Fertility Question
Question:
for a while now I have been having an unusual menstral cycle ..... When I first started menstrating when I was 12 it was like normal 12 yr olds they weren't regular and then during secondry school they started to slow done rather than becoming regular. I wasnt eating and verging on anorexia and my periods where every 2nd month and then around the age of 17 on wards they slowed down to twice a year how ever I was putting on a alot of weight to recover from years of not eating I am now 21 and I have been trying to figure out an other way of contreception rather than condoms as they reduce the pleasure of sex what can I do?
Answer
If the menstrual cycles last longer than 35 days (in other words, if your period occur once every 35 days or more), the condition is called "oligomenorrhea", or rare periods. Oligomenorrhea is a sign of hypogonadism. In more extreme cases, lack of a period for more than 3 months is called "amenorrhea". Amenorrhea is one of the signs of anorexia nervosa. Anorexia nervosa is considered a psychosomatic disorder. You may consult a gynecologist inquire about best solutions for birth control. In cases like yours, contraceptive pills are usually given to normalize the menstrual cycle rather than to be used strictly for contraception.
Tuesday, 26 June 2007
Wednesday, 13 June 2007
No Period But Not Pregnant: Secondary Amenorrhea
Question :
I'm 18 years old and menstruation has been fairly normal for me for the last 6 years or so. My problem is that I haven't had my period for the last 5 months. I'm not sexually active, so I know I cannot be pregnant. I've had no problems until now, and I've never visited a gynecologist.
Amenorrhea: The Clinical Term for Lack of Menstruation Lack of a menstrual period is called amenorrhea. When this occurs in a woman who has never had a period it is called primary amenorrhea. In cases like yours, where there has been cycles in the past, it can be called secondary amenorrhea. Of course, not every missed period warrants a clinical diagnosis and evaluation. Most physicians will consider missed periods a potential problem after 6 months, in a woman who has had regular cycles before. If a woman was irregular before, than twelve months is the usual timeframe.
Possible Cause of Secondary Amenorrhea
Benign CausesThe most common cause is pregnancy. It is also common at both ends of woman's menstrual history--in early adolescence and just before menopause.
Hormonal Causes
In order to menstruate, hormones must pass from a gland called the hypothalamus to the pituitary, to the ovaries. This chain of hormonal events must also stimulate the lining of the uterus, called the endometrium. If there is any breakdown of the normal chain of events, there will be secondary amenorrhea.
Hypothalamic Problems
All of these factors listed below lead to the lack of normal stimulation of the hypothalamus. Thus, the chain fails to get started in the first place. Returning to normal body weight, removing the offending drugs, or reducing stress, usually solves the problem.
-Anorexia Nervosa
-Simple Weight Loss
-Anxiety Reactions
-Marijuana Use
-Medications -- tricyclic antidepressants and phenothiazines
Pituitary Problems There are several different reasons for pituitary failure, which in turn, leads to secondary amenorrhea.
Simmond's disease--when the pituitary fails for without any particular cause (idiopathic).
Sheehan's syndrome--when the pituitary is damaged from massive bleeding caused by stresses of childbirth.
Microadenomas--tumors that interfere with the function of the pituitary.
Other Causes
Polycystic Ovarian Disease This is the most common cause of secondary amenorrhea. Women with this problem do not ovulate, and are thus infertile. They tend to show signs of excess testosterone, as well as excess estrogen. They are often obese, but this can occur in normal weight women as well. Signs and Symptoms: Large Breasts, excess cervical mucous, acne, male pattern hair growth (face, lower abdomen, thighs and chest), and heavy vaginal bleeding.
Premature Ovarian Failure (Early Menopause) This is often suspected by women themselves, but actually quite rare. Signs and Symptoms: Hot flashes, breast atrophy, decreased sex drive, and vaginal dryness.
Diagnosis
Secondary Amenorrhea is a symptom, not a disease in and of itself. In order to determine which of many causes is responsible, your doctor will start with a history. She will review any other symptoms you have, and relevant medical history. She will examine you for signs of bodily changes that occur with the various causes. If indicated, she will order tests to measure your hormone levels. If the problem is suspected as being at the level of the endometrium (lining of the uterus), then progestins will be given and then stopped to evaluate it. This is called a Progestin Withdrawal test.
Treatment
Treatment will be tailored to the cause. It will focus on eliminating causative agents, be they lifestyle, tumor, or medications. Alternatively, it will focus on replacing inadequate hormone production at the appropriate level.
Question :
I'm 18 years old and menstruation has been fairly normal for me for the last 6 years or so. My problem is that I haven't had my period for the last 5 months. I'm not sexually active, so I know I cannot be pregnant. I've had no problems until now, and I've never visited a gynecologist.
Amenorrhea: The Clinical Term for Lack of Menstruation Lack of a menstrual period is called amenorrhea. When this occurs in a woman who has never had a period it is called primary amenorrhea. In cases like yours, where there has been cycles in the past, it can be called secondary amenorrhea. Of course, not every missed period warrants a clinical diagnosis and evaluation. Most physicians will consider missed periods a potential problem after 6 months, in a woman who has had regular cycles before. If a woman was irregular before, than twelve months is the usual timeframe.
Possible Cause of Secondary Amenorrhea
Benign CausesThe most common cause is pregnancy. It is also common at both ends of woman's menstrual history--in early adolescence and just before menopause.
Hormonal Causes
In order to menstruate, hormones must pass from a gland called the hypothalamus to the pituitary, to the ovaries. This chain of hormonal events must also stimulate the lining of the uterus, called the endometrium. If there is any breakdown of the normal chain of events, there will be secondary amenorrhea.
Hypothalamic Problems
All of these factors listed below lead to the lack of normal stimulation of the hypothalamus. Thus, the chain fails to get started in the first place. Returning to normal body weight, removing the offending drugs, or reducing stress, usually solves the problem.
-Anorexia Nervosa
-Simple Weight Loss
-Anxiety Reactions
-Marijuana Use
-Medications -- tricyclic antidepressants and phenothiazines
Pituitary Problems There are several different reasons for pituitary failure, which in turn, leads to secondary amenorrhea.
Simmond's disease--when the pituitary fails for without any particular cause (idiopathic).
Sheehan's syndrome--when the pituitary is damaged from massive bleeding caused by stresses of childbirth.
Microadenomas--tumors that interfere with the function of the pituitary.
Other Causes
Polycystic Ovarian Disease This is the most common cause of secondary amenorrhea. Women with this problem do not ovulate, and are thus infertile. They tend to show signs of excess testosterone, as well as excess estrogen. They are often obese, but this can occur in normal weight women as well. Signs and Symptoms: Large Breasts, excess cervical mucous, acne, male pattern hair growth (face, lower abdomen, thighs and chest), and heavy vaginal bleeding.
Premature Ovarian Failure (Early Menopause) This is often suspected by women themselves, but actually quite rare. Signs and Symptoms: Hot flashes, breast atrophy, decreased sex drive, and vaginal dryness.
Diagnosis
Secondary Amenorrhea is a symptom, not a disease in and of itself. In order to determine which of many causes is responsible, your doctor will start with a history. She will review any other symptoms you have, and relevant medical history. She will examine you for signs of bodily changes that occur with the various causes. If indicated, she will order tests to measure your hormone levels. If the problem is suspected as being at the level of the endometrium (lining of the uterus), then progestins will be given and then stopped to evaluate it. This is called a Progestin Withdrawal test.
Treatment
Treatment will be tailored to the cause. It will focus on eliminating causative agents, be they lifestyle, tumor, or medications. Alternatively, it will focus on replacing inadequate hormone production at the appropriate level.
All About Secondry Amenorrhea
Secondary Amenorrhea
Lack of menstrual periods in a woman that has had periods previously
Background
Secondary amenorrhea is the absence of menstrual periods for 6 months in a woman who had previously been regular, or for 12 months in a woman who had irregular periods.
This problem is seen in about 1% of women of reproductive age.
Primary amenorrhea is when the woman has never had a period in her life. This page will not discuss primary amenorrhea which is rare. The causes of primary amenorrhea are also quite different from secondary amenorrhea.
A very common cause of secondary amenorrhea in reproductive age women is pregnancy and this should always be excluded by physical exam and laboratory testing for the pregnancy hormone - HCG.
History
A good history can reveal the etiologic diagnosis in up to 85% of cases of amenorrhea.
A detailed menstrual history should be taken.
Any history of galactorrhea (milky discharge from the breasts) is important and indicates the need for a prolactin hormone level to rule out hyperprolactinemia.
A woman who has had hot flashes, breast atrophy and decreased libido along with her amenorrhea may have premature ovarian failure.
Certain medications such as phenothiazines (used for psychiatric disorders) and some narcotics can cause amenorrhea, usually in association with an elevated prolactin and galactorrhea.
A large amount of weight loss or gain can also lead to anovulation - as can stress or extensive exercise.
Anorexia nervosa is often accompanied by secondary amenorrhea.
Both Cushing's disease (over activity of adrenal glands) and hypothyroidism (under-functioning thyroid gland) can cause amenorrhea.
If the patient has a history of severe postpartum hemorrhage (very heavy bleeding after a delivery), she may have pituitary insufficiency from infarction (Sheehan's syndrome).
When amenorrhea follows a D&C (dilation and curettage) one should suspect intrauterine adhesions (Asherman's syndrome), particularly if the procedure was pregnancy related.
Asherman's can also occasionally be seen following other types of uterine surgery such as metroplasty, myomectomy or cesarean section.
Amenorrhea following cervical conization, or other procedures on the cervix (LEEP, etc.) can be due to procedure related cervical stenosis.
Following discontinuation of oral contraception some women will not have periods for up to several months. However, the reported incidence for amenorrhea lasting more than 6 months after the pill is stopped is 0.8% which is essentially the same as the incidence of amenorrhea in the general population. Therefore, amenorrhea of greater than 6 months duration after oral contraceptive use is not related to the pill use.
Physical examination (what the OB/GYN doctor will look for on the exam)
Signs of androgen excess such as hirsutism (excess hair growth) and clitoromegaly (enlargement of the clitoris).
The breast exam may reveal galactorrhea (milky discharge from the breasts).
Estrogen deficiency may be suggested on pelvic exam by a smooth vagina that lacks the normal rugae (wrinkles) and a dry endocervix with no mucous.
Workup after history and physical (what the doctor will do next)
If the history and physical exam are suggestive of a certain etiology then the initial laboratory or radiographic workup can be tailored appropriately.
For example, a 32 year old woman who has previously had regular menses presents with 10 months of amenorrhea following a curettage for heavy bleeding associated with an incomplete abortion. She has no signs or symptoms that suggest ovarian failure or thyroid disease. There is no galactorrhea and she uses no medications or street drugs. She most likely has intrauterine adhesions causing her amenorrhea. A reasonable approach to this patient would be an hCG level to rule out pregnancy, an FSH level to demonstrate the presence or absence of ovarian function, and then a hysterosalpingogram or hysteroscopy if these first 2 tests are normal. One could also do the entire diagnostic workup as recommended for patients without any etiology apparent. However, for the sake of efficiency and cost-effectiveness, the workup can sometimes be more directed.
Some patients will not demonstrate any obvious etiology for their amenorrhea on history and physical exam. These patients can be worked up in a logical manner using a stepwise approach. Diagnostic approaches may vary, however, differences between them pertain mainly to the order in which tests are performed.
There are several ways that a workup for secondary amenorrhea can be approached. One reasonable diagnostic approach is described here. If your doctor did things differently, that doesn't mean that he or she was wrong or that this approach is wrong. Every case should be treated individually.
In the approach described here, the first tests to perform after pregnancy is ruled out are a progesterone withdrawal test as well as a TSH (thyroid stimulating hormone) and prolactin level.
Thyroid function
Both hypothyroidism and hyperprolactinemia can cause primary or secondary amenorrhea. If these entities are discovered, appropriate therapy should result in resumption of regular menstrual periods.
Progestational challenge (progesterone withdrawal test)
The progestational challenge test is performed by giving oral medroxyprogesterone acetate 10 mg daily for 7-10 days or progesterone in oil 100-200 mg intramuscularly. A positive response is any bleeding more than light spotting that occurs within 2 weeks after the progestin is given. This bleeding will usually occur 2-7 days after the progestin is finished. Withdrawal bleeding will usually be seen if the patient's estradiol level is 40 pg/ml or more.
If the patient experiences bleeding after the progestin she has estrogen present but is not ovulating. If no withdrawal bleeding occurs, either the patient has very low estrogen levels or there is a problem with the outflow tract such as uterine synechiae (adhesions) or cervical stenosis (scarring).
Lack of menstrual periods in a woman that has had periods previously
Background
Secondary amenorrhea is the absence of menstrual periods for 6 months in a woman who had previously been regular, or for 12 months in a woman who had irregular periods.
This problem is seen in about 1% of women of reproductive age.
Primary amenorrhea is when the woman has never had a period in her life. This page will not discuss primary amenorrhea which is rare. The causes of primary amenorrhea are also quite different from secondary amenorrhea.
A very common cause of secondary amenorrhea in reproductive age women is pregnancy and this should always be excluded by physical exam and laboratory testing for the pregnancy hormone - HCG.
History
A good history can reveal the etiologic diagnosis in up to 85% of cases of amenorrhea.
A detailed menstrual history should be taken.
Any history of galactorrhea (milky discharge from the breasts) is important and indicates the need for a prolactin hormone level to rule out hyperprolactinemia.
A woman who has had hot flashes, breast atrophy and decreased libido along with her amenorrhea may have premature ovarian failure.
Certain medications such as phenothiazines (used for psychiatric disorders) and some narcotics can cause amenorrhea, usually in association with an elevated prolactin and galactorrhea.
A large amount of weight loss or gain can also lead to anovulation - as can stress or extensive exercise.
Anorexia nervosa is often accompanied by secondary amenorrhea.
Both Cushing's disease (over activity of adrenal glands) and hypothyroidism (under-functioning thyroid gland) can cause amenorrhea.
If the patient has a history of severe postpartum hemorrhage (very heavy bleeding after a delivery), she may have pituitary insufficiency from infarction (Sheehan's syndrome).
When amenorrhea follows a D&C (dilation and curettage) one should suspect intrauterine adhesions (Asherman's syndrome), particularly if the procedure was pregnancy related.
Asherman's can also occasionally be seen following other types of uterine surgery such as metroplasty, myomectomy or cesarean section.
Amenorrhea following cervical conization, or other procedures on the cervix (LEEP, etc.) can be due to procedure related cervical stenosis.
Following discontinuation of oral contraception some women will not have periods for up to several months. However, the reported incidence for amenorrhea lasting more than 6 months after the pill is stopped is 0.8% which is essentially the same as the incidence of amenorrhea in the general population. Therefore, amenorrhea of greater than 6 months duration after oral contraceptive use is not related to the pill use.
Physical examination (what the OB/GYN doctor will look for on the exam)
Signs of androgen excess such as hirsutism (excess hair growth) and clitoromegaly (enlargement of the clitoris).
The breast exam may reveal galactorrhea (milky discharge from the breasts).
Estrogen deficiency may be suggested on pelvic exam by a smooth vagina that lacks the normal rugae (wrinkles) and a dry endocervix with no mucous.
Workup after history and physical (what the doctor will do next)
If the history and physical exam are suggestive of a certain etiology then the initial laboratory or radiographic workup can be tailored appropriately.
For example, a 32 year old woman who has previously had regular menses presents with 10 months of amenorrhea following a curettage for heavy bleeding associated with an incomplete abortion. She has no signs or symptoms that suggest ovarian failure or thyroid disease. There is no galactorrhea and she uses no medications or street drugs. She most likely has intrauterine adhesions causing her amenorrhea. A reasonable approach to this patient would be an hCG level to rule out pregnancy, an FSH level to demonstrate the presence or absence of ovarian function, and then a hysterosalpingogram or hysteroscopy if these first 2 tests are normal. One could also do the entire diagnostic workup as recommended for patients without any etiology apparent. However, for the sake of efficiency and cost-effectiveness, the workup can sometimes be more directed.
Some patients will not demonstrate any obvious etiology for their amenorrhea on history and physical exam. These patients can be worked up in a logical manner using a stepwise approach. Diagnostic approaches may vary, however, differences between them pertain mainly to the order in which tests are performed.
There are several ways that a workup for secondary amenorrhea can be approached. One reasonable diagnostic approach is described here. If your doctor did things differently, that doesn't mean that he or she was wrong or that this approach is wrong. Every case should be treated individually.
In the approach described here, the first tests to perform after pregnancy is ruled out are a progesterone withdrawal test as well as a TSH (thyroid stimulating hormone) and prolactin level.
Thyroid function
Both hypothyroidism and hyperprolactinemia can cause primary or secondary amenorrhea. If these entities are discovered, appropriate therapy should result in resumption of regular menstrual periods.
Progestational challenge (progesterone withdrawal test)
The progestational challenge test is performed by giving oral medroxyprogesterone acetate 10 mg daily for 7-10 days or progesterone in oil 100-200 mg intramuscularly. A positive response is any bleeding more than light spotting that occurs within 2 weeks after the progestin is given. This bleeding will usually occur 2-7 days after the progestin is finished. Withdrawal bleeding will usually be seen if the patient's estradiol level is 40 pg/ml or more.
If the patient experiences bleeding after the progestin she has estrogen present but is not ovulating. If no withdrawal bleeding occurs, either the patient has very low estrogen levels or there is a problem with the outflow tract such as uterine synechiae (adhesions) or cervical stenosis (scarring).
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