Secondary amenorrhea

Generality

Secondary amenorrhea is the absence of menstruation:

for at least three months, in women who have never suffered from irregularities in the menstrual cycle in the past,
or for at least 9 months, in women with a past history of oligomenorrhea.

The possible causes of secondary amenorrhea are numerous; for example, the disorder could depend on: pregnancy, menopause, drug use, anorexia nervosa, bulimia, malnutrition, excessive stress, pituitary or hypothalamus tumors or Sheehan's syndrome .

Secondary amenorrhea is often associated with other symptoms, including: headache, hirsutism, acne, vision disorders, breast milk loss, vaginal dryness, hair loss and / or hot flushes.

Accurate diagnosis of secondary amenorrhea makes it possible to establish the causes with precision.

Knowledge of the causes of secondary amenorrhea is the starting point for planning the most appropriate treatment.

Brief review of the hypothalamus axis - pituitary - ovaries

In a woman with a regular menstrual cycle, the hypothalamus, pituitary gland, ovaries and uterus function properly:

Through a specific hormone, called GnRh, the hypothalamus stimulates the pituitary gland to produce the so-called gonadotropins FSH (or follicle-stimulating hormone) and LH (or luteinizing hormone);
Once secreted, the FSH and LH gonadotropins reach the ovaries through the bloodstream, stimulating them to produce the hormones estrogen and progesterone ;
Estrogens and progesterone have the task of regulating the various passages of the menstrual cycle, from the release of the follicle to the exfoliation of the endometrium and the appearance of menstruation.

What is secondary amenorrhea?

Secondary amenorrhea is the medical term that indicates the absence of menstruation for at least three months, in women who have never suffered in the past of irregularities in the menstrual cycle, and for at least 9 months, in women with a past history of oligomenorrhea (lack of regularity of menstruation, in women of childbearing age).

Secondary amenorrhea is so called to distinguish it from the so-called primary amenorrhea .

For primary amenorrhea, doctors mean the absence of menstruation:

in women who, at the age of 16, have not yet had a period (not even menarche) but have developed all secondary sexual characteristics (breast, pubic hair, etc.)
or in women who, at the age of 14, have not yet had a period and have not yet developed any secondary sexual character.

Amenorrhea is the generic medical term that indicates the absence of menstruation in women of childbearing age.

Causes

The causes of secondary amenorrhea include:

Natural conditions, such as pregnancy, lactation or menopause;
The use of contraceptives . Secondary amenorrhea from contraceptive use affects only a part of women. In these situations, the return to normality takes place when the interested parties stop using contraceptives.
Intake of certain drugs, including antipsychotics, chemotherapy, antidepressants, blood pressure control drugs and allergy drugs.
Special lifestyles or habits . Among the lifestyles or habits that can determine secondary amenorrhea, they deserve a mention: excessive weight loss, some eating disorders (eg anorexia nervosa and bulimia), severe obesity, excessive exercise practice physical, excess stress and drug abuse (eg, heroin, cocaine, etc.).
Hormonal imbalances along the hypothalamic-pituitary-ovarian axis, consequent to conditions such as: pituitary tumors (eg craniopharyngioma), hypothalamus tumors, severe nutritional deficiencies (malnutrition), polycystic ovary syndrome (polycystic ovarian), Sheehan's syndrome, etc.
Hormonal imbalances, which do not depend on the hypothalamic-pituitary-ovarian axis . Hormonal imbalances not dependent on the hypothalamic-pituitary-ovarian axis may derive from acquired thyroid malfunctions (hypothyroidism and hyperthyroidism), Cushing's syndrome, prolactinoma episodes, etc.
Acquired anatomical anomalies of the female genital system . The main anatomical acquired anatomy of the female genital joint, capable of causing secondary amenorrhea, is the condition known as Asherman's syndrome . Asherman's syndrome consists of the abnormal presence of scar tissue (intrauterine adhesions) in the uterus.
Other causes, including: radiotherapy for the treatment of tumors, sarcoidosis, depression and psychiatric disorders in general, tuberculosis, etc.

Symptoms, signs and complications

The sign that distinguishes secondary amenorrhea is the lack of blood loss by women during that phase of the menstrual cycle in which menstruation should take place.

ASSOCIATED SYMPTOMS

The presence of secondary amenorrhea is often accompanied by other symptoms and signs.

Symptoms and signs that most frequently accompany secondary amenorrhea include:

Headache;
Vision disorders;
Excessive growth of facial hair (hirsutism);
Acne;
Pelvic pain;
Vaginal dryness;
Hair loss;
Abnormal leakage of milk from the breast (galactorrhea);
Hot flashes and night sweats;
Sleep disorders;
Clear increase or reduction in body weight.

WHEN TO REFER TO THE DOCTOR?

They should contact their doctor, for inquiries:

All women who have been missing menstruation for the first time in their lives for at least three months

All women with a history of oligomenorrhea, who have been complaining of menstruation for at least nine months.

Diagnosis

The diagnosis of secondary amenorrhea begins, first of all, from the observation of the absence of menstruation and continues with a series of investigations aimed at identifying the triggering causes (causal diagnosis).

Knowledge of the causes of secondary amenorrhea is essential for planning the most appropriate treatment.

HOW TO SEARCH FOR CAUSES

The diagnostic procedure for the identification of the causes of secondary amenorrhea may include:

An investigation of the symptoms that accompany the absence of menstruation;
A pelvic exam;
An examination of the breast and genitals;
A pregnancy test, to see if the patient is pregnant or not;
Blood tests, aimed at quantifying the hormone levels of FSH, LH, TSH and prolactin;
An ultrasound of the pelvis. The doctors prescribe it with the intent to observe the anatomy of the internal genital organs and identify any malformations (eg, scars on the uterus);
A CT and / or nuclear magnetic resonance of the head. Both painless, they provide very significant images of the internal anatomical structures of the head. Doctors could prescribe them if, based on the symptoms reported by the patient, they suspect hypothalamus or pituitary tumors. Compared to nuclear magnetic resonance, CT has the advantage of showing some more details and the disadvantage of exposing the patient to a non-negligible dose of ionizing radiation;
Hysteroscopy and / or hysterosalpingography. The first is, in fact, an endoscopic ultrasound examination of the uterus. The second, instead, is a radiological examination of the uterus and fallopian tubes. In general, doctors use them if the pelvic exam and pelvic ultrasound were not exhaustive.

Therapy

To treat secondary amenorrhea, doctors must focus on the proper treatment of triggers. As a result, secondary amenorrhea therapy varies from patient to patient, depending on what triggered the absence of menstruation. All this explains why the doctors consider the causal diagnosis essential.

EXAMPLES OF TREATMENT FOR SECONDARY AMENORREAS

In the following, the article reports some examples of therapy for secondary amenorrhea. This is a general overview, which shows how, in some cases, the treatment is very simple while, in other situations, it is very complex and of uncertain outcome.

In the presence of secondary amenorrhea due to an excessive drop in body weight, the treatment includes the planning of a diet, aimed at gradually restoring the normal body weight.
It should be pointed out that, if the excessive drop in body weight is due to a disturbance in eating behavior (anorexia nervosa, bulimia, etc.), psychotherapy is also essential.
In the presence of secondary amenorrhea due to excessive physical activity, the treatment is very simple and consists in reducing the number of hours dedicated to physical exercise and in dedicating a few more hours to rest;
In the presence of secondary amenorrhea due to the use of certain drugs (eg antidepressants), the treatment simply consists of stopping the use of the aforementioned drugs;
In the case of secondary amenorrhea due to an excessive increase in body weight, the treatment includes a slimming diet and the constant practice of physical activity, also aimed at weight loss;
In the case of secondary amenorrhea due to too much stress, the treatment involves the use of relaxation techniques;
When secondary amenorrhea is a consequence of a pituitary tumor, the treatment is surgical and consists of a delicate removal operation, from the pituitary gland, of the tumor mass;
In the case of secondary amenorrhea resulting from intrauterine adhesions, the treatment is surgical and consists of the difficult removal of scar tissue from the uterus;
In the presence of secondary amenorrhea following polycystic ovaries, the therapy is of a pharmacological type and involves the administration of medicines, such as: the contraceptive pill, progesterone derivatives and clomiphene.

Prognosis

The prognosis in the case of secondary amenorrhea depends on the triggering factors: if a cause is successfully curable, the chances that secondary amenorrhea has a favorable prognosis are considerable; vice versa, if a cause is not treatable (because, for example, it is particularly severe), there is a not inconsiderable probability that secondary amenorrhea has an unfavorable prognosis.

Prevention

Practicing physical activity without exaggerating, eating in a balanced way, neither too much nor too little, and learning to manage stressful situations are some of the preventive measures, provided by doctors, to reduce the risk of secondary amenorrhea.