Symptom Finder - Hypomenorrhea and Amenorrhea
HYPOMENORRHEA AND AMENORRHEA
Combining the anatomy of the female genital tract with the endocrine system will key in on the major sources of absent or diminished menstrual flow. It is perhaps best to begin at the bottom and work upward to the head.
1. Female genital tract: Such congenital anomalies as an imperforate hymen, imperforate vagina, cervical stenosis, double uterus, or the complete absence of any one or more of these organs would obviously cause amenorrhea. Radiation therapy may destroy the endometrium so that it cannot respond to female hormones. Pregnancy is the most common cause of amenorrhea, and it must be considered the cause of sudden onset of amenorrhea in an apparently healthy woman until proven otherwise. Excessive blood levels of endogenous or exogenous estrogen or progesterone will cause amenorrhea. The tubes should immediately suggest an ectopic pregnancy as the cause, although spotting and metrorrhagia are frequent in these cases.
2. Ovary: The mnemonic MINTS serves well in subdividing the causes here.
M—Malformations of the ovary include Turner syndrome (where the ovaries are reduced to a fibrotic, pea-sized nodule),
Stein–Leventhal syndrome, and other congenital cysts. Acquired malformations suggest the atrophy of menopause, which may occur as early as the late 20s.
I—Intoxication includes the ovarian dysfunction of exogenous hormones, irradiation, chronic alcoholism, or drug addiction. I for inflammation helps to recall autoimmune oophoritis. I for idiopathic helps to recall idiopathic ovarian failure.
N—Neoplasms of the ovary frequently cause amenorrhea, especially if they secrete hormones or are bilateral. The arrhenoblastomas, granulosa cell and theca cell tumors, and cystadenocarcinomas must be considered in this category.
T—Trauma as a cause of amenorrhea is well known, but this is generally due to diffuse body trauma such as an automobile crash, severe burns, or extensive surgery. Direct trauma to the ovary merely reminds one that oophorectomy can cause amenorrhea. Emotional trauma is probably a more common cause of amenorrhea than any of the above.
S—Systemic disease suggests the amenorrhea of leukemia, Hodgkin lymphoma, chronic nephritis, fever, and severe malnutrition.
3. Thyroid: It is well known that hyperthyroidism causes hypomenorrhea or amenorrhea and hypothyroidism causes hypermenorrhea; however, the exact reverse may occur.
4. Adrenal gland: Visualizing this organ should stimulate the recall of amenorrhea in the adrenogenital syndrome of adrenal hyperplasia or carcinomas and in Addison disease.
5. Pituitary gland: MINT is a useful mnemonic here also.
M—Malformations here are Fröhlich syndrome and Chiari– Frommel syndrome, but perhaps more important is the reduced output of pituitary hormone in many states of congenital mental retardation and brain damage.
I—Inflammation suggests the hypopituitarism of sarcoid and TB.
N—Neoplasm suggests the largest group of causes of hypopituitarism, including chromophobe adenomas and basophilic adenomas.
T—Trauma recalls the hypopituitarism of postpartum hemorrhage and amniotic fluid emboli or Sheehan syndrome.
Approach to the Diagnosis
Obviously the first thing to do is rule out pregnancy both by examination and a pregnancy test, preferably the serum β-subunit human chorionic gonadotropin (HCG). One must keep an ectopic pregnancy in mind even if the examination is normal and plan follow-up examinations and ultrasonography should the situation warrant. Altered secondary sex characteristics should be noted. If the examination fails to show evidence of pregnancy, congenital anomalies, or tumors of the ovaries, the physician should order thyroid function studies, a Wassermann test, CBC, and sedimentation rate. If these tests are normal, a gynecologist should be consulted. The gynecologist may give a test dose of intramuscular progesterone to prove that the endometrium functions well. He or she may do a D&C first. Then serum or urine FSH, LH, and prolactin levels are done; if the FSH level is high, the ovary is probably the site of the trouble. If the levels are low, even after gonadotropin-releasing factor (GRF) is administered, the pituitary is responsible. X-rays of the skull, CT scans, culdoscopy, and exploratory laparotomy all share their place in the workup.
Combining the anatomy of the female genital tract with the endocrine system will key in on the major sources of absent or diminished menstrual flow. It is perhaps best to begin at the bottom and work upward to the head.
1. Female genital tract: Such congenital anomalies as an imperforate hymen, imperforate vagina, cervical stenosis, double uterus, or the complete absence of any one or more of these organs would obviously cause amenorrhea. Radiation therapy may destroy the endometrium so that it cannot respond to female hormones. Pregnancy is the most common cause of amenorrhea, and it must be considered the cause of sudden onset of amenorrhea in an apparently healthy woman until proven otherwise. Excessive blood levels of endogenous or exogenous estrogen or progesterone will cause amenorrhea. The tubes should immediately suggest an ectopic pregnancy as the cause, although spotting and metrorrhagia are frequent in these cases.
2. Ovary: The mnemonic MINTS serves well in subdividing the causes here.
M—Malformations of the ovary include Turner syndrome (where the ovaries are reduced to a fibrotic, pea-sized nodule),
Stein–Leventhal syndrome, and other congenital cysts. Acquired malformations suggest the atrophy of menopause, which may occur as early as the late 20s.
I—Intoxication includes the ovarian dysfunction of exogenous hormones, irradiation, chronic alcoholism, or drug addiction. I for inflammation helps to recall autoimmune oophoritis. I for idiopathic helps to recall idiopathic ovarian failure.
N—Neoplasms of the ovary frequently cause amenorrhea, especially if they secrete hormones or are bilateral. The arrhenoblastomas, granulosa cell and theca cell tumors, and cystadenocarcinomas must be considered in this category.
T—Trauma as a cause of amenorrhea is well known, but this is generally due to diffuse body trauma such as an automobile crash, severe burns, or extensive surgery. Direct trauma to the ovary merely reminds one that oophorectomy can cause amenorrhea. Emotional trauma is probably a more common cause of amenorrhea than any of the above.
S—Systemic disease suggests the amenorrhea of leukemia, Hodgkin lymphoma, chronic nephritis, fever, and severe malnutrition.
3. Thyroid: It is well known that hyperthyroidism causes hypomenorrhea or amenorrhea and hypothyroidism causes hypermenorrhea; however, the exact reverse may occur.
4. Adrenal gland: Visualizing this organ should stimulate the recall of amenorrhea in the adrenogenital syndrome of adrenal hyperplasia or carcinomas and in Addison disease.
5. Pituitary gland: MINT is a useful mnemonic here also.
M—Malformations here are Fröhlich syndrome and Chiari– Frommel syndrome, but perhaps more important is the reduced output of pituitary hormone in many states of congenital mental retardation and brain damage.
I—Inflammation suggests the hypopituitarism of sarcoid and TB.
N—Neoplasm suggests the largest group of causes of hypopituitarism, including chromophobe adenomas and basophilic adenomas.
T—Trauma recalls the hypopituitarism of postpartum hemorrhage and amniotic fluid emboli or Sheehan syndrome.
Approach to the Diagnosis
Obviously the first thing to do is rule out pregnancy both by examination and a pregnancy test, preferably the serum β-subunit human chorionic gonadotropin (HCG). One must keep an ectopic pregnancy in mind even if the examination is normal and plan follow-up examinations and ultrasonography should the situation warrant. Altered secondary sex characteristics should be noted. If the examination fails to show evidence of pregnancy, congenital anomalies, or tumors of the ovaries, the physician should order thyroid function studies, a Wassermann test, CBC, and sedimentation rate. If these tests are normal, a gynecologist should be consulted. The gynecologist may give a test dose of intramuscular progesterone to prove that the endometrium functions well. He or she may do a D&C first. Then serum or urine FSH, LH, and prolactin levels are done; if the FSH level is high, the ovary is probably the site of the trouble. If the levels are low, even after gonadotropin-releasing factor (GRF) is administered, the pituitary is responsible. X-rays of the skull, CT scans, culdoscopy, and exploratory laparotomy all share their place in the workup.
