Ammenorrhoea and Homeopathy

The absence of menstruation is called amenorrhea.  It can be  of two  types, primary and secondary. Primary is the one in which  a girl has never menstruated before and secondary ammenorrhoea is when  there is  a cessation  of menses after three or more  cycles  of  normal menses.

Hormonal conditions  involving the pituitary,  thyroid  and ovaries and adrenals may cause amenorrhea Ovarian or uterine deformities  and  pathologies, malnutrition, anemia, obesity are some other causes.

Primary ammenorrhoea:

• Secondary sexual characteristics normal

• Imperforate hymen

The imperforate hymen may present at two ages of development. It may present in early childhood when the infant presents with a bulging hymen behind which is a mucocele, the vagina expanded by vaginal secretions of mucus. This is easily released and does not subsequently cause any problems following hymenectomy.

• Transverse vaginal septum

In circumstances where the vagina fails to cannulate the upper and lower parts of the vagina are separate. These girls present with cyclical abdominal pain due to the development of a haematocolpos, but the thickness of the transverse vaginal septum means that the clinical appearance is very different from that of an imperforate hymen. Again, an abdominal mass may be palpable but inspection of the vagina shows that it is blind ending and, although it may be bulging, it is pink not blue.

• Absent vagina and functioning uterus

This is a rare phenomenon when embryologically the uterine body has developed normally, but there is failure of development of the cervix. This leads to failure of the development of the upper vagina. The presenting symptom is again cyclical abdominal pain, but there is no pelvic mass to be found because there is no vagina to be distended.

• Absent vagina and non-functioning uterus

This is the second mostcommoncause of primary amenorrhoea, second only to Turner syndrome. Secondary sexual characteristics are normal as would be expected as ovarian function is unaffected. Examination of the genital area discloses normal female external genitalia but a blind ending vaginal dimple which is usually not more than 1.5 cm in depth. This is known as the Meyer-Rokitansky- Kuster-Hauser syndrome (or the MRKH syndrome) and the uterine development is usually very rudimentary.

• XY female – androgen insensitivity

There are a number of ways in which an individual may have an XY karyotype and a female phenotype. These are failure of testicular development, enzymatic failure of the testis to produce androgen, particularly testosterone, and androgenic receptor absence or failure of function. In androgen insensitivity there is a structural abnormality with the androgen receptor, due to abnormalities of the androgen receptor gene, which results in a non-functional receptor. This means that the masculinizing effect of testosterone during normal development is prevented and patients are therefore phenotypically female with normal breast development.

• Resistant ovary syndrome

This is an extremely rare condition as a cause of primary amenorrhoea, but it has been described. There are elevated levels of gonadotrophin in the presence of apparently normal ovarian tissue; patients do have some degree of secondary sexual characteristic development, but never produce adequate amounts of oestrogen to result in menstruation.

• Constitutional delay

There are, however, a number of girls in whom normal secondary sexual characteristics exist. There is no anatomical anomaly and endocrine investigations are all normal. If serial sampling is carried out during a 24-h period these young women are found to have immature pulsatile release of GnRH.

• Secondary sexual characteristics absent

• Normal stature

• Hypogonadotrophic hypogonadism

• Congenital

Isolated gonodotrophin-releasing hormone deficiency/Olfactogenital syndrome

In this condition the hypothalamus lacks the ability to produce GnRH and therefore there is a hypogonadotrophic state. The pituitary gland is normal and stimulation with exogenousGnRHleads to normal release of gonadotrophins.

• Acquired

• Weight loss/anorexia

Weight loss is more commonly associated with secondary amenorrhoea than primary amenorrhoea, but unfortunately it is increasingly apparent that young girls may suffer from anorexia nervosa in the prepubertal state

• Excessive exercise

A number of examples of this exist including ballet dancers, athletes and gymnasts. These girls fail to menstruate and may actually develop frank anorexia nervosa.

• Hyperprolactinaemia

This is an unusual cause of primary amenorrhoea and much more commonly seen as a cause of secondary amenorrhoea. There may be a recognizable prolactinoma in the pituitary, but often no apparent reason is seen.

• Hypergonadotrophic hypogonadism

Gonadal agenesis/XX agenesis XX or XY agenesis

In this situation there is complete failure of development of the gonad. These girls may be either 46XX or 46XY. The 46XX pure gonadal dysgenesis is an autosomal recessive disorder and other genes other than those located on the X chromosome are involved.

• Gonadal dysgenesis/Turner mosaic/Other X deletions or mosaics/XY enzymatic failure

The gonad is described as dysgenetic if it is abnormal in its formation. This encompasses a spectrum of conditions which vary with the degree of differentiation. The commonest is Turner syndrome, which is a single X chromosome giving 45X as the karyotype. The missing chromosome may be either X or Y. There are other circumstances in which the gonadal dysgenesis may be associated with a mosaic. Here two cell lines exist within one individual, the most common being 45X/46XX.

• Ovarian failure

These unfortunate girls have ovarian failure as a result of either chemotherapy or radiotherapy for childhood malignancy.

• Galactosaemia

These unfortunate girls have ovarian failure as a result of either chemotherapy or radiotherapy for childhood malignancy.

• Short stature

• Hypogonadotrophic hypogonadism

• Congenital Hydrocephalus

The most common aetiology in this group is hydrocephalus, as a result of childhood or neonatal infection. It is believed that this aetiology damages the hypothalamus and renders the GnRH-secreting neurones functionless, thereby creating a hypogonadotrophic hypogonadic state.

• Acquired

• Trauma

Trauma to the skull base may also damage the hypothalamus, and prevent GnRH secretion.

• Empty sella syndrome

In this unusual condition the sella turcica is found to be empty and there is congenital absence of the pituitary gland or at least part of it leading to failure to produce gonadotrophins. Thus secondary sexual characteristics do not develop.

• Tumours

A number of tumours have been described in the pituitary which may lead to destruction of the gland. The most common of which is craniopharyngioma. Hypergonadotrophic hypogonadism

• Turner syndrome

In pure Turner syndrome the chromosome complement is 45X and here a syndrome of short stature and ovarian failure lead to the typical features of this syndrome. Other X deletions or mosaics

• Heterosexual development

• Congenital adrenal hyperplasia

This anomaly occurs as a result of an enzyme deficiency in the steroid pathway of the adrenal gland

• Androgen-secreting tumour:

These extremely rare situations arise when the ovary contains an arrhenoblastoma. Here excessive production of androgen results in virilization and removal of the tumour resolves the problem.

• 5α-Reductase deficiency

This form of XY female results from an enzyme deficiency, which prevents the conversion of testosterone to 5-hydroxytestosterone, which is a necessary biochemical step in the development of the external genitalia in the male.

• True hermaphrodite

In this condition the child has the presence of both testicular and ovarian tissue. This may occur either in isolation, such that there is an ovary and a testis in the same individual, or the gonad may contain both ovarian and testicular tissue.

• Absent Müllerian inhibitor

There is a rare condition in which an XY individual may not produce Müllerian-inhibitory substance (MIS) which means that the internal genitalia are female with persistence of the Müllerian structures and also because testosterone is produced the Wolffian structures also persist.

Secondary ammenorrhoea

• GENITAL TRACT ABNORMALITIES

• Asherman’s syndrome :

Asherman’s syndrome is a condition in which intrauterine adhesions prevent normal growth of the endometrium.This may be the result of a too vigorous endometrial curettage affecting the basalis layer of the endometrium or adhesions may follow an episode of endometritis. It is thought that oestrogen deficiency increases the risk of adhesion formation in breastfeeding women who require a puerperial currettage for retained placental tissue.

• Cervical stenosis 

Cervical stenosis is an occasional cause of secondary amenorrhoea. It was relatively common following a traditional cone biopsy for the treatment of cervical intraepithelial neoplasia.

• OVARIAN CAUSES OF SECONDARY AMENORRHOEA :

• Polycystic ovary syndrome 

polycystic ovary syndrome (PCOS), which is a condition that presents with ovarian dysfunction and endocrine problems and is also associated with hyperinsulinaemia and metabolic disease. The polycystic ovary syndrome is a heterogeneous condition which is defined by the presence of two out of the following three criteria [1]: oligo- and/or anovulation [2], hyperandrogenism (clinical and/or biochemical) [3], polycystic ovaries, with the exclusion of other aetiologies. PCOS therefore encompasses symptoms of menstrual cycle disturbance and as such is the commonest cause of secondary amenorrhoea. Polycystic ovaries are commonly detected by ultrasound or other forms of pelvic imaging, with estimates of the prevalence in the general population being in the order of 20–33%  The characteristic features are accepted as being an increase in the number of follicles and the amount of stroma as compared with normal ovaries, resulting in an increase in ovarian volume. The ‘cysts’ are not cysts in the sense that they do contain oocytes and indeed are follicles whose development has been arrested. The actual number of cysts may be of less relevance than the volume of ovarian stroma or of the ovary itself, which has been shown to closely correlate with serum testosterone concentrations  The criteria fulfilling sufficient specificity and sensitivity to define the polycystic ovary (PCO) are the presence of 12 or more follicles measuring 2–9mmin diameter and increased ovarian volume (>10 cm3). If there is a follicle greater than 10 mm in diameter, the scan should be repeated at a time of ovarian quiescence to calculate volume and area.

• Premature ovarian failure. 

Ovarian failure by definition, is the cessation of periods accompanied by raised gonadotropin level prior to the age of 40 years. It may occur at any age. The exact incidence of this condition is unknown as many cases go unrecognized, but estimates vary between 1 and 5% of the female population. Studies of amenorrhoeic womenreport the incidence of premature ovarian failure to be between 10 and 36%.Overall, the most common cause of POF is autoimmune disease; with infection, previous surgery, chemo- and radiotherapy also contributing ovarian autoantibodies can be measured and have been found in up to 69% of cases of POF.

• Pituitary causes of secondary amenorrhoea: 

Hyperprolactinaemia is the commonest pituitary cause of amenorrhoea. There are many causes of a mildly elevated serumprolactin concentration, including stress, and a recent physical or breast examination. If the prolactin concentration is greater than 1000 mμ/l then the test should be repeated and if still elevated it is necessary to image the pituitary fossa (CT or MRI scan). Hyperprolactinaemia may result from a prolactin-secreting pituitary adenoma, or from a non-functioning ‘disconnection’ tumour in the region of the hypothalamus or pituitary, which disrupts the inhibitory influence of dopamine on prolactin secretion.

• Hypothalamic causes of secondary amenorrhoea :

Hypothalamic causes of amenorrhoea may be either primary or secondary. Primary hypothalamic lesions include craniopharyngiomas, germinomas, gliomas and dermoid cysts. These hypothalamic lesions either disrupt the normal pathway of prolactin inhibitory factor (dopamine), thus causing hyperprolactinaemia or compress or destroy hypothalamic and pituitary tissue.

• Systemic disorders causing secondary amenorrhoea :

Chronic disease may result in menstrual disorders as a consequence of the general disease state, weight loss or by the effect of the disease process on the hypothalamicpituitary axis. Furthermore, a chronic disease that leads to immobility such as chronic obstructive airways disease, may increase the risk of amenorrhoea associated osteoporosis.

• Weight-related amenorrhoea :

Weight can have profound effects on gonadotropin regulation and release. Weight and eating disorders are also common in women. A regular menstrual cycle will not occur if the BMI is less than 19 kg/m2. Fat appears to be critical to a normally functioning hypothalamic-pituitarygonadal axis. It is estimated that at least 22% of body weight should be fat to maintain ovulatory cycles

• Exercise-related amenorrhoea: 

Menstrual disturbance is common in athletes undergoing intensive training. Between 10 and 20% have oligomenorrhoea or amenorrhoea, compared with 5% in the general population  Amenorrhoea is more common in athletes under 30 years and is particularly common in women involved in the endurance events (such as long distance running). Up to 50% of competitive runners training 80 miles per week may be amenorrhoeic

• PSYCHOLOGICAL STRESS 

Studies have failed to demonstrate a link between stressful life events and amenorrhoea of greater than 2 months. However, stress may lead to physical debility such as weight loss which may then cause menstrual disturbance.

• Iatrogenic causes of amenorrhoea 

There are many iatrogenic causes of amenorrhoea, which may be either temporary or permanent. These include malignant conditions that require either radiation to the abdomen/pelvis or chemotherapy.Gynaecological procedures such as oophorectomy, hysterectomy and endometrial resection inevitably result in amenorrhoea.


Treatment
Homeopathy can do wonders in treating both types of amenorrhea. Good remedies are there in homeopathy and can show excellent results . After a good study of the case the best remedy has to be found out from the individualistic symptoms. The best remedies that have given me good results include pulsatilla, sepia,calcarea,natrum mur , kali carb,Graphites,Lycopodium

Ref: Dewhurst’s Textbook of Obstetrics & Gynaecology