Pure gonadal dysgenesis and spontaneous pregnancy: a case report

We report a case of pure gonadal dysgenesis with streak gonads in which spontaneous conception occurred 10 years after the diagnosis. Her pregnancy proceeded as normal, and she gave birth to a live baby at term by cesarean section. A lactation period lasting for 1 year and afterwards proceeded as amenorrheic. Gonadotropins measurements in post-lactational period were at the menopausal levels again. To the best of our knowledge, this is the first case of pure gonadal dysgenesis with streak gonads in which spontaneous conception occurred.

The young female athlete

Participation of adolescents and young women in strenuous sports activity may lead to various metabolic and psychological derangements of clinical relevance to the endocrinologist. The most common manifestations encountered in practice are primary and secondary amenorrhea, reduced bone mineral density and eating disorders. The occurrence of all three together has been named "the athletic triad". The underlying hormonal drivers that lead to some of these manifestations are the reduced leptin level as well as the persistent low grade stress response commonly observed in such females. "Exercise-related female reproductive dysfunction" (ERFRD), can possibly include short-term (infertility) and long-term (osteoporosis) consequences. Functional hypothalamic amenorrhea, a manifestation of ERFRD in adolescence, is an integrated response to the combination of excessive physical and emotional stress, exercise, and/or reduced food intake characterized by decreased endogenous GNRH secretion. The primary aim of treating these athletes should be the prevention of the development of any component of the triad as well as the whole complex by educating athletes, trainers, parents and health care professionals about proper nutrition and safe training. The long term prognosis is good. However, significant long term morbidity may affect these young women later in life.

Ethnopharmacological uses of Erythrina senegalensis: a comparison of three areas in Mali, and a link between traditional knowledge and modern biological science

This paper describes ethnopharmacological knowledge on the uses of Erythrina senegalensis DC (Fabaceae) in traditional medicine in three different areas (Dioila, Kolokani and Koutiala) in Mali. Data were collected using interviews of traditional healers selected randomly. The main reported diseases for which E. senegalensis was used by the traditional healers were amenorrhea, malaria, jaundice, infections, abortion, wound, and body pain (chest pain, back pain, abdominal pain etc). The fidelity level (which estimates the agreement of traditional healers on the same area about a reported use of the plant) was calculated to compare the results from the three areas. Certain differences were noticed, the most striking was the fact that amenorrhea was the most reported disease in Dioila and Kolokani with 21% of agreement for both areas, while this use was not reported in Koutiala at all. Similarities existed between the three areas on the use of the plant against malaria and infections, although with different degree of agreement among the healers. We also report the results of a literature survey on compounds isolated from the plant and their biological activities. A comparison of these results with the ethnopharmacological information from Mali and other countries showed that some of the traditional indications in Mali are scientifically supported by the literature. For instance, the use of E. senegalensis against infectious diseases (bilharzias, schistosomiasis, pneumonia etc.) is sustained by several antibacterial and antifungal compounds isolated from different parts of the plant. The comparison also showed that pharmacologists have not fully investigated all the possible bioactivities that healers ascribe to this plant.

Absence of endometrium as a cause of primary amenorrhea

OBJECTIVE

To describe congenital endometrial absence.

DESIGN

Case report.

SETTING

University hospital.

PATIENT(S)

A 32-year-old woman presented with primary amenorrhea and infertility. Hormone analysis, physical and gynecologic examinations, transvaginal ultrasonography, and karyotype analysis were normal.

INTERVENTION(S)

Progesterone challenge test, laparoscopy, hysteroscopy were performed, and hysteroscopic biopsies were obtained from the uterine cavity.

MAIN OUTCOME MEASURE(S)

Presence of endometrium, menstruation.

RESULT(S)

The progesterone challenge test was negative. Laparoscopy revealed normal pelvic structures. Evaluation of biopsies from uterine cavity revealed absence of endometrium.

CONCLUSION(S)

Endometrial absence is a differential diagnosis for primary amenorrhea; assessment of the uterine cavity and obtaining biopsy samples may help in diagnosis of suspected cases before they undergo assisted reproduction and can avoid unnecessary treatment.

Anorexia, bulimia, and the athletic triad: evaluation and management

Caloric restriction caused by undernutrition or over-exercise is increasingly common and has significant health consequences such as hypothalamic amenorrhea, infertility, attainment of low peak bone mass, and bone loss leading to fracture. In these patients, the pathophysiology of amenorrhea and bone loss is multifactorial, involving hormones that integrate the nutritional state with the hypothalamic-pituitary-ovarian axis, including leptin and possibly ghrelin. The pathophysiology of bone loss includes nutritional deficiencies, possibly estrogen deficiency, and direct and indirect effects of leptin on bone. Identifying patients at risk for low bone mineral density and fracture is important, as is screening with dual energy radiograph absorptiometry. Treatment has focused on oral contraceptive use, yet improved bone mineral density is marked by nutritional recovery and anovulation reversal. Therefore, resolving the nutrition deficiency should be the cornerstone of treatment. Cognitive-behavioral therapy aims for weight recovery, which can lead to reversal of amenorrhea and improvement in other associated metabolic abnormalities. During treatment, estradiol levels can be followed to assess hypothalamic-pituitary-ovarian recovery because estradiol secretion may increase well before ovulation occurs. In patients failing the above interventions, hormone replacement should be considered, but bone mineral density should be followed because patients may continue to lose bone despite treatment with oral contraceptives if nutrition is not improved.

Anorexia nervosa and Raynaud's phenomenon: a case report

OBJECTIVE

To describe and discuss potential relationships between anorexia nervosa (AN) and Raynaud's phenomenon, the course and concurrent treatment of these two disorders as they appeared simultaneously, and a potential treatment modification entailed in such concurrent therapies.

BACKGROUND

Although Raynaud's phenomenon has been described during the course of AN, the associations and interactions between these two conditions are not clear.

METHOD

We report the medical workup, treatment, and outcomes in a 19-year old female patient who developed Raynaud's phenomenon following the onset of AN.

RESULTS

After treatment with nutritional rehabilitation, counseling, and individual and group therapy, the patient's weight, eating disorder-related behaviors, and attitudes improved significantly. Raynaud's related symptoms improved, following treatment with a calcium channel blocker and antiaggregant therapy. In conjunction with nutritional efforts to treat the patient's long-standing amenorrhea and osteopenia, the treatment team elected to also administer estrogen hormone in addition to oral calcium and vitamin D supplementation. Since oral contraceptives are to be avoided in patients with Raynaud's phenomenon who show clinical findings suggesting connective tissue disorder, the treatment team elected to treat this patient with transdermal hormone replacement therapy.

CONCLUSION

The co-occurrence of AN and Raynaud's phenomenon merits close and persistent follow-up by a multidisciplinary team and may lead to alterations of usual therapeutic approaches.

Athletic amenorrhea and endothelial dysfunction

OBJECTIVES

To determine if menstrual status changed in amenorrheic college runners over a 2-year period and what effect this had on brachial artery flow-mediated dilation.

PARTICIPANTS

Eighteen athletes first studied in our laboratory 2 years prior were available for follow-up. Nine of the 10 original women with athletic amenorrhea (mean +/- SE, age 21.3 +/- 1.2 yrs), and 9 of the 11 eumenorrheics/controls (age 20.1 +/- 0.5 yrs) were studied 2 years after baseline measurements.

METHODS

Questionnaires/personal interviews and blood draws were performed to determine menstrual status. A non-invasive ultrasound technique was used to determine brachial artery flow-mediated dilation (endothelium-dependent).

RESULTS

Menstrual status changed in 7 of 9 original amenorrheic subjects (2 were taking hormone replacement, 2 were taking oral contraceptives, 3 had a natural menstrual period prior to testing, and 2 remained amenorrheic). Endothelium-dependent brachial artery dilation, measured as the percent change in maximal brachial artery diameter from baseline during reactive hyperemia, was improved in the original amenorrheic subjects (a 1.1% +/- 1.0 increase in the original study versus 5.6% + 1.1 increase in the current study, P=0.01) while in the eumenorrheic/control group there was no change (6.3% +/- 1.7 versus 8.0% +/- 1.3, P=0.42).

CONCLUSIONS

Menstrual status changed in 7 of the 9 original amenorrheic athletes, and this change was associated with an improvement in brachial artery flow-mediated dilation.

Use of cognitive behavior therapy for functional hypothalamic amenorrhea

Behaviors that chronically activate the hypothalamic-pituitary-adrenal (HPA) axis and/or suppress the hypothalamic-pituitary-thyroidal (HPT) axis disrupt the hypothalamic-pituitary-gonadal axis in women and men. Individuals with functional hypothalamic hypogonadism typically engage in a combination of behaviors that concomitantly heighten psychogenic stress and increase energy demand. Although it is not widely recognized clinically, functional forms of hypothalamic hypogonadism are more than an isolated disruption of gonadotropin-releasing hormone (GnRH) drive and reproductive compromise. Indeed, women with functional hypothalamic amenorrhea display a constellation of neuroendocrine aberrations that reflect allostatic adjustments to chronic stress. Given these considerations, we have suggested that complete neuroendocrine recovery would involve more than reproductive recovery. Hormone replacement strategies have limited benefit because they do not ameliorate allostatic endocrine adjustments, particularly the activation of the adrenal and the suppression of the thyroidal axes. Indeed, the rationale for the use of sex steroid replacement is based on the erroneous assumption that functional forms of hypothalamic hypogonadism represent only or primarily an alteration in the hypothalamic-pituitary-gonadal axis. Potential health consequences of functional hypothalamic amenorrhea, often termed stress-induced anovulation, may include an increased risk of cardiovascular disease, osteoporosis, depression, other psychiatric conditions, and dementia. Although fertility can be restored with exogenous administration of gonadotropins or pulsatile GnRH, fertility management alone will not permit recovery of the adrenal and thyroidal axes. Initiating pregnancy with exogenous means without reversing the hormonal milieu induced by chronic stress may increase the likelihood of poor obstetrical, fetal, or neonatal outcomes. In contrast, behavioral and psychological interventions that address problematic behaviors and attitudes, such as cognitive behavior therapy (CBT), have the potential to permit resumption of full ovarian function along with recovery of the adrenal, thyroidal, and other neuroendocrine aberrations. Full endocrine recovery potentially offers better individual, maternal, and child health.

Aménorrhées psychogènes

Any amenorrhoea noticed outside pregnancy, lactation and menopause periods might be of organic or functional origin. Today, non organic amenorrhoea are either called hypothalamic amenorrhoea, more exactly supra hypothalamic amenorrhoea; functional amenorrhoea--this definition being characterized by its lack of any anatomic substratum; or, psychogenic amenorrhoea--an etiologic definition. Like any amenorrhoea, functional or psychogenic amenorrhoea is the consequence of either anovulation or endometrial hypotrophy. Neuroendocrine sciences do open new exciting research perspectives but other ways all the more promising since hormonal mechanics would not be the explanation. Work on the unconscious is indeed the other road leading to these psychogenic amenorrhoea. The term "psychogenic"--of psychological origin--does not mean of unknown origin, provided we recognize the strong link between psyche and soma. Treatment for this kind of amenorrhoea is twofold: medical and psychotherapeutic. Even though psychological etiology is obvious, clinical examination must be rigorous and completed by complementary exams which will guide the therapeutics. This is reassuring to the patient for the gynaecologist she chose to consult is implied, and not the psychotherapist. This reassures us too, because what we care for, as doctors, is first of all the body. Psychotherapeutic support can be provided by the general practitioner or the gynaecologist, both with psychosomatics training, but a multidisciplinary approach must often be worked out.

Amenorrhea: evaluation and treatment

A thorough history and physical examination as well as laboratory testing can help narrow the differential diagnosis of amenorrhea. In patients with primary amenorrhea, the presence or absence of sexual development should direct the evaluation. Constitutional delay of growth and puberty commonly causes primary amenorrhea in patients with no sexual development. If the patient has normal pubertal development and a uterus, the most common etiology is congenital outflow tract obstruction with a transverse vaginal septum or imperforate hymen. If the patient has abnormal uterine development, müllerian agenesis is the likely cause and a karyotype analysis should confirm that the patient is 46,XX. If a patient has secondary amenorrhea, pregnancy should be ruled out. The treatment of primary and secondary amenorrhea is based on the causative factor. Treatment goals include prevention of complications such as osteoporosis, endometrial hyperplasia, and heart disease; preservation of fertility; and, in primary amenorrhea, progression of normal pubertal development.

Practical use of the International Olympic Committee Medical Commission Position Stand on the Female Athlete Triad: a case example

The female athlete triad consists of the interrelated problems of disordered eating, amenorrhea, and osteoporosis, and it is believed to affect female athletes in all sports and at all levels of competition.

OBJECTIVE

The current article highlights the Position Stand on the Female Athlete Triad of the International Olympic Committee's Medical Commission (IOCMC).

METHOD

The literature related to disordered eating, energy availability, amenorrhea, and bone loss in athletes is briefly reviewed. A hypothetical case is presented to illustrate some of the common issues and problems encountered when working with athletes affected by the triad, such as the effect of weight on performance in "thin" sports, coach involvement, sport participation by symptomatic athletes, and treatment resistance/motivation.

RESULTS

Strategies recommended by the position stand for managing those issues and problems are presented regarding the referral, evaluation, and treatment phases of the management process.

CONCLUSION

Implications of the position stand are discussed in terms of the IOCMC's endorsement of the athlete's health being primary to her performance.

Primary amenorrhea. Varied etiology

Investigation of primary amenorrhea is usually initiated by the age of 14 years if there is delayed puberty absent secondary sexual characteristics and absent menses, or no menstruation within 4 years of the onset of adrenarche and thelarche. We established diagnosis in our 3 cases on the basis of chromosomal analysis, hormonal analysis, diagnostic laparoscopy, and histopathological examination of the samples biopsied. We identified 3 varied etiologies.

Early identification and interventions for female athlete triad

The diagnosis of female athlete triad is based on three criteria: (a) disordered eating, (b) amenorrhea, and (c) osteopenia. Prevention involves increasing awareness of this problem in athletes, parents, and coaches. Routine and opportunistic screening for risk factors by health care providers will increase early detection in athletes. Appropriate evaluation and treatment will decrease the consequences of this disorder. Consequences include stress fractures, development of eating disorders, and lower peak bone mass resulting in increased risk of osteoporosis later in life. A primary care case manager who provides motivation and support along with a multidisciplinary approach to treatment is recommended. This approach includes nutritional, exercise, and psychological therapies and possibly supplements and medication for optimal results.