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The Federation of Obstetric & Gynecological Societies of India (http://www.fogsi.org) > Archives Articles
(http://www.fogsi.org/category/archives-articles/) > Review of the month archives
(http://www.fogsi.org/category/archives-articles/review-of-the-month-archives/) > Managing Amenorrhea 2
Managing Amenorrhea 2
Dr Ameya C Purandare
It is absolutely essential to determine which organ is dysfunctional and then to establish the precise cause so
that specific treatment can be advised
Any patient with amenorrhea who has a uterus pregnancy should be first ruled out and serum levels of
thyroid-stimulating hormone (TSH) and prolactin estimated. Galactorrhea should be identified by clinical
examination.
1. Psychological disorder
2. Emotional stress
3. Weight loss
4. Obesity
5. Exercise induced
6. Idiopathic
Hirsutism-virilism
1. PCOD
2. Ovarian tumor
3. Adrenal tumor
4. Cushings syndrome
5. Congenital and maturity-onset adrenal hyperplasia
Systemic disease
Hypothyroidism
Hyperthyroidism
Addisons disease
Chronic renal failure
Diagnosis of Amenorrhea Associated with Galactorrhea-Hyperprolactinemia
1. Dopamine antagonists
1. Phenothiazines
2. Thioxanthenes
3. Butyrophenone
4. Diphenylbutylpiperidine
2. Catecholamine-depleting agents
3. False transmitters (-methyldopa)
Interruption of normal hypothalamicpituitary relationship
Encephalitis
Craniopharyngioma
Pineal tumors
Hypothalamic tumors
Pseudotumor cerebri
Treatment
Laparoscopic ovarian drilling (LOD) is a surgical method of ovulation induction in PCOS patients. LOD involves
electrocautery or laser drilling with the goal of creating foci of laser or thermal damage in the cortex and
ovarian stroma. The mechanism of action may involve destruction of androgen-producing stromal cells, a
sudden drop in ovarian androgen levels, improved follicular microenvironment, or increased gonadotropin
secretion. This procedure may cause postoperative pelvic adhesions, resulting in tubal compromise.
Patients taking drugs that raise the prolactin level should discontinue them if possible, but continued use of
such drugs is not a contraindication to therapy.
Patients who are hypoestrogenic must be treated with a combination of estrogen and progesterone to
maintain bone density and prevent genital atrophy.
Oral contraceptives are effective replacement therapy for most women.
Combinations of 0.6251.25 mg of conjugated estrogens orally daily on days 1 through 25 of the cycle with 5
10 mg of medroxyprogesterone acetate on days 16 through 25 are an alternative. Calcium intake should be 1
1.5 g of elemental calcium daily.
Patients who respond to the progestin challenge require progestin administration to prevent the development
of endometrial hyperplasia and carcinoma.
Oral contraceptive pills may be used for regularization of the menstrual cycle.. Alternatively,
medroxyprogesterone acetate, 10 mg orally daily for 1013 days every month or every other month, is
sufficient to induce withdrawal bleeding and to prevent the development of endometrial hyperplasia.
Patients with hyperprolactinemia need periodic prolactin measurements and radiographic cone views of the
sella turcica to check for the development of macroadenoma.
The complications of amenorrhea can be numerous, ranging from infertility to psychosocial developmental
delays with lack of normal physical sexual development.
Hypoestrogenic patients can develop severe osteoporosis and fractures. The complications associated with
amenorrhea in patients who respond to progestin challenge are endometrial hyperplasia and carcinoma
resulting from unopposed estrogen stimulation.
Conclusion
References
1. Aloi JA: Evaluation of amenorrhea. Compr Ther 1995 Oct; 21(10): 575-8
2. ASRM: Practice Committee of the American Society for Reproductive Medicine. Current evaluation of
amenorrhea. Fertil Steril 2004 Sep; 82 Suppl 1: S33-9
3. American College of Obstetricians and Gynecologists. Amenorrhea (ACOG Technical Bulletin 128).
Washington, D.C.: ACOG, 1989.
4. Speroff L, Fritz MA. Amenorrhea. In: Clinical gynecologic endocrinology and infertility. 7th ed.
Philadelphia, Pa.: Lippincott Williams & Wilkins, 2005;401-64.
5. Pletcher JR, Slap GB. Menstrual disorders. Pediatr Clin North Am 1999;46:505-18.
6. McIver B, Romanski SA, Nippoldt TB. Evaluation and management of amenorrhea. Mayo Clin Proc
1997;72:1161-9.
7. Laufer MR, Floor AE, Parsons KE, Kuntz KM, Barbieri RL. Hormone testing in women with adult onset
amenorrhea. Gynecol Obstet Invest 1995;40:200-3.
8. Pickett CA. Diagnosis and management of pituitary tumors: recent advances. Prim Care 2003;30:765-89.
9. Folch M, Pigem I, Konje JC. Mllerian agenesis: etiology, diagnosis, and management. Obstet Gynecol
Surv 2000;55:644-9.
10. American College of Obstetricians and Gynecologists. ACOG Practice Bulletin. Clinical management
guidelines for obstetrician-gynecologists: number 41, December 2002. Obstet Gynecol 2002;100:1389-
402.
11. Anasti JN. Premature ovarian failure: an update. Fertil Steril 1998;70:1-15.
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