Amenorrhoea; it's types, causes and it's Homoeopathic Treatment. (Part-10)

           At my last part, I have left up to the factor; H
yperprolactinaemia & Amenorrhoea, some points are left,so today i'm going to start from that, Hyperprolactinaemia causes secondary amenorrhoea in about 30% of women. There is anovulation & hypogonadotrophic hypogonadism. (I) Pituitary Adenoma (Prolactinoma):-Hyperprolactinaemia is commonly due to pituitary adenomas (microadenoma or macroadenoma). There are other various causes of hyperprolactinaemia. Causes of Hyperprolactinaemia;
[A] Physiological:-(1) Stress & exercise(raised endogenous opioids) (2)Pregnancy(3)Stimulation of nipples (4) Sleep (5) Idiopathic.
[B] Hypothalamus & pituitary:-(1) Craniopharyngioma (2) Tuberculosis (3) Hypothyroidism (4) Multiple endocrine disorder (Cushing's syndrome, Acromegaly) (5)Pituitary adenomas (Prolactinomas) (6) Resection of pituitary stalk.
[C]Drugs:-Some drugs, like antidepressants
[D] Others:- (1) Renal failure (2) Cirrhosis of liver (3) PCOS (4) Idiopathic. (J) SHEEHAN'S Syndrome:-There is history of severe postpartum haemorrhage, shock or severe infection. Depending upon the degree of anterior pituitary necrosis, the features vary. The common manifestations are failing lactation, loss of pubic & axillary hair, lethargy, hypotension, secondary amenorrhoea and atrophy of the breasts & genitalia. Gonadotrophin level is low, so also T3,T4 and cortisol. The hormones affected in order of frequency are, growth hormone (GH), prolactin, Gonadotrophins(FSH and LH), TSH and ACTH (Adrenocorticotrophic hormone). Hyponatremia may be present (30%). The syndrome may develop slowly over 8-10 years time. (K)Adrenal Tumour or Hyperplasia:-There is secondary amenorrhoea, infertility, acne and features of defeminisation followed by virilisation(hoarness of voice, hirsutism and enlargement of clitoris). In both the conditions there is excess production of androgens. Serum level of DHEA-S (dehydroepiandrosterone sulphate) correlates well with daily urinary 17KS excretion. (L) Cushing syndrome:- Cushing first described the syndrome in 1932. Androgens are formed as intermediate products in the synthesis of cortisol. The elevated cortisol level found in Cushing syndrome encompasses two distinct pathologic entities- (1) Cushing disease(ACTH dependent) (2) Adrenal tumour(ACTH independent). 

    syndrome; In Cushing disease, there is excess production of ACTH from the anterior pituitary or from ectopic sites. The increased ACTH causes hyperstimulation of adrenal cortex leading to its hyperplasia which in turn leads to excess production of cortisol & androgens. ACTH independent causes(adrenal adenoma or cancer) may be iatrogenic(high dose corticosteroid therapy)or adrenal tumour. The cause of adrenal mischief is cortisol secreting adenoma which produces excess cortisol. The androgen production is usually less but may be markedly elevated in presence of adrenal carcinoma. Symptoms include:-weakness, oligomenorrhoea, amenorrhoea, acne and hirsutism. Virilism is rare. The syndrome is often associated with hypertension, osteoporosis and insulin dependent diabetes. (M) Thyroid Dysfunction:- Both hypo & hyperthyroid states may produce secondary amenorrhoea & anovulation, the former is common. Serum TSH is raised, while T3 and T4 values are lowered in hypothyroid state. In subclinical hypothyroid state,serum TSH is elevated but T4 is normal. Serum prolactin may be raised even beyond 20ng/ml in hypothyroid state. This is due to increased sensitivity of prolactin secreting cells of anterior pituitary to TRH (Thyroid Releasing Hormone). (N) Postpill Amenorrhoea:-It is observed in less than 1% of the women following the use of COC pills (Combined Oral Contraceptive) pills. The association is more coincidental rather than causal. Fertility rate is normal following discontinuation of the drug. Spontaneous resumption of menstruation occurs in majority of cases after a varying period. Otherwise such amenorrhoea should be investigated as in other cases of secondary amenorrhoea. (O) General disease:- Malnutrition, tuberculosis- both pulmonary & pelvic, diabetes & chronic nephritis are all implicated. Their diagnostic criteria vary accordingly. Straight X-ray chest in pulmonary tuberculosis, blood sugar in diabetes, urine analysis & blood urea in chronic nephritis are helpful to substantiate the diagnosis.

[INVESTIGATIONS]:-Investigations aims at:- (1)To diagnose or confirm the offending factor. (2)To guide the management protocol either to restore menstruation and/or fertility.

       Investigations aims at:-In secondary amenorrhoea, there is altered coordinated function of the hypothalamopituitary ovarian axis are to some pathology. As such, it is not easy in most cases to pinpoint the diagnosis only by clinical examination. However, meticulous history taking & clinical examinations are mandatory. Laboratory investigations either to diagnose or to confirm the clinical diagnosis are mostly needed. These are especially helpful for formulation of management protocols either to restore menstruation or fertility. It should be emphasised that pregnancy must be excluded prior hand irrespective of the status of the women -married, unmarried, widow, divorced or separated. With the aetiological factors in mind, one should proceed for investigations.

          Detailed history :- Enquiry should be made about (1)Mode of onset:-whether sudden or gradual preceded by hypomenorrhoea or oligomenorrhoea. (2) Sudden change in environment,emotional stress, psychogenic shock, or eating disorder(anorexia nervosa) (3)Sudden change in weight-loss or gain. (4) Intake of psychotrophic or antihypertensive drugs. Intake of oral 'pills' or its recent withdrawal. History of radiotherapy & chemotherapy or surgery. (5) Appearance of abnormal manifestations either coinciding or preceding the amenorrhoea such as:- (a) Acne, hirsutism (excessive growth of hair in normal & abnormal sites in female)or change in voice. (b) Inappropriate lactation (galactorrhoea)- abnormal secretion of milk unrelated to pregnancy & lactation.(c)Headache or visual disturbances. (d)Hot flushes & vaginal dryness (6) Obstetric history:-overzealous curettage leading to synechiae. (a) Caesarean section may be extended to hysterectomy of which the patient may be unaware. (b) Severe postpartum haemorrhage, or shock or infection. (c) Postpartum or postabortal uterine curettage (d) Prolonged lactation:-The patient may be amenorrhoeic since childbirth or she may have one or two periods, followed by amenorrhoea. (7) Medical history of tuberculosis (pulmonary or extra-pulmonary), diabetes, and chronic nephritis or over hypothyroid state should be enquired. (8) Family history-Premature menopause often runs in the family(mother or sisters)

General examination:-The following features are to be noted-(1)Nutritional status(2)Extreme emaciation or marked obesity(3)Presence of acne or hirsutism (4)Discharge of milk from breast.

Writer
Dr Priyanka