Primary Amenorrhea and Premature Ovarian Insufficiency

This review focuses on primary amenorrhea and primary/premature ovarian insufficiency due to hypergonadotropic hypogonadism. Following a thoughtful, thorough evaluation, a diagnosis can usually be discerned. Pubertal induction and ongoing estrogen replacement therapy are often necessary. Shared decision-making involving the patient, family, and health-care team can empower the young person and family to successfully thrive with these chronic conditions.

My 28 Days - a global digital women's health initiative for evaluation and management of secondary amenorrhea: case report and literature review

There is a need to close the gap between knowledge and action in health care. Effective care requires a convenient and reliable distribution process. As global internet and mobile communication increase capacity, innovative approaches to digital health education platforms and care delivery are feasible. We report the case of a young African woman who developed acute secondary amenorrhea at age 18. Subsequently, she experienced a 10-year delay in the diagnosis of the underlying cause. A global digital medical hub focused on women's health and secondary amenorrhea could reduce the chance of such mismanagement. Such a hub would establish more efficient information integration and exchange processes to better serve patients, family caregivers, health care providers, and investigators. Here, we show proof of concept for a global digital medical hub for women's health. First, we describe the physiological control systems that govern the normal menstrual cycle, and review the pathophysiology and management of secondary amenorrhea. The symptom may lead to broad and profound health implications for the patient and extended family members. In specific situations, there may be significant morbidity related to estradiol deficiency: (1) reduced bone mineral density, 2) cardiovascular disease, and 3) cognitive decline. Using primary ovarian insufficiency (POI) as the paradigm condition, the Mary Elizabeth Conover Foundation has been able to address the specific global educational needs of these women. The Foundation did this by creating a professionally managed Facebook group specifically for these women. POI most commonly presents with secondary amenorrhea. Here we demonstrate the feasibility of conducting a natural history study on secondary amenorrhea with international reach to be coordinated by a global digital medical hub. Such an approach takes full advantage of internet and mobile device communication systems. We refer to this global digital women's health initiative as My 28 Days®.

Functional Hypothalamic Amenorrhea: Recognition and Management of a Challenging Diagnosis

Functional hypothalamic amenorrhea is responsible for approximately a third of the cases of secondary amenorrhea. The condition is a result of disturbances in gonadotropin-releasing hormone pulsatile secretion at the level of the hypothalamus, which in turn disrupts gonadotropin secretion. It is due to psychosocial stress, disordered eating, and/or excessive exercise. Often, however, it is a combination of more than one etiology, with a possible role for genetic or epigenetic predisposition. The dysfunctional gonadotropin-releasing hormone release leads to the cessation of ovarian function, resulting in amenorrhea, infertility, and a long-term impact on affected women's bone health, cardiovascular risk, cognition, and mental health. Functional hypothalamic amenorrhea is a diagnosis of exclusion, and treatment involves identifying and reversing the underlying cause(s). The aim of this concise review is to summarize the current knowledge of functional hypothalamic amenorrhea, review its pathophysiology and the adverse health consequences, and provide recommendations for diagnosis and management of this condition. Furthermore, this review will emphasize the gaps in research on this common condition impacting women of reproductive age all over the world.

Idiopathic hyperprolactinemia - A challenge for primary care

Hyperprolactinemia is a condition of elevated serum prolactin, which usually occurs in women as compared to men. Most patients present to primary care clinics with a history of galactorrhoea, oligomenorrhea, amenorrhoea or infertility. Literature search reveals that there were few idiopathic causes of hyperprolactinemia, which resolved by itself without specific pharmacological or surgical treatment. This case is of a 39-year-old woman presented with amenorrhea for four months after Implanon removal and concomitantly noted to have galactorrhoea for four years without any medical attention. The condition persisted after cessation of breastfeeding. After undergoing several investigations including imaging studies, the underlying cause of hyperprolactinemia was noted to be idiopathic. Due to the unclear cause of its aetiology, this case caused various challenges to the primary care. Exhaustive physiological and pathological causes of hyperprolactinemia have been ruled out. Nevertheless, with adequate treatment, she gained her normal menstrual and resolved galactorrhoea symptoms.

MANAGEMENT OF ENDOCRINE DISEASE: Diagnosis and management of primary amenorrhea and female delayed puberty

Puberty is the period of transition from childhood to adulthood characterized by the attainment of adult height and body composition, accrual of bone strength and the acquisition of secondary sexual characteristics, psychosocial maturation and reproductive capacity. In girls, menarche is a late marker of puberty. Primary amenorrhea is defined as the absence of menarche in ≥ 15-year-old females with developed secondary sexual characteristics and normal growth or in ≥13-year-old females without signs of pubertal development. Furthermore, evaluation for primary amenorrhea should be considered in the absence of menarche 3 years after thelarche (start of breast development) or 5 years after thelarche, if that occurred before the age of 10 years. A variety of disorders in the hypothalamus-pituitary-ovarian axis can lead to primary amenorrhea with delayed, arrested or normal pubertal development. Etiologies can be categorized as hypothalamic or pituitary disorders causing hypogonadotropic hypogonadism, gonadal disorders causing hypergonadotropic hypogonadism, disorders of other endocrine glands, and congenital utero-vaginal anomalies. This article gives a comprehensive review of the etiologies, diagnostics and management of primary amenorrhea from the perspective of pediatric endocrinologists and gynecologists. The goals of treatment vary depending on both the etiology and the patient; with timely etiological diagnostics fertility may be attained even in those situations where no curable treatment exists.

Aetiology And Management Of Primary Amenorrhoea

BACKGROUND

Amenorrhoea is absence of menstruation. It could be primary, if menstruation has not occurred by the age of 16 years in the presence of normal growth and secondary sexual characters or by the age of 14 years in the absence of secondary sexual characters. It is secondary if periods have not occurred for six months. This study was done with the objective to determine the frequency of etiologic causes of primary amenorrhoea.

STUDY DESIGN

Cross-sectional descriptive study.

METHODS

The study was conducted in the department of Obstetrics and Gynaecology Sheikh Khalifha Bin Zyed Al Nahyan /Combined Military Hospital Muzaffarabad Azad Jammu Kashmir (SKBZ/CMH MZD AJK) from December 2014 to November 2017. Women with primary amenorrhoea reported and managed in the hospital are included in the study. Cases were analysed according to clinical profile, development of secondary sexual characteristics, physical examination, pelvic and rectal examination, hormonal profile, pelvic ultrasound, magnetic resonance imaging and cytogenetic study including karyotyping..

RESULTS

Three most common causes of primary amenorrhoea were Mullerian anomalies (36.7%) followed by gonadal dysgenesis (33.3%), hypothalamic causes (23.3%) and Pituitary causes (6.7%). There were 03 cases of polycystic ovarian syndrome and 02 cases of hyperprolactinemia.

CONCLUSIONS

The most common etiological factor leading to primary amenorrhoea is Mullerian anomalies followed by gonadal dysgenesis. Genetic and environmental factors could also play role in the causes of primary amenorrhoea.

Osteoporosis in Premenopausal Women: A Clinical Narrative Review by the ECTS and the IOF

CONTEXT

Consensus regarding diagnosis and management of osteoporosis in premenopausal women (PW) is still lacking due to few studies carried out in this population.

DESIGN

The European Calcified Tissue Society and the International Osteoporosis Foundation convened a working group to produce an updated review of literature published after 2017 on this topic.

RESULTS

Fragility fractures in PW are rare and mostly due to secondary osteoporosis (ie, in presence of an underlying disease such as hormonal, inflammatory, or digestive disorders). In absence of another disorder, low bone mineral density (BMD) together with fragility fractures qualifies as idiopathic osteoporosis. In contrast, low BMD alone does not necessarily represent osteoporosis in absence of bone microarchitectural abnormalities. BMD increases in PW with osteoporosis when the underlying disease is treated. For example, in celiac disease, an increase of 9% in radius trabecular volumetric density was achieved after 1 year of gluten-free diet, while anti-tumor necrosis factor alpha improved BMD in PW with inflammatory bowel diseases. In amenorrhea, including anorexia nervosa, appropriately delivered estrogen replacement therapy can also improve BMD. Alternatively, antiresorptive or anabolic therapy has been shown to improve BMD in a variety of conditions, the range of improvement (3%-16%) depending on skeletal site and the nature of the secondary cause. No studies were powered to demonstrate fracture reduction. The effects of bisphosphonates in childbearing women have been scantly studied and caution is needed.

CONCLUSION

The majority of PW with osteoporosis have an underlying disease. Specific therapy of these diseases, as well as antiresorptive and anabolic drugs, improve BMD, but without evidence of fracture reduction.

Long-Term Follow-Up and Treatment of a Female With Complete Estrogen Insensitivity

CONTEXT

We previously reported the first female with a causative ESR1 gene variant, who exhibited absent puberty and high estrogens. At age 15 years, she presented with lower abdominal pain, absent breast development, primary amenorrhea, and multicystic ovaries. The natural history of complete estrogen insensitivity (CEI) in women is unknown.

OBJECTIVE

The purpose of this report is to present the neuroendocrine phenotype of CEI, identify potential ligands, and determine the effect of targeted treatment.

DESIGN

We have characterized gonadotropin pulsatility and followed this patient's endocrine profile and bone density over 8 years. Seventy-five different compounds were tested for transactivation of the variant receptor. A personalized medicine approach was tailored to our patient.

SETTING

Academic medical center.

PATIENT OR OTHER PARTICIPANTS

A 24-year-old adopted white female with CEI.

INTERVENTION(S)

The patient was treated with diethylstilbestrol (DES) for approximately 2.5 years.

MAIN OUTCOME MEASURE(S)

Induction of secondary sexual characteristics.

RESULTS

Luteinizing hormone (LH) pulse studies demonstrated normal pulsatile LH secretion, elevated mean LH, and mildly elevated mean follicle-stimulating hormone (FSH) in the presence of markedly increased estrogens. DES transactivated the variant ESR1 in vitro. However, DES treatment did not induce secondary sexual characteristics in our patient.

CONCLUSIONS

Treatment with DES was not successful in our patient. She remains hypoestrogenic despite the presence of ovarian cysts with a hypoestrogenic vaginal smear, absent breast development, and low bone mineral mass. Findings suggest additional receptor mechanistic actions are required to elicit clinical hormone responses.

Treatment of postpill amenorrhea with abdominal obesity by traditional Korean medicine treatment focused on pharmacopuncture and moxibustion: A case report

RATIONALE

Hormone imbalance and menstrual irregularities are normal for postpill women. Pharmacopuncture and moxibustion can stimulate acupoints with herbal extract and heat, respectively, to regulate the function of qi and blood, expel pathogens, and support health.

PATIENT CONCERNS

A 39-year-old female patient presented with amenorrhea, >6 months after she had stopped taking the oral contraceptive pill, which she had taken for more than 10 years, and possible associated infertility. Additionally, she reported sudden weight gain of approximately 12 kg in 1 year.

DIAGNOSES

In this study, we examined the amenorrhea lasted more than 6 months for postpill patient.

INTERVENTIONS

She refused a strong acupuncture stimulus; she underwent lower abdomen pharmacopuncture with wild ginseng complex (WGC) and moxibustion at CV4, 5 times during 1 month. As a secondary treatment, 1 g Geoseub-hwan pills were prescribed for overeating and during social events. After 5 weekly primary treatments, Geoseub-hwan was prescribed intermittently.

OUTCOME

After 3 primary treatments, she began menstruation without menstrual cramps or discomfort. After 5 treatments, she exhibited improvement of body weight and body composition. At 1- and 3-month follow-up examinations, she confirmed regular menstruation without discomfort.

LESSONS

Pharmacopuncture with WGC and moxibustion may be effective for the treatment of postpill amenorrhea with abdominal obesity and can be used for patients with fear of a strong acupuncture stimulus.

Amenorrhea: A Systematic Approach to Diagnosis and Management

Menstrual patterns can be an indicator of overall health and self-perception of well-being. Primary amenorrhea, defined as the lifelong absence of menses, requires evaluation if menarche has not occurred by 15 years of age or three years post-thelarche. Secondary amenorrhea is characterized by cessation of previously regular menses for three months or previously irregular menses for six months and warrants evaluation. Clinicians may consider etiologies of amenorrhea categorically as outflow tract abnormalities, primary ovarian insufficiency, hypothalamic or pituitary disorders, other endocrine gland disorders, sequelae of chronic disease, physiologic, or induced. The history should include menstrual onset and patterns, eating and exercise habits, presence of psychosocial stressors, body weight changes, medication use, galactorrhea, and chronic illness. Additional questions may target neurologic, vasomotor, hyperandrogenic, or thyroid-related symptoms. The physical examination should identify anthropometric and pubertal development trends. All patients should be offered a pregnancy test and assessment of serum follicle-stimulating hormone, luteinizing hormone, prolactin, and thyroid-stimulating hormone levels. Additional testing, including karyotyping, serum androgen evaluation, and pelvic or brain imaging, should be individualized. Patients with primary ovarian insufficiency can maintain unpredictable ovary function and may require hormone replacement therapy, contraception, or infertility services. Functional hypothalamic amenorrhea may indicate disordered eating and low bone density. Treatment should address the underlying cause. Patients with polycystic ovary syndrome should undergo screening and intervention to attenuate metabolic disease and endometrial cancer risk. Amenorrhea can be associated with clinically challenging pathology and may require lifelong treatment. Patients will benefit from ample time with the clinician, sensitivity, and emotional support.

Hypothalamic Amenorrhea and the Long-Term Health Consequences

The menstrual cycle is a reproductive vital sign and provides insight into hormonal imbalance as well as pregnancy. The significance of estrogen, however, extends beyond fertility and plays a role on tissues and organs throughout the body. Functional hypothalamic amenorrhea is a common form of secondary amenorrhea resulting in estrogen deficiency in young premenopausal women. While reversible, the cause of this disorder is related to psychological stress, excessive exercise, disordered eating or a combination of these factors resulting in suppression of the hypothalamic–pituitary–ovarian axis. The resulting loss of estrogen has profound effects on many systems throughout the body including cardiac, skeletal, psychological and reproductive. Often, these young women are the ‘walking well’ as they do not have bothersome symptoms of low estrogen and are unaware of the consequences of estrogen deficiency. This review focuses on the health consequences of hypothalamic amenorrhea, current research and available treatment options.

Amenorrhea in the Female Athlete: What to Do and When to Worry

Functional hypothalamic amenorrhea is a diagnosis of exclusion that is common in female athletes, particularly those participating in aesthetic sports (ballet, other dance genres, figure skating, and gymnastics) and endurance sports (cross-country running). Although common, it should be considered abnormal even in the high-level elite athlete. Amenorrhea in combination with low energy availability and low bone density is labeled "the Female Athlete Triad." Studies have demonstrated numerous long-term consequences of athletes suffering from all or a portion of this triad, including increased rate of musculoskeletal injuries, stress fractures, abnormal lipid profiles, endothelial dysfunction, potential irreversible bone loss, depression, anxiety, low self- esteem, and increased mortality. This article provides the clinician with the tools to evaluate an athlete with secondary amenorrhea, reviews the recommended treatment options for affected athletes, and discusses when to return to the activity in an effort to facilitate "healthy" participation.

Nearly Normal Congenital Cervical Fragmentation: A Hard-To-Diagnose and Successful End-To-End Anastomosis

BACKGROUND

Congenital cervical fragmentation is a very rare genital tract malformation that usually presents in adolescence with primary amenorrhea and cyclic, monthly, lower abdominal pain. We report a nearly normal case of congenital cervical fragmentation and successful end-to-end anastomosis.

CASE

A 15-year-old girl presented with primary amenorrhea with cyclic, monthly lower abdominal pain lasting for 15 months without any abnormal imaging findings (pelvic CT scan, ultrasonography, and hysteroscopy). Misdiagnosis and appendectomy was performed at the time of the initial lower abdominal pain. Diagnostic combined hysteroscopy and laparoscopy were performed in our hospital, and cervical fragmentation was diagnosed. A converted laparotomy end-to-end anastomosis was performed successfully, and regular menstruation was restored after the operation.

SUMMARY AND CONCLUSION

The malformation of nearly normal congenital cervical fragmentation is existent and hard to diagnose. As long as the patient has persistent primary amenorrhea with cyclic, monthly lower abdominal pain, even if no abnormal findings on imaging, obstructive malformation of the reproductive duct should be the primary suspicion. Diagnosis and treatment should occur as early as possible to preserve the patient's fertility. End-to-end anastomosis is the best method for this type of patient.

GnRH pulse frequency-dependent differential regulation of LH and FSH gene expression

The pituitary gonadotropin hormones, FSH and LH, are essential for fertility. Containing an identical α-subunit (CGA), they are comprised of unique β-subunits, FSHβ and LHβ, respectively. These two hormones are regulated by the hypothalamic decapeptide, GnRH, which is released in a pulsatile manner from GnRH neurons located in the hypothalamus. Varying frequencies of pulsatile GnRH stimulate distinct signaling pathways and transcriptional machinery after binding to the receptor, GnRHR, on the cell surface of anterior pituitary gonadotropes. This ligand-receptor binding and activation orchestrates the synthesis and release of FSH and LH, in synergy with other effectors of gonadotropin production, such as activin, inhibin and steroids. Current research efforts aim to discover the mechanisms responsible for the decoding of the GnRH pulse signal by the gonadotrope. Modulating the response to GnRH has the potential to lead to new therapies for patients with altered gonadotropin secretion, such as those with hypothalamic amenorrhea or polycystic ovarian syndrome.

Diagnostic pitfalls in the evaluation and management of amenorrhea in adolescents

Amenorrhea is a common menstrual problem seen in adolescents. Amenorrhea has been shown to have a negative impact on adolescents' quality of life. In this paper we discuss the various causes and investigations of amenorrhea in adolescents and address management dilemmas for specific conditions. Specific approaches in dealing with adolescents using the HEADSS (Home, Education, Activity, Drugs, Sexual activity, Suicidal) approach are discussed.

Amenorrhea: an approach to diagnosis and management

Although amenorrhea may result from a number of different conditions, a systematic evaluation including a detailed history, physical examination, and laboratory assessment of selected serum hormone levels can usually identify the underlying cause. Primary amenorrhea, which by definition is failure to reach menarche, is often the result of chromosomal irregularities leading to primary ovarian insufficiency (e.g., Turner syndrome) or anatomic abnormalities (e.g., Müllerian agenesis). Secondary amenorrhea is defined as the cessation of regular menses for three months or the cessation of irregular menses for six months. Most cases of secondary amenorrhea can be attributed to polycystic ovary syndrome, hypothalamic amenorrhea, hyperprolactinemia, or primary ovarian insufficiency. Pregnancy should be excluded in all cases. Initial workup of primary and secondary amenorrhea includes a pregnancy test and serum levels of luteinizing hormone, follicle-stimulating hormone, prolactin, and thyroid-stimulating hormone. Patients with primary ovarian insufficiency can maintain unpredictable ovarian function and should not be presumed infertile. Patients with hypothalamic amenorrhea should be evaluated for eating disorders and are at risk for decreased bone density. Patients with polycystic ovary syndrome are at risk for glucose intolerance, dyslipidemia, and other aspects of metabolic syndrome. Patients with Turner syndrome (or variant) should be treated by a physician familiar with the appropriate screening and treatment measures. Treatment goals for patients with amenorrhea may vary considerably, and depend on the patient and the specific diagnosis.

Too much of a good thing: female athlete triad

The history and pathophysiology of the Female Athletic Triad is discussed along with the short-term and long-term complications. The work-up for hormonal abnormalities and specific treatment options are discussed. Also, nutrition and its affect on the Female Athletic Triad is mentioned within the realm of treatment.

Impact of electro-acupuncture and physical exercise on hyperandrogenism and oligo/amenorrhea in women with polycystic ovary syndrome: a randomized controlled trial

Polycystic ovary syndrome (PCOS), the most common endocrine disorder in women of reproductive age, is characterized by hyperandrogenism, oligo/amenorrhea, and polycystic ovaries. We aimed to determine whether low-frequency electro-acupuncture (EA) would decrease hyperandrogenism and improve oligo/amenorrhea more effectively than physical exercise or no intervention. We randomized 84 women with PCOS, aged 18-37 yr, to 16 wk of low-frequency EA, physical exercise, or no intervention. The primary outcome measure changes in the concentration of total testosterone (T) at week 16 determined by gas and liquid chromatography-mass spectrometry was analyzed by intention to treat. Secondary outcome measures were changes in menstrual frequency; concentrations of androgens, estrogens, androgen precursors, and glucuronidated androgen metabolites; and acne and hirsutism. Outcomes were assessed at baseline, after 16 wk of intervention, and after a 16-wk follow-up. After 16 wk of intervention, circulating T decreased by -25%, androsterone glucuronide by -30%, and androstane-3α,17β-diol-3-glucuronide by -28% in the EA group (P = 0.038, 0.030, and 0.047, respectively vs. exercise); menstrual frequency increased to 0.69/month from 0.28 at baseline in the EA group (P = 0.018 vs. exercise). After the 16-wk follow-up, the acne score decreased by -32% in the EA group (P = 0.006 vs. exercise). Both EA and exercise improved menstrual frequency and decreased the levels of several sex steroids at week 16 and at the 16-wk follow-up compared with no intervention. Low-frequency EA and physical exercise improved hyperandrogenism and menstrual frequency more effectively than no intervention in women with PCOS. Low-frequency EA was superior to physical exercise and may be useful for treating hyperandrogenism and oligo/amenorrhea.

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.