Download Group A amenorrhea

Group A: Brigitte, Jennifer, Lori, and Nkechi
Question A1: Discuss the most common etiologies of secondary amenorrhea. (Group A)
Definition of Amenorrhea
Secondary amenorrhea is the absence of menstruation in women of reproductive age for a
time equivalent to three or more cycles or six months, who have previously menstruated
and are not pregnant. It is common during early adolescence, perimenopausal period, and
lactation. (McCance & Huether, 2006, p. 775).
Mosby (1994) defines Hypothalamic amenorrhea as the termination of menses, which
originates from disorders that prevent the hypothalamus from initiating the cycle of
neuro-hormonal interactions of the brain, pituitary, and ovary essential for ovulation and
later menstruation. Approximately four percent of women have secondary amenorrhea,
which can be triggered by extreme and prolonged exercise, if a woman has less than 15 17% body fat, is obese, or takes hormonal supplements (Medline Plus, 2006). Procedures
such as dilation and curretage (D & C), metroplasty, myomectomy or cesarean section
may cause intrauterine adhesions leading to secondary amenorrhea (Advanced Fertility
Center of Chicago, 2008).
Etiologies of Secondary amenorrhea
The release of growth hormone subsequent to insulin-induced hypoglycemia is the most
common abnormality seen in women with amenorrhea. The high frequency of abnormal
release of prolactin indicates that serum prolactin should be measured when this test is
performed. In addition, patients with prolactin-secreting adenomas and those with
Sheehan's syndrome should be given an insulin tolerance test before treatment is
instituted, so that patients with secondary adrenal insufficiency can be identified.
Polycystic ovary disease is a common disease resulting in secondary amenorrhea.
However, Cushing's disease, a hormonal disorder that occurs when the body’s tissues are
revealed to high levels of cortisol and most commonly resulting from benign pituitary
adenomas, should also be considered. Therefore, a careful history, observation, physical
examination, and endocrine studies can differentiate between patients with polycystic
ovary disease and Cushing's disease (Liao et al. (2006) by testing for cortisol levels and
the body’s secretion of adrenocorticotropin (ACTH) (National Endocrine and Metabolic
Diseases Information Service, 2002).
Shienfelf, Gal, Bunzel and Vishne (2007) believe that secondary amenorrhea can occur as
a result of psychogenic or hormonal factors, for example an insult to feminine
development after rape or marital problems. The right etiology will be the guide for the
appropriate therapeutic method depending on whether it is psychotherapy related to
psychogenic disorders, or neuroleptic, or anti-ovulatory drugs in conditions related to a
biological etiology.
The central nervous system refers to the brain and spinal cord (Medline, 2007) with the
hypothalamus located in the brain. Huether and McCance (2006, pg. 738) include a
diagram that illustrates the hormonal stimulation of the gonads. Hydrocephalus, or too
much cerebral spinal fluid around the brain, will affect the hypothalamus and therefore
interfere in the secretion of Gonadotropin-releasing hormone (GnRH), follicle stimulating
hormone (FSH) and luteinizing hormone (LH) and directly affect the gonads i.e. the
ovaries. The interruption doesn’t allow the hormonal changes to take place, and
amenorrhea occurs. Secondary amenorrhea is the absence of menstruation for a time
equivalent to three or more cycles or six months in women who have previously
menstruated, as is the case with Ms. T.
Secondary amenorrhea is normal in adolescence, perimenopausal women, pregnancy and
lactation, and may be triggered by dramatic weight loss. Various explanations of
secondary amenorrhea include:
- Structural abnormalities
- Asherman’s syndrome -formation of intrauterine adhesions from removal of
the endometrial decidua basalis (Medline, 2006), (McCance & Huether, 2006, p.
775).
- Removal of the uterus
- Elevated ovarian steroid hormone levels (inhibited ovulation)
- Depressed ovarian hormone levels prevent ovulation, therefore, amenorrhea
- Contraceptives
- Breast-feeding (although ovulation may occur, menstruation may not)
- Stress as it alters the function of your hypothalamus
- Medications – antidepressants antipsychotics, oral corticosteroids, and some
chemotherapy drugs (Mayoclinic, 2007)
-
Illness
- Hormonal imbalance – high levels of estrogen and androgen, which decreases
the pituitary hormone that leads to ovulation. This is common with Polycystic
Ovary Syndrome
- Thyroid malfunction – an increase or decrease in prolactin can effect your
hypothalamus and alter the menstrual cycle
- Pituitary tumor – can cause over production of prolactin and interferes in the
regulation of the menstrual cycle (Mayoclinic, 2007), (Huether and McCance,
2006)
Lack of ovulation (anovulation) may result from increased levels of prolactin, decreased
levels of gonadotropins, irregular secretion of gonadotropins, or abnormally low levels of
CNS neurotransmitters. All of these alter the feedback effects that the ovarian hormones
have on the hypothalamus and pituitary and may result in amenorrhea. (McCance &
Huether, 2006, p. 775).
According to Huether and McCance (2006, pg. 776), testing for pregnancy via the urine
for hCG is ideal. If positive then amenorrhea may be due to pregnancy, lactation, or
trophoblastic tumor. Trophoblastic tumors are cells that grow in the tissues following the
joining of the sperm and egg either without the development of the baby, or following the
abortion or delivery of the baby (National Cancer Institute, 2005). If the hCG is negative
then a following serum prolactin should be tested, and within the results of the prolactin,
Huether and McCance (2006) clearly illustrate recommended actions such as testing
TSH, identify the need for a CT, MRI, and pharmacological interventions.
Treatment for amenorrhea may include oral contraceptives, injectable hormone
replacement therapy, vaginal or injectable hormone replacement therapy (estrogen,
thyroid hormone, glucocorticoids, gonadotropins, bromocriptine, or surgical interventions
such as removal of pituitary tumors (McCance & Huether, 2006, pg. 777).
Question A2
Explain why a woman who has hydrocephalus or a space-occupying lesion of the CNS
may also develop primary amenorrhea.
Lee et al. (2001), state that amenorrhea is an unusual manifestation of endocrine
disturbances in patients of chronic hydrocephalic disorders. They stress that the exact
mechanism of the association of amenorrhea and hydrocephalus is not well known. Lee et
al. (2001), however suggest that an increased intracranial pressure due to hydrocephalus
rather than a hypothalamic tumor causes an inhibitory effect on the hypothalamuspituitary-ovary axis at the level of the hypothalamus. According to them this increased
intraventricular pressure causes a functional disturbance only in the gonadotropinreleasing hormone (GnRH) secreting neurons in the ventral hypothalamus and not in the
median eminence, leading to a relative GnRH deficiency. According to some other
reports, it could be suggested that if the third ventricle is dilated progressively in chronic
hydrocephalus, GnRH release is disturbed only in the ventral hypothalamus without the
disturbance of the GnRH production elsewhere, subsequently causing a deficiency of
GnRH and resulting in amenorrhea. Having said this, most women who undergo surgical
treatment for chronic hydrocephalus report achieving normal menstruation post surgery,
all women with hypothalamic amenorrhea should be investigated for the presence of any
intracranial cause. A brain MRI is preferred, if available. This whole system is part of a
feedback loop. The hypothalamus and ovaries send messages back and forth to each other
resulting in a fine balance.
Ascerin and Tasker (2007) support the above theory by stating that given the critical role
of anterior pituitary hormones in the regulation of growth development in childhood,
early detection of hormonal abnormalities caused by increased ICP is vital. Endocrine
assessment is required for the long-term management and rehabilitation of children and
adolescents who survive moderate to severe head injury.
Short Case study
Lee et al. (2001), gives an example of 2 female patients of ages 30 and 20 who
presented with amenorrhea and increasing headache. Magnetic resonance images
revealed marked, non-communicating hydrocephalus without any tumorous lesions. In
one patient, emergent extraventricular drainage was necessary because of progressive
neurological deterioration. Each patient underwent surgical intervention for the
hydrocephalus-ventriculoperitoneal shunt and endoscopic third ventriculostomy. Both
resumed normal menstruation continuing so far with further normal menstrual bleeding.
These two cases indicate that the surgical intervention for hydrocephalus resolves
amenorrhea in all the cases of amenorrhea due to hydrocephalus. The suspected role of
the surgery is the correction of increased intracranial pressure, which is an important
pathogenetic factor in the development of amenorrhea.
References
Acerini, C.L., & Tasker, R. C. (2007). Endocrine sequelae of traumatic brain injury in
childhood. Department of Paediatrics, university of Cambridge, UK. Hormonal
Res, 68(5), 14-117.
Advanced Fertility Center of Chicago. (1996-2008). Secondary Amenorrhea: Lack of
menstrual periods in a woman that has had periods previously [Fact sheet].
Retrieved from http://www.advancedfertility.com/amenor.htm
CNN. (2005). Amenorrhea. Retrieved June 9, 2008 from
http://www.cnn.com/HEALTH/library/DS/00581.html
Lee, J. K., Kim, J. H., Kim, J. S., Kim, T. S., Jung, S., Kim, S. H., Kang, S. S., & Lee, J.
H. (2001). Secondary amenorrhea caused by hydrocephalus due to aqueductal
stenosis: Report of two cases. Korean Medical Science, 16(4), 532-536.
Liao, C. C., Lin, S. Y., Lin, H. W., Chen, K. H., Chang L. H., Chen, S. T., & Wang, T.
(2006). Menstrual abnormalities in a woman with ACTH-dependent pituitary
macroadenoma mimicking polycystic ovary syndrome. Taiwan Obstetrical
Gynecology, 45(2), 176-179.
Mayoclinic. (2008). Amenorrhea. Retrieved June 8, 2008 from
http://www.mayoclinic.com/health/amenorrhea/DS00581/DSECTION=3
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adults and children (5th ed. ,pp.738-776) . Salt Lake City: Elsevier Mosby.
Morente, C., & Keletzky, O. A. (1984). Pituitary response to insulin-induced
hypoglycemia in patients with amenorrhea of different etiologies. Obstetrical
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National Cancer Institute. (2005). Gestational Trophoblastic Tumors Treatment.
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National Endocrine and Metabolic Information Service. (2002). Cushing’s Syndrome.
Retrieved June 11, 2008 from
http://www.endocrine.niddk.nih.gov/pubs/cushings/cushings.htm
Shiendfeld, H., Gal, M., Bunzel, M. E., & Vishne, T. (2007). The etiology of some
menstrual disorders: A gynecological and psychiatric issue. Health Care Women
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Smith, M.N. (2006). Secondary amenorrhea. Medical Encyclopedia.
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