Secondary – the termination of periods for six months and more at women of reproductive age with the established menstrual cycle. The defining sign - absence monthly not less than half a year. Secondary can be followed by pains in the bottom of a stomach (at a uterine form), mental violations (at a psychogenic form), obesity (at an endocrine form), vegetative violations (at a yaichnikovy form) etc. For establishment of the reasons of an amenorea the general and gynecologic inspection, hormonal researches, ultrasonography of bodies of a small pelvis, a X-ray analysis of the Turkish saddle, gistero-and a laparoscopy is performed. Treatment is aimed at correction of the factors which led to a secondary amenorea.
Secondary – the violation of a menstrual cycle which is characterized by lack of periods for 6 months and longer. Unlike primary amenorea, the secondary form develops at earlier menstruating women. At the age of 16-45 years the frequency of emergence of the secondary amenorea which is not connected with the physiological reasons (pregnancy, a lactation, a climax) makes 3-10% of cases. Secondary is among the most difficult problems of reproductive health as women with such violation always have infertility. The spontaneous termination of periods indicates serious dysfunction of an organism which can be in the plane of consideration of gynecology, endocrinology, psychiatry.
Classification of a secondary amenorea
Distinguish true and false its forms from a secondary amenorea. Violation of neuroendocrine regulation of a menstrual cycle is the cornerstone of a true amenorea. False it is diagnosed at safety of hormonal function of ovaries and cyclic changes in a uterus; in this case lack of periods is connected with anatomic obstacles for outflow of blood from a uterus and a genital tract. At a false amenorea blood can accumulate in uterine tubes (), a uterus (gematometr) or in a vagina ().
Depending on the level of content of the gonadotropny hormones regulating menstrual function subdivide on:
- gipogonadotropny, caused by organic damages of a hypophysis or hypothalamus;
- gipergonadotropny, caused by dysfunction of ovaries of genetic, fermental, autoimmune or other etiology;
- the normogonadotropny, caused by pathology uterus, SPKYa, psychogenic factors, violation of food, wearisome physical activities, a giperprolaktinemiya.
Reasons of a secondary amenorea
Development of a pathological secondary amenorea can be connected with various anatomic, genetic, biochemical, hormonal, psychological factors. Taking into account an etiology and the level of defeat distinguish secondary hypothalamic, gipotalamo-hypophysial, nadpochechnikovy, yaichnikovy, uterine, psychogenic genesis.
Secondary hypothalamic it is observed at women with functional violations in the "hypothalamuses-hypophysis-adrenal glands-ovaries" system - a so-called hypothalamic syndrome. Such pathology develops under the influence of frequent viral diseases or chronic infections, excessive physical and intellectual activities, surgeries. Usually arises at girls in 1-3 years after menarche. The pathogenesis of a hypothalamic syndrome is connected with hyper activation of simpatoadrenalovy system and stimulation of hypothalamic structures. On this background the increased secretion of LG, FSG, Prolactinum, AKTG, TTG, cortisol, aldosteron is noted; decrease in level of an estradiol and progesterone, STG. Further in process of exhaustion of simpatoadrenalovy system, activity - hypophysial systems also decreases that is followed by secondary amenorey.
Violations in work of a hypothalamus can also arise against the background of considerable loss of body weight owing to a low-calorie diet or nervous anorexia. It is known that even loss of 10-15% of weight of physiological and age norm can cause symptoms of a secondary amenorea, and weight reduction results less than 46 kg in tolerance of a hypophysis to stimulation of a gonadoliberinama. False pregnancy can become one more reason of a hypothalamic amenorea. At this syndrome the increased secretion of LG and Prolactinum with simultaneous oppression of synthesis of FSG is noted.
Secondary gipotalamo-hypophysial genesis it is most often connected with a functional and organic giperprolaktinemiya. Increase in production of Prolactinum is followed by decrease in synthesis of gonadotrophins, as causes the termination of periods. The functional giperprolaktinemiya can develop against the background of a hypothyroidism, a long lactation, a stress, abortions, long reception of psychotropic, hormonal drugs, the COOK. Tumors of a hypophysis (prolaktinom) can act as the reasons of an organic giperprolaktinemiya. Disorders of gipotalamo-hypophysial regulation of a menstrual cycle are noted at Shikhan's syndrome, adenoma of a hypophysis, ChMT, neuroinfections.
The Nadpochechnikovy option of a secondary amenorea meets at an adrenogenital syndrome (a congenital giperplaziya of adrenal glands), viriliziruyushchy tumors of adrenal glands, a giperplaziya of bark of adrenal glands, Itsenko-Cushing's syndrome. Yaichnikovy forms are observed at a syndrome of exhaustion of ovaries, a syndrome of resistant ovaries, SPKYa, tumors of ovaries, ooforita, the artificial menopause induced by surgical intervention or radiation therapy.
Uterine forms of a secondary amenorea are most often connected with inflammatory or traumatic damage of endometrium. Destruction of endometrium can happen owing to an endometritis of a tubercular or gonorrheal etiology, numerous abortions and medical and diagnostic vyskablivaniye, an endometrium ablyation. At the same time as a result of damage of a basal layer of a uterus cyclic transformation of endometrium in response to hormonal stimulation and its deskvamation does not happen. Less often Asherman's syndrome, an atresia of the tservikalny channel owing to a uterus neck elektrokonization occur among uterine factors of an amenorea.
Psychogenic, or the stress-amenoreya makes about 10% of cases among other forms of violation. It can be provoked by sharp or chronic emotional and mental injuries. Stress-amenoreya often arises at women during the periods of armed conflicts and social disasters therefore quite often is defined as " wartime". Stressful impact on an organism causes emission of a large number of AKTG, neurotransmitters which block secretion of a gonadotrophin-rileasing-factor that leads to violation of production of gonadotropny hormones (FSG and LG) a hypophysis and to decrease in synthesis of sex hormones ovaries.
Forms of a secondary amenorea
Regardless of the reason of a secondary amenorea, the general for all forms is the termination of the menstrual bleedings which were earlier occurring more or less regularly and infertility. Criterion it is considered to be absence monthly within 6 and more months in a row. Other symptoms are variable and depend on a form of a secondary amenorea.
Psychogenic in addition is followed astenonevrotichesky, depressive or ipokhondricheskiya by syndromes. Patients note increased fatigue, uneasiness, sleep disorders, tendency to depressions, decrease in a libido. Tachycardia, dryness of skin, locks can disturb. Periods stop suddenly, the period of an oligomenorea is absent.
Amenory against the background of loss of body weight noticeable deficiency of weight accompanies; at medical examination the hypoplasia of mammary glands and genitals comes to light. Other signs of insufficient food include arterial hypotonia, bradycardia, a hypothermia, a hypoglycemia, locks. Appetite is reduced, the permanent disgust for food and a kakheksiya indicating the beginning of development of anorexia can develop.
Secondary at a hypothalamic syndrome it is combined with early puberty, obesity, a girsutizm, existence of an acne and striya on skin, vegeto-vascular dystonia. Of the amenorea associated with a giperprolaktinemiya it is characteristic spontaneous . Complaints to a tsefalgiya, dizzinesses, arterial hypertension are frequent. Psychoemotional violations take place: variability of mood, irritability, depressive reactions.
At yaichnikovy forms of a secondary amenorea disappearance of periods is quite often preceded by the oligomenorea period. In the anamnesis at patients - the timely beginning of menarche and quite often normal menstrual function. At a syndrome of resistant ovaries the periods stop aged up to 35 years, however the vegetovascular violations characteristic of a premature menopause, no. Amenorey, connected with a syndrome of exhaustion of ovaries, on the contrary, is followed by inflows, hyperaemia of the person, perspiration, headaches.
As the defining symptom of a false amenorea serve the spastic pains in the bottom of a stomach caused by violation of outflow of menstrual blood. At a chronic endometritis violation of a menstrual cycle develops gradually: eventually intensity and duration of monthly is reduced up to complete cessation.
Diagnostics of a secondary amenorea
Secondary diagnose on the basis of the anamnesis and a clinical picture. However differential diagnostics of a form of an amenorea and definition of its reasons becomes more complex challenge for gynecologists-endocrinologists, neurologists, psychotherapists and other experts. At clarification of the gynecologic status of the patient consider age of menarche, character of periods in the past, the obstetric anamnesis, the postponed gynecologic and ekstragenitalny diseases, operations and injuries, heredity, food, susceptibility to stresses and other factors influencing menstrual function.
At a secondary amenorea survey on a chair, carrying out functional tests (a pupil symptom, measurement of basal temperature, a kolpotsitologiya), kolposkopiya, ultrasonography of bodies of a small pelvis are obligatory. Within differential diagnostics pharmacological tests are widely applied: with progesterone, estrogen and gestagena, clomifene, gonadotrophins. For detection of intrauterine pathology the gisterosalpingografiya and hysteroscopy is carried out. At yaichnikovy forms of a secondary amenorea the diagnostic laparoscopy is informative.
For the purpose of identification of hormonal violations research TTG, T4, insulin is shown, to LG and FSG, an estradiola, progesterone, testosterone, Prolactinum, AKTG, cortisol and other hormones taking into account estimated option of a secondary amenorea. At suspicion of pathology of a hypophysis the X-ray analysis of the Turkish saddle is made; according to indications hypophysis KT or MPT is carried out. The plan of inspection joins consultation of the ophthalmologist with survey of an eye bottom (oftalmoskopiya) and a research of fields of vision.
Treatment of a secondary amenorea
Options of treatment of a secondary amenorea are closely connected with its form. Therapy is directed to elimination of the reasons of an amenorea, whenever possible - restoration of menstrual and reproductive functions.
Secondary , caused by deficiency of weight or anorexia, it is treated together with psychotherapists and nutritionists. To patients the high-calorific diet with frequent fractional food, sedative medicines, polyvitamins, psychotherapy is appointed. If on this background there is no spontaneous restoration of a menstrual cycle, appoint hormonal therapy to 4-6 months. To patients with a psychogenic form of an amenorea recommend to exclude provocative factors, to normalize a working condition and rest. Physical therapy courses are shown: endonasal electrophoresis, massage of ShVZ, balneoterapiya.
If the hypothyroidism is the reason of an amenorea, tireoidny hormones are applied by long courses. Reception of a bromokriptin, kabergolin and their analogs is shown to patients with a giperprolaktinemiya. Detection of macroadenoma of a hypophysis by results of inspection is the basis for surgical or beam treatment.
Therapy of yaichnikovy forms of a secondary amenorea consists in purpose of cyclic hormonal therapy, low-dosed the COOK. At detection of a tumor of an ovary the ovariektomiya or an adneksektomiya (removal of appendages) is required. At an atresia of the tservikalny channel make its buzhirovaniye. Treatment of sinekhiya of a cavity of a uterus – quick, by means of a gisterorezektoskopiya. At infectious processes purpose of etiotropny antibacterial therapy is shown. Further for improvement of metabolic processes in a uterus holding physiotherapeutic procedures - ultrasound, an electrophoresis, a diathermy on area of a small pelvis is expedient.
In most cases by means of correctly organized treatment it is possible to reach renewal of periods. The forecast in respect of restoration of reproductive function depends on a form of a secondary amenorea. At the remaining infertility consultation of a reproduktolog is recommended to the woman. Modern reproductive technologies allow to make extracorporal fertilization (by the IMSI or IKSI method), if necessary with use of donor sperm, a donor ovum or a donor embryo. The cryopreservation of embryos with their subsequent defrosting and replanting in the patient's uterus is made for increase in chances of approach of pregnancy after artificial insemination and a successful embryological stage. Chronic not incubation of pregnancy is the indication to surrogacy application.