INTRODUCTION
Amenorrhoea is the absence of a
menstrual period in a woman of reproductive age. Physiological states of
amenorrhoea are seen, most commonly, during pregnancy and lactation, the latter
also forming the basis of a form of contraception known as the lactation
amenorrhoea method. Outside of the reproductive years there is absence of
menses during childhood and after menopause.
Amenorrhoea is a symptom with
many potential causes. Primary amenorrhoea (menstruation cycles never starting)
may be caused by developmental problems such as the congenital absence of the
uterus, failure of the ovary to receive or maintain egg cells. Also, delay in
pubertal development will lead to primary amenorrhoea. It is defined as an
absence of secondary sexual characteristics by age 14 with no menarche or
normal secondary sexual characteristics but no menarche by 16 years of age.
Secondary amenorrhoea (menstruation cycles ceasing) is often caused by hormonal
disturbances from the hypothalamus and the pituitary gland, from premature
menopause or intrauterine scar formation. It is defined as the absence of
menses for three months in a woman with previously normal menstruation or nine
months for women with a history of oligomenorrhoea
Classification
There are two primary ways to
classify amenorrhoea. Types of amenorrhoea are classified as primary or
secondary, or based on functional "compartments". The latter
classification relates to the hormonal state of the patient that hypo-, eu-, or
hypergonadotropic (whereby interruption to the communication between gonads and
follicle stimulating hormone (FSH) causes FSH levels to be either low, normal
or high).
• Primary amenorrhoea is the
absence of menstruation in a woman by the age of 16. As pubertal changes
precede the first period, or menarche, women by the age of 14 who still have
not reached menarche, plus having no sign of secondary sexual characteristics,
such as thelarche or pubarche—thus are without evidence of initiation of
puberty—are also considered as having primary amenorrhoea. Secondary amenorrhoea
is where an established menstruation has ceased—for three months in a woman
with a history of regular cyclic bleeding, or nine months in a woman with a
history of irregular periods. This usually happens to women aged 40–55.
However, adolescent athletes are more likely to experience disturbances to the
menstrual cycle than athletes of any other age.[5] Amenorrhoea may cause
serious pain in the back near the pelvis and spine. This pain has no cure, but
can be relieved by a short course of progesterone to trigger menstrual
bleeding.
• By
compartment: The reproductive axis can be viewed as having four compartments:
1. Outflow tract (uterus, cervix,
and vagina),
2. Ovaries,
3. Pituitary gland, and
4. Hypothalamus.
Pituitary and hypothalamic causes
are often grouped together Primary/Secondary Outflow
tract anomalies/obstruction Gonadal/end-organ
disorders Pituitary and
hypothalamic/central regulatory disorders
Overview The hypothalamic-pituitary-ovarian axis is functional. The ovary or gonad does not respond to
pituitary stimulation. Gonadal dysgenesis or premature menopause are possible
causes.Chromosome testing is usually indicated in younger individuals with
hypergonadotropic amenorrhoea. Low oestrogen levels are seen in these patients
and the hypo-oestrogenism may require treatment. Generally, inadequate levels of FSH lead to inadequately
stimulated ovaries which then fail to produce enough oestrogen to stimulate
theendometrium (uterine lining), hence amenorrhoea. In general, women with
hypogonadotropic amenorrhoea are potentially fertile.
FSH
Outflow tract abnormalities tend
to be normogonadotropic and FSH levels are in the normal range. Gonadal, usually ovarian, abnormalities
tend to be linked to elevated FSH levels or hypergonadotropic amenorrhoea. FSH
levels are typically in the menopausal range. Both
hypothalamic and pituitary disorders are linked to low FSH levels leading to
hypogonadotropic amenorrhoea.
Primary
• Uterine: Müllerian agenesis (Second
most common cause, 15% of primary amenorrhoea)
• Vaginal:
Vaginal atresia, cryptomenorrhoea, imperforate hymen.
• Gonadal
dysgenesis, including Turner syndrome,
is the most common cause.
• Androgen
insensitivity syndrome (Testicular feminization syndrome)
• Receptor
abnormalities for hormones FSH and LH
• Specific
forms of congenital adrenal hyperplasia
• Swyer
syndrome
• Galactosaemia
• Aromatase
deficiency
• Prader-Willi
syndrome
• Male
pseudo-hermaphroditism (about 1 in every 150,000 births)
• Müllerian
agenesis/MRKH Syndrome
• Other
intersexed conditions
• hypothalamic: Kallmann syndrome
Secondary
• Intrauterine
adhesions (Asherman's syndrome)
• Pregnancy
(most common cause)
• Anovulation
• Menopause
• Premature
menopause
• Polycystic
ovary syndrome
• Drug-induced
• Breastfeeding
• Hypothalamic:
Exercise amenorrhoea, related tophysical exercise, stress amenorrhoea, eating
disorders and weight loss (obesity, anorexia nervosa, or bulimia)
• Pituitary:
Sheehan syndrome, hyperprolactinaemia,haemochromatosis
• Other
central regulatory: hypothyroidism, hyperthyroidism, arrhenoblastoma
Cause Low body weight
Women who perform considerable
amounts of exercise on a regular basis or lose a significant amount of weight
are at risk of developing hypothalamic (or 'athletic') amenorrhoea. Functional
Hypothalamic Amenorrhoea (FHA) can be caused by stress, weight loss, and/or
excessive exercise. Many women who diet or who exercise at a high level do not
take in enough calories to expend on their exercise as well as to maintain their
normal menstrual cycles. The threshold of developing amenorrhoea appears to be
dependent on low energy availability rather than absolute weight because a
critical minimum amount of stored, easily mobilized energy is necessary to
maintain regular menstrual cycles.
Energy imbalance and weight loss
can disrupt menstrual cycles through several hormonal mechanisms. Weight loss
can cause elevations in the hormone ghrelin which inhibits the
hypothalamic-pituitary-ovarial axis.[9] Elevated concentrations of ghrelin
alter the amplitude of GnRH pulses, which causes diminished pituitary release
of LH and follicle-stimulating hormone (FSH).
Secondary amenorrhea is caused by
low levels of the hormone leptin in females with low body weight. Like ghrelin, leptin signals energy balance
and fat stores to the reproductive axis. Decreased levels of leptin are closely
related to low levels of body fat, and correlate with a slowing of GnRH
pulsing.
When a woman is experiencing
amenorrhoea, an eating disorder, and osteoporosis together, this is called
female athlete triad syndrome. A lack of eating causes amenorrhoea and bone
loss leading to osteopenia and sometimes progressing to osteoporosis.[citation
needed]
The social effects of amenorrhoea
on a person vary significantly. Amenorrhoea is often associated with anorexia
nervosa and other eating disorders, which have their own effects. If secondary
amenorrhoea is triggered early in life, for example through excessive exercise
or weight loss, menarche may not return later in life. A woman in this
situation may be unable to become pregnant, even with the help of drugs.
Long-term amenorrhoea leads to an estrogens deficiency which can bring about
menopause at an early age. The hormone oestrogen plays a significant role in
regulating calcium loss after ages 25–30. When her ovaries no longer produce oestrogen
because of amenorrhoea, a woman is more likely to suffer rapid calcium loss,
which in turn can lead to osteoporosis. Increased testosterone levels cause by
amenorrhoea may lead to body hair growth and decreased breast size. Increased
levels of androgens, especially testosterone, can also lead to ovarian cysts.
Some research among amenorrhoea runners indicates that the loss of menses may
be accompanied by a loss of self-esteem.
Drug-induced
Certain medications, particularly
contraceptive medications, can induce amenorrhoea in a healthy woman. The lack
of menstruation usually begins shortly after beginning the medication and can
take up to a year to resume after stopping a medication. Hormonal
contraceptives that contain only progestogen like the oral contraceptive
Micronor, and especially higher-dose formulations like the injectable Depo
Provera commonly induce this side-effect. Extended cycle use of combined
hormonal contraceptives also allow suppression of menstruation. Patients who
use and then cease using contraceptives like the combined oral contraceptive
pill may experience secondary amenorrhoea as a withdrawal symptom. The link is
not well understood, as studies have found no difference in hormone levels
between women who develop amenorrhoea as a withdrawal symptom following the
cessation of OCOP use and women who experience secondary amenorrhoea because of
other reasons. New contraceptive pills, like continuous oral contraceptive
pills (OCPs) which do not have the normal 7 days of placebo pills in each
cycle, have been shown to increase rates of amenorrhoea in women. Studies show
that women are most likely to experience amenorrhoea after 1 year of treatment
with continuous OCP use.
The use of opiates (such as
heroin) on a regular basis has also been known to cause amenorrhoea in longer
term users.[citation needed]
Anti-psychotic drugs used to
treat schizophrenia have been known to cause amenorrhoea as well. New research
suggests that adding a dosage of Metformin to an anti-psychotic drug regimen
can restore menstruation. Metformin decreases resistance to the hormone
insulin, as well as levels of prolactin, testosterone, and lutenizing hormone
(LH). Metformin also decreases the LH/FSH ratio. Results of the study on
Metformin further implicate the regulation of these hormones as a main cause of
secondary amenorrhoea.
Breastfeeding
Breastfeeding is a common cause
of secondary amenorrhoea, and often the condition lasts for over six
months.[20] Breastfeeding typically lasts longer than lactational amenorrhoea,
and the duration of amenorrhoea varies depending on how often a women
breastfeeds. Lactational amenorrhoea has been advocated as a method of family
planning, especially in developing countries where access to other methods of
contraception may be limited. Breastfeeding is said to prevent more births in
the developing world than any other method of birth control or contraception.
Lactational amenorrhoea is 98% percent effective as a method of preventing
pregnancy in the first six months postpartum.
Physical
Amenorrhoea can also be caused by
physical deformities. One example of this is Mayer–Rokitansky–Küster–Hauser
syndrome, the second-most common cause of primary amenorrhoea. The syndrome is
characterized by Müllerian agenesis. In MRKH Syndrome, the Müllerian ducts do
not develop, which prevents menstruation. The syndrome usually develops during
the first trimester of pregnancy. MRI techniques can be helpful in determining
the extent of the problem. Women may recover from MRKH syndrome, but other
times primary amenorrhoea, which is characteristic of the disorder, may prevent
pregnancy for life.
DiagnosisPrimary amenorrhoea
Primary amenorrhoea can be
diagnosed in women by age 14 if no secondary sex characteristics, such as
enlarged breasts and body hair, are present In the absence of secondary sex
characteristics, the most common cause of amenorrhoea is low levels of FSH and
LH caused by a delay in puberty. Gonadal dysgenesis, often associated
withTurner's Syndrome, or premature ovarian failure may also be to blame. If
secondary sex characteristics are present, but menstruation is not, primary
amenorrhoea can be diagnosed by age 16. A reason for this occurrence may be
that a person phenotypically female but genetically male, a situation known as
androgen insensitivity syndrome. If undescended testes are present, they are
often removed after puberty (~21 years of age) due to the increased risk of
testicular cancer. In the absence of undescended testes, an MRI can be used to
determine whether or not a uterus is present. Müllerian agenesis causes around
15% of primary amenorrhoea cases. If a uterus is present, outflow track obstruction
may be to blame for primary amenorrhoea.
Secondary amenorrhea
Secondary amenorrhea's most
common and most easily diagnosable causes are pregnancy, thyroid disease, and
hyperprolactinemia. A pregnancy test is a common first step for diagnosis.[Hyperprolactinemia,
characterized by high levels of the hormone prolactin, is often associated with
a pituitary tumor. A dopamine agonist can often help relieve symptoms. The
subsiding of the causal syndrome is usually enough to restore menses after a
few months. Secondary amenorrhea may also be caused by outflow tract
obstruction, often related to Asherman's Syndrome. Polycystic ovary syndrome
can cause secondary amenorrhea, although the link between the two is not well
understood. Ovarian failure related to early onset menopause can cause
secondary amenorrhea, and although the condition can usually be treated, it is
not always reversible. Secondary amenorrhea is also caused by stress, extreme
weight loss, and excessive exercise. Young athletes are particularly vulnerable,
although normal menses usually return with healthy body weight. Causes of
secondary amenorrhea can also result in primary amenorrhea, especially if
present before onset of menarche.
Treatments
Treatments vary based on the
underlying condition. Key issues are problems of surgical correction if
appropriate and oestrogen therapy if oestrogen levels are low. For those who do
not plan to have biological children, treatment may be unnecessary if the
underlying cause of the amenorrhoea is not threatening to their health.
However, in the case of athletic amenorrhoea, deficiencies in estrogen and
leptin often simultaneously result in bone loss, potentially leading to
osteoporosis.
"Athletic" amenorrhoea
which is part of the female athlete triad is treated by eating more and
decreasing the amount and intensity of exercise. If the underlying cause is the
athlete triad then a multidisciplinary treatment including monitoring from a
physician, dietitian, and mental health counselor is recommended, along with
support from family, friends, and coaches. Although oral contraceptives can
causes menses to return, oral contraceptives should not be the initial
treatment as they can mask the underlying problem and allow other effects of
the eating disorder, like osteoporosis, continue to develop. Weight recovery,
or increased rest does not always catalyze the return of a menses.
Recommencement of ovulation suggests a dependency on a whole network of
neurotransmitters and hormones, altered in response to the initial triggers of
secondary amenorrhoea. To treat drug-induced amenorrhoea, stopping the
medication on the advice of a doctor is a usual course of action.
Looking at Hypothalamic
amenorrhoea, studies have provided that the administration of a selective
serotonin reuptake inhibitor (SSRI) might correct abnormalities of Functional
Hypothalamic Amenorrhoea (FHA) related to the condition of stress-related
amenorrhoea. This involves the repair of the PI3K signaling pathway, which
facilitates the integration of metabolic and neural signals regulating
gonadotropin releasing hormone (GnRH)/luteinizing hormone (LH). In other words,
it regulates the neuronal activity and expression of neuropeptide systems that
promote GnRH release. However, SSRI therapy represents a possible hormonal
solution to just one hormonal condition of hypothalamic amenorrhoea.
Furthermore, because the condition involves the inter workings of many
different neurotransmitters, much research is still to be done on presenting
hormonal treatment that would counteract the hormonal affects.
As for physiological treatments
to hypothalamic amenorrhoea, injections of metreleptin (r-metHuLeptin) have
been tested as treatment to oestrogen deficiency resulting from low
gonadotropins and other neuroendocrine defects such as low concentrations of
thyroid and IGF-1. R-metHuLeptin has appeared effective in restoring defects in
the hypothalamic-pituitary-gonadal axis and improving reproductive, thyroid,
and IGF hormones, as well as bone formation, thus curing the amenorrhoea and
infertility. However, it has not proved effective in restoring of cortisol and
adrenocorticotropin levels, or bone resorption
Ayurvedic treatment
1-the use of bastis is
beneficial.
2-fish kulattha,sour substances
(kanji),tail,mamsa , wine ,urine(cow urine), butter-milk mixed with half water,
curd and sukta should be used in diet and drinks
3-in all disorders of artava use of lasuna , satpushpa and satavari is beneficial.
4-A pessary made with powdered
seed of ikswaku,danti,capala,jiggery,madanphla ,kinva and yavasuka triturated
with latex of snuhi should be placed in yoni(cervix).this induces menstruation.
5-use of powdered leaves of
jyotismati, swarjikasara or rajika ugra and steam bark of asana with cold water
for three days induces menstruation positively
6-use of satawaryadi anuwasana
basti is beneficial
AYURVEDIC FORMULATIONS
1 Phalaghrata
2-Vrhatsatavari ghrta
3-Arogya vardhini vati
4- Rajaha pravartini vati
5-Dashmularista
6-Rkata pachak kwath
7-Rashpachak kwath
