endocrine disorder. Additional, can be probed through stimulation - inhibition.

Hormone testing is also called trial treatment:

Progesterone experience. Give progesterone 10mg a day by intramuscular injection for 8 consecutive days. If after 2 to 5 days after stopping the drug, bleeding is a sign of mild inactivity of the lower system of the lower region - pituitary - ovary. Without bleeding is severe inactivity.

Estrogen test. Use this test when the progesterone test is negative. Give Mikrofollin 0.10mg per day or Akrolollin or Ben / ogynoestryl 5mg per day by injection for 10 days. If the drug is stopped for 5 to a day, if the bleeding occurs, you will have severe depression in the hypothalamus or pituitary gland, or your ovaries. If there is no bleeding, think of no cervix or uterine stickiness.

Experience gonadotropic symptoms; Curettage of the uterine lining, test to study vaginal hormones, and quantify estrogen, progesterone before and after the injection of gonadotropic hormones. If after the injection, the results are increased: hypothalamic or pituitary failure. If not increased, ovarian failure or atrophy of the ovaries.

Experience clomiJen. For 5 consecutive days, 100mg daily primer of clomifen citrate to inhibit the receptors of the hypothalamus and release the release more than release. Re-quantify FSH, LH. If compared with before injection, there is an increase: inactive hypothalamus. If not increased: inactive pituitary gland, it could also be the underactive hillside.

Practical application

Primary amenorrhea

In fact, primary amenorrhea has only 2 types of causes, endocrine disorders of the hypothalamus - pituitary - ovary axis, genital malformation, namely, the absence of a uterus.

Clinically, if you see normal genital secondary properties such as well-developed breast, normal pubic hair, no neck pain in menstruation, then diagnosis is almost always without a uterus.

If there are normal secondary genital properties, at the same time periodic abdominal pain, detecting a tumor in the subframe, it may be boring to predict that the period is closed due to the absence of a vagina or a punctured hymen, of course. entity, no cervix, no vagina or no perforation of the hymen.

If secondary sexual properties do not develop, ovarian hormones are either primary, or secondary, deficient. Primary is congenital atrophy of the ovaries, secondary to hypothalamic or pituitary failure leading to ovarian failure.

In primary amenorrhea, the causes account for the following proportion:

Ovarian abnormality due to infectious disorder: 30%.

Development disorders: 19%.

Causes of the hypothalamus - pituitary: Ovarian damage: 17%.

Adrenal - genital syndrome: 7%.

Feminized testicles: 7%.

Feminized testicles (Morris syndrome) :

Morris describes the clinic in 1953. Rarely, scale 1 / 20,000. Male chromosome (XY). Outward appearance is female. Breast development, sometimes more than usual. Slender people, beautiful girls, many beautiful models, and a feminine temperament. No pubic or armpit hair. The testicles secrete estrogen but amenorrhea because there is no uterus. Testicular amputation to prevent cancer. But wait for the breast to fully develop and then cut. After surgery, replacement estrogen is used to continue to maintain the femininity in accordance with the familiar social life of the patient.

Adrenal - genital syndrome:

The renal cortex increases androgen secretion (male hormone). There are ovaries but male. Is a genetic disease. Lack of enzyme hydroxylase of the adrenal cortex, first of all, low cortisol vomiting 21 hydroxylase, increased ACTH secretion leads to overproduction of adrenal cortex and increased androgen secretion. In high concentrations, androgens inhibit the pituitary gonadotropin production.

Patients soon develop pubic hair, armpit hair and beard. Dwarfs are short because of high androgens that quickly close the ends of long bones. Big clit. amenorrhea. Treatment with corticosteroids (prednisolon, dexamethasone) both replace deficiency and inhibit ACTH secretion. It is possible to get pregnant. Clitoris does not degenerate, must be cut for aesthetics.

Turrn er syndrome:

The illness described by Turmer in 1938: Childish figure, stretched out on his arms, neck with a thin skin. Disorders of heavy development of the gonads due to the lack of an X chromosome. Hence, it is also called "atrophic ovary", "ovary not growing". Chromosome pour 45, XO. Sometimes there is mosaic, sometimes there is a structural chromosomal abnormality.


Undeveloped breasts, sparse pubic hair. All parts of the genitals are small: large lips without fat pad, atrophic lips, small clitoris, short, narrow vagina, uterus with little fingertips, relatively long and thin oviduct, chamber eggs with no or just a small strip.

Despite the growth hormone, the person is still short, rarely reaching 1.50m. There are many different types of symptoms, up to 60 types, sometimes including color vision disorders, cataracts, atrophy of the aorta, osteoporosis (due to lack of estrogen) ...

Delayed mind, poor intelligence, sexlessness, amenorrhea: However, although very rarely, there may be menstruation, menstrual disorders.

Treatment: the only way to replace hormones, for estrogen, for artificial menstrual cycles, to develop female sexuality, to resolve psychology and to help with osteoporosis.

Amenorrhea due to genital tract abnormalities:

Mayer - Rokitansky - Kuster syndrome: Vaginal atrophy, uterine atrophy, with two small bands. The ovaries are normal, the endocrine is normal, but amenorrhea. Also need to be distinguished from:

Stick to the uterus due to tuberculosis, infected from a young age. Examination has uterus, vagina

Mayer - Rokitansky - Kusler syndrome (evoked by the Rokitansky syndrome) and tuberculosis uterine adhesions have not been practically treated so far.

Without a vagina, the hymen doesn't have perforation causing menstrual cramps. Treatment with a needle with Douglas gear to drain menstrual bleeding. Sometimes a hysterectomy is required.

The general prognosis of primary amenorrhea

It depends on the cause of the disease, but in general the prognosis is not good.

Treatment of the endocrine system is primarily hormone replacement.

For anatomic abnormalities, if possible, it can be resolved with surgery (removal of the large clitoris, puncture of the hymen to drain stagnant menstrual blood, removal of the feminized testicles, etc.). But most of them are just symptomatic treatment, not completely resolved.

Secondary amenorrhea

The causes of amenorrhea secondary

All primary causes of amenorrhea can be secondary to amenorrhea, except for congenital anatomical abnormalities in the genital tract and other congenital abnormalities. For example, the adrenal-genital syndrome, the ultimate Rokitansky syndrome, causes primary amenorrhea. The most common causes of primary amenorrhea are hypothalamus (78%), pituitary (2%), ovaries (8%), genitals (7%), according to Chau. Europe. But in Vietnam it is mainly due to premature ovarian failure.

Amenorrhea secondary to the hypothalamus:

There are 2 groups, groups due to mental factors and groups caused by physical damage. In fact, both are mostly due to the cortex acting down the hypothalamus, not from the hypothalamus.

Psychological and psychological factors that can be traumatic in the family such as divorce, mourning, changing living circumstances, long-distance journey, fear, etc. amenorrhea.

Anatomic changes (injury to the entity) such as encephalitis, traumatic brain injury affect the function of the hypothalamus or the nucleus groups above the hypothalamus such as the contouring system, the gliding structure.

It is not uncommon for cases to occur during the mother's pregnancy that lead to harm to the baby such as infections, pregnancy poisoning, radiation, and drugs. In drugs, it is noted that fenethazine, reserpine, drugs that block the nerve nodes have an effect on the hypothalamus. Many cases of postpartum infertility with obesity are considered during pregnancy and after breastfeeding cessation, the hypothalamus centers are not adequately nourished. It is difficult to distinguish hypothalamic-cause amenorrhea from pituitary amenorrhea because although the cause is from the hypothalamus, it ultimately leads to pituitary inactivity.

Amenorrhea caused by pituitary gland:

Due to the high potency of the pituitary gland, amenorrhea is rarely due to pituitary failure. The most common is postpartum pituitary failure and pituitary adenoma, causing amenorrhea.

In tumors, it is necessary to distinguish those with inactive endocrine tumors such as adenomas, nasopharyngeal tumors and endocrine tumors such as giant eosinophils, major diseases, and eosinophils. alkali causes Cushing disease, prolactin-producing adenoma (adénnome à prolactine) causes amenorrhea - lactation. Although the pituitary adenocarcinoma cells inhibit hormones, do not cause endocrine symptoms, but also cause amenorrhea due to the destruction of the anterior pituitary.

Clear pituitary insufficiency seen in Sheechan syndrome and Simmonds disease is also caused by necrosis of the anterior lobe of the anterior lobe.

Sheehan syndrome:

During pregnancy, the volume of the pituitary increases by about 1.5 times. After childbirth, the pituitary gland rapidly decreases in volume, parallel with the decrease in overall circulation of the pregnant woman. If a lot of blood loss occurs during childbirth or after childbirth, the blood supply to the pituitary will decrease rapidly and the anterior pituitary becomes necrotic. Up to 15% of cases of blood loss due to dizziness leads to a decrease in the secretion of gonadotropic hormones. If 90% of pituitary tissue is necrotic, it will lead to a complete loss of secretion of hormone directions. The encounter rate is one case per 5 to 10,000 births.

Symptom. The earliest is the symptom of milk loss. Then the breasts shrink gradually. Loss of armpit hair and pubic hair. Genitals atrophy gradually. If more severe, impaired thyroid function and adrenal cortex will be prominent. Loss of period, fatigue, emaciation. The vagina is dry, the sebaceous and sebaceous glands are less active. Loss of sexuality. In mild forms, menstruation may remain, but few, and there are no signs of adrenocortical insufficiency, hypothyroidism because ACTH-secreting cells and TSH-secreting cells of the pituitary are not susceptible. damage such as gonadotropin secreting hormone cells.

One of the important issues to note is that even with adrenocortical insufficiency, the patient still shows no signs of tanning, although other signs of adrenocortical insufficiency are present such as decreased blood pressure, fatigue. fatigue. This is due to a weak pituitary gland, unable to secrete ACTH, and causing darkening of the skin.

Additional tests such as quantification of hypoglycemic pituitary hormones are also of good value in helping diagnose the disease.

Treatment: First of all, to compensate for the deficiency of thyroid hormones. But also, for cortisol (10-20mg) to solve the lack of adrenal cortex hormones. A diet high in protein, carbohydrates, and more NaCl than usual. Add extra estrogen because of ovarian inactivity. For mild forms, it is possible to conceive a healthy, normal child. For severe forms, but not hypothyroidism and adrenal so much that it must be treated with high doses of hormones, infertility can be treated, stimulating oocyte release with alternative gonadotropic hormones.

B Stand nh Simmonds:

Simmonds disease is caused by atrophy or necrosis of the pituitary gland not related to pregnancy or childbirth. Pathogenesis and pathogenesis are very similar to Sheehan's syndrome.

Milk amenorrhea syndrome:

There are three syndromes noted in the diagnosis. Chiari - Frommel syndrome occurs after childbirth. Years of amenorrhea and lactation. Severe atrophy of the uterus, atrophy of the uterine lining. Fatty. There are disorders of the hypothalamus-pituitary system leading to increased prolactin secretion, lactation and amenorrhea. Argonz - del Castillo syndrome occurs in the absence of a single birth. Forbes - Albright syndrome has a pituitary tumor.

Up to 50% of lactation cases have no known cause. But some known causes can cause lactation such as estrogen use, psychiatric drugs (aminazin for example), irritation in the chest, in the breast (surgical scars, burns, trauma ...) , endocrine diseases (hypothyroidism, increased secretion of TRH), etc., increase prolactin secretion.

Diagnosis: Based on pituitary imaging, eye examination for signs of pituitary enlargement. Determine if prolactin is high (normal 5-25ng / ml).

Treatment: If there is no physical cause, you can use bromocriptin (2 - brom - alpha - ergocriptin), Partodel brand name, used for many months, 1-2 capsules can be up to 4 tablets per day (tablets 2.5mg). While using, it is possible to become pregnant. If you suspect that there is a prolactin-producing tumor of the pituitary gland, you should not get pregnant because the pregnancy endocrine can stimulate the rapid growth of a pituitary tumor leading to dangerous complications such as compression of the visual interference causing blindness. bleeding or tumor that compresses the brain like a hemorrhage. Contraception by conventional methods except hormonal contraceptives, such as insertion, rubber bags VV ... After 1-2 years of treatment, if you are sure there is no pituitary tumor, you can allow pregnancy. Before deciding to allow pregnancy, it is possible to give some artificial menstrual cycles to probe the response of the pituitary gland through the tolerance and mechanical signs such as headache, blurred vision of the patient. In addition to Parlodel, for the purpose of stimulating oocyte release, clomiíen citrate, gonadotropin hormone can be used. Clomiíen usually gives worse results than Parlodel.

Amenorrhea secondary to ovarian causes:

There can be specific causes such as premature ovarian decline, ovarian masculinization tumors, Stein-Leventhal syndrome, decreased estrogen secretion by the ovaries, and increased androgen secretion.

Ovarian failure is caused by premature atrophy of the primitive oocysts. The cause may be hereditary, possibly due to being a fetus, being a fetus, the hypothalamus - pituitary system has overstimulated, causing rapid atrophy of the primitive follicles. radiotherapy, mumps, tuberculosis, viral disease, ovarian autoimmune etc ...

The ovaries have a masculinized tumor (arrhenoblastoma) that secrete a lot of androgens, which are antagonistic to the effects of estrogen. On the other hand, this androgen also inhibits the secretion of hormones released by the hypothalamus, and eventually the healed ovary on the other side also works. From the above events, the reclining occurs.

Clinical matcha characteristics:

In the case of premature deterioration of the ovaries, the woman will have the same condition as the menopausal because it is essentially an early menopause. Hot flashes, nervousness, sweating, cold limbs, daytime sleepiness, etc. are all foldable symptoms. The cause cannot be treated. Estrogen can be used to alleviate unpleasant symptoms, and to menstruation for the patient's peace of mind.

In the case of a masculinized tumor, the patient will have sub-sexual properties such as leg hair, belly hair, beard, mustache, and large clitoris. Amenorrhea is an early sign that causes a woman to see a doctor. Single treatment by resection of the tumor. The remaining healthy ovaries will function normally. The woman will return to her normal period again, and can be pregnant. Only the secondary sexual properties are slower to regress and sometimes not return to normal. For example, a large clitoris may have to be removed for cosmetic reasons, if after a few years of follow-up it does not become noticeable.

In the case of Stein-Leventhal syndrome, in addition to the classic signs of amenorrhea, amenorrhea, and amenorrhea, a woman may have masculine secondary genital signs, but usually not as much as in the case of the case. Masculine tumors. The disease described above is common in Europe. In Vietnam, instead of menstruating less, amenorrhea can lead to heavy menstrual bleeding. Signs of masculinity are much softer, not even present. This comment suggests that Vietnamese are less sensitive to androgens than Europeans. The anatomical properties of the ovaries are the same as those of the Stein-Leventhal syndrome in Europe, meaning that both ovaries are polycystic, have a thick, porcelain-white, pearl-like shell, hidden underneath. many follicles are developing. Treatment by cutting the ovary angle brings high results, regular menstruation, ovulation, can be conceived, the rate up to 70 - 90%. The syndrome was first written by Stein and Leventhal in 1935. The cause is not clear, but it can be caused experimentally by injecting testosterone into immature mice, or by interfering with the solution of Gn. - RH of the hypothalamus down to the pituitary gland.

Secondary amenorrhea ph ace nh materials â n t a weak provision:

The main cause is uterine stickiness, loss of uterine mucosa due to too deep curettage or tuberculosis of the uterine lining, eventually leading to the entire uterine cavity and amenorrhea, infertility. A curettage of the uterus is also known as Asherman's syndrome. The common symptom of these two types of whole uterine adhesions is amenorrhea after a lessened period while the menstrual cycle remains regular. Despite a missed period, her secondary sexual and sexual properties are still normal. Tuberculosis of the uterus is considered to be a stable phase of the disease, but it is not possible to return a normal uterine cavity, even with anti-TB drugs, even by dilatation of the uterus. Curettage of the uterus from curettage can be treated with uterine dilatation. Angioplasty is usually easy because the boundaries between the walls of the uterus remain the same.

To prevent uterine stickiness, early treatment and thorough treatment of genital tuberculosis, avoid too deep abortion of the uterine lining, especially be very careful in curettage of vegetables after giving birth, very often causing uterine stickiness. After curettage, it is always advisable to give estrogen so that the uterine lining can regenerate well, because after birth, the ovaries are not working again, not yet estrogen secretion. The minimum dose of Mikrofbllin is 0.05mg / day for 7 days. It is best for the menstrual cycle, the first 14 days with estrogen, 12 days after combining estrogen with progesterone, or with progestin in general (preferably the combined oral contraceptive pill).

Diagnosis of uterine adhesions is relatively easy, based on the measurement of the uterus, but based on the mammogram is most certain. You will not see the uterus, but only the cervical canal because the cervical canal is never sticky. Endocrine tests such as endocrine vaginal cytology also contribute to the diagnosis of the disease. For example, if you see normal hormonal activity of the ovary and still amenorrhea, then it is possible that there is no uterine lining and uterine stickiness. However, these conclusions are not entirely convincing, and should be tried further with a menstrual cycle at a slightly higher dose than usual. If after stopping the drug, still no menstruation, it can be assured to diagnose uterine adhesions.

Secondary amenorrhea due to other disorders of endocrine activity. Severe endocrine diseases can cause amenorrhea. Nephrotic-genital syndrome, Cushing's syndrome, Addison's disease, Basedovv's disease, severe diabetes can all lead to amenorrhea.

Secondary amenorrhea caused by hormonal contraceptives:

Prolonged use of oral contraceptives can cause amenorrhea because the hypothalamus and pituitary are long inhibited, prolactin increases secretion, and uterine atrophy. Treatment is by giving ovarian hormones to replace, giving artificial menstrual rings so that the uterine lining can regenerate well.

Ch hide differential diagnosis nh materials â n secondary amenorrhea

Methods of inquiry, physical examination and exploration are the same as for primary amenorrhea. In addition, to pay attention to the pathogenetic circumstances such as postpartum blood loss, post-miscarriage, curettage, mental disorders, inflammation, etc.

The general definition of e the treatment of secondary amenorrhea

In each cause of secondary amenorrhea, specific directions for resolution have been given. In general, first of all, it is necessary to exclude physiological amenorrhea such as pregnancy, lactation and pseudo-amenorrhea (menstruation) before being allowed to use female sex hormones to induce menopause.

The menstrual cycle is a method of using estrogen and progesterone sequentially in the first phase with only estrogen and in later stages with estrogen and progesterone like the natural menstrual cycle. After stopping the drug, menstruation will occur. The purpose of using the artificial menstrual cycle is to replace the missing female sex hormone, helping the uterine lining to develop like normal physiology, which can prepare the egg for implantation in the following menstrual cycles. Also has the purpose of causing menstrual bleeding to check the integrity of the uterus, especially of the uterus.

We usually give the first 14 days, a 0.05mg ethinyl - estradiol tablet (Mikrofollin or Lynoral), followed by 12 days, 1 Ovidon or Eugynon oral contraceptive pill each day containing 0.05mg ethinyl estradiol and 0, 25mg norgestrel (progestin). After stopping the drug for 2 days, the patient will menstruate. Such cycle will be 28 days. If a second menstrual cycle is needed, we wait for the patient to clear before starting the medication again. If the patient has a new period for 3 days to clean and create one as above, the second cycle will be 28 + 3 = 31 days long. A cycle change from 28 to 31 days is not of concern, but on the contrary, it is also beneficial to wait for the uterine lining to overlap, causing overplasia of the uterine lining if long-term treatment is required.

There are physicians who use artificial menstrual cycles in two successive stages, the first stage uses pure estrogen, the second stage uses only progestin. For example, in the first 14 days, 1 tablet Mikrolollin per day, after 12 days period, 1 tablet of Duphaston 10rng per day. In fact, the use of this drug is not natural and there are cases of premature bleeding before stopping the drug, especially in the case of a lower dose of progestin (Duphaston or progesterone 5 mg per day).

Artificial amenorrhea is a method for estrogen and progesterone in a relatively short time, the limb is needed enough to cause changes in the lining of the uterus that induces menstruation, for the purpose of diagnostic examination, not therapeutic intentions. Mikrolollin 0.05mg 1 tablet, or more certainly, 2 tablets per day combined with Duphaston 10mg per day can be given, in all 7 days. After stopping the drug for 2-7 days, the patient menstrual period.

Treatment of the cause is weakness. But many times when the cause cannot be treated, because of the limited medical ability to both detect the cause and address the cause, symptomatic treatment is necessary. However, symptomatic treatment for a while, sometimes the result becomes cured. For example, in the case of secondary amenorrhea due to mental trauma, for 3 - 6 months of artificial amenorrhea, sometimes the patient may return to normal.