AMENORRHEA (the Greek negative prefix a-, mzn — month and rhoia — a current, the expiration) — lack of periods within 6 months and more. Emergence of periods of 1 times in 2 — 3 months is called an oligomenorrhea.
And. can be physiological — before puberty, during pregnancy, a lactation and a menopause.
Temporary, passing And. it is observed during the periods of puberty and a climax. After approach of the first periods the subsequent menstrual bleedings can come with considerable breaks. If the rhythm of periods is not established within a year, And. it is necessary to consider pathological. In a climacteric physiological passing And. it is necessary to differentiate with bleedings as a result of new growths.
Lack of periods at women is more senior than 18 years is called primary And.; the termination of earlier observed periods (at least once) is called secondary
A. A. can be true and false. False And. happens at different types of a gynatresia: atresias of the cervical channel after intrauterine interventions or abortion, at an atresia of a vagina and a hymen owing to the postponed diphtheria or inborn character.
In these cases women have no external manifestations of periods, i.e. outside bleeding from generative organs, however there is a normal menstrual cycle, but menstrual blood is not emitted outside, and accumulates in a uterus or a vagina.
True And. — one of manifestations of disturbance menstrual cycle (see), caused by various functional and organic diseases. Depending on the level of defeat in system a hypothalamus — a hypophysis — ovaries — a uterus it is accepted to distinguish hypothalamic, pituitary, ovarian and uterine forms A. Besides, allocate And., caused also by dysfunction of cortical substance of adrenal glands and a thyroid gland.
The hypothalamic amenorrhea
the Hypothalamic amenorrhea meets in 60% of cases of A. Chashche happens organic character functional less often.
It is necessary to emphasize that all types hypothalamic And. arise always at secondary involvement in pathological process of an adenohypophysis. At the same time its gonadotropic function decreases. To hypothalamic And. belong:
1. Psychogenic And., arising owing to mental stresses (the death of relatives, accident, the heavy conflict, a fright, etc.); here carry And. wartime.
2. And. at Kiari's syndrome — Frommelya (see. Kiari — Frommelya a syndrome ).
3. And. at false pregnancy (see).
4. And. because of debilitating diseases and intoxications with the subsequent recovery of menstrual function at recovery. And. can be at diabetes, a serious illness of a liver and cardiovascular system; And. appears at every third sick with schizophrenia and maniac-depressive psychosis.
5. And. at adiposogenital dystrophy (see), or Pekhkrants's diseases — Babinsky — Frelikh.
6. And. at Laurence — Muna — Bidlya a syndrome (see), it is caused by an inborn malformation and functions of a mezentsefalon; can have hereditary character. The syndrome is characterized And., obesity in combination with mental retardation, a polydactylia, the progressing degeneratsionny retinitis sometimes leading to a blindness.
A pituitary amenorrhea
the Pituitary amenorrhea of generally organic origin, unlike hypothalamic, having often functional character. Pituitary And. results from death of the most part of fabric of an adenohypophysis with substitution by the last connecting fabric (Shikhen's syndrome, Simmonds's disease) that is clinically shown by a panginopituitarizm, or as a result of development of a tumor of an adenohypophysis with defeat of basphilic or acidophilic cells and it is clinically shown by an acromegalia or Itsenko's disease — Cushing with development And. owing to decrease in gonadotropic function of a hypophysis (a partial hypopituitarism). Pituitary And. it is observed at a number of diseases:
1. At Simmonds A. disease appears owing to a panhypopituitarism, the last arises as result of extensive destruction of a parenchyma of an adenohypophysis a septicheky necrosis, tubercular or syphilitic process (see. Pituitary cachexia ).
2. At Shikhen's syndrome (see. Shikhena syndrome ), arising as a special form of a disease of Simmonds at a necrosis of 90% of fabric of an adenohypophysis owing to massive blood loss in a puerperal period and hypovolemic shock that causes a sharp and long vasospasm of an adenohypophysis with the subsequent ischemic necrosis.
3. At a tumor of an adenohypophysis And. it is combined with various clinical symptomatology depending on type of cells of which the tumor is formed of growth rate, localizations of a tumor (see. Hypophysis ).
The ovarian amenorrhea
the Ovarian amenorrhea is characterized by generally genetically caused and is more rare the acquired primary ovarian insufficiency. Depending on character and expressiveness of genetic or enzymatic disorders its following types differ:
1. A dysgenesis of gonads, or Turner's syndrome — primary defect of development of ovarian fabric which is caused by a malformation or an incomplete set of chromosomes (HO) therefore inborn lack of ovaries is observed. Clinically the dysgenesis of gonads is shown primary And., lack of secondary sexual characteristics (mammary glands and sexual pilosis), a short neck, the low growth (135 — 150 cm) expressed by a hypogenitalism, malformations, mental retardation, osteoporosis.
2. Primary ovarian insufficiency, can be inborn in the presence of the erased form of a dysgenesis of gonads with partial preservation of ovarian fabric or acquired in pre-or the post-pubertal period as a result of the serious infectious diseases postponed at children's age, inflammatory and tumoral processes in ovaries and ovariotomies. These patients both with inborn, and with the acquired hypogonadism are characterized by an eunuchoid constitution and have high excretion of gonadotrophins (higher than 100 PIECES at 24 o'clock).
3. Premature ovarian insufficiency (an early climax) is other, easier kind of a dysgenesis of gonads, at a cut there is a premature fading of function of often defective ovaries. Clinically it is shown at externally normally developed women by approach of an early menopause in 30 — 35 years with frequent emergence of characteristic vegetovascular, psychological and exchange and endocrine disturbances. At these patients secondary And. it is combined with inflows of heat to the head, dizzinesses, headaches, sleeplessness, sometimes serdtsebiyeniye and pains in heart, irritability, tearfulness, etc. (see. Climacteric ).
4. Testicular feminization — genetically caused perversion of function of men's gonads therefore seed plants at persons with a negative sex chromatin and a karyotype of XY produce estrogen, more active in the biological relation, than androgens. Clinically it is shown primary And. at persons with a female phenotype, well developed mammary glands and external genitals, but scanty pilosis, underdevelopment or lack of a vagina and, as a rule, lack of a uterus.
5. Sclerocystic ovaries, or a syndrome of Matte — Leventalya, are characterized by existence of the broken steroidogenesis in ovaries owing to inferiority of enzymatic systems that, perhaps, is connected with genetic or hypothalamic disorders (see. Matte — Leventalya a syndrome ). Clinically sclerocystic ovaries are shown by emergence And. or acyclic bleeding at patients with obesity, infertility, pilosis on men's type (see. Hirsutism ) and bilateral increase in ovaries in the presence of the correct female constitution and well developed secondary sexual characteristics.
6. Gormonalnoaktivny tumors of an ovary in the form of an arrhenoblastoma, lipidokletochny tumors and a tumor from cells of gate of an ovary can cause And. because they synthesize testosterone in a large number. Idiosyncrasy for these tumors — emergence And. at the women who had before a normal menstrual cycle.
The uterine form of an amenorrhea
the Uterine form of an amenorrhea is caused by the pathological changes which are initially arising in an endometria or inborn lack of a uterus. Uterine And. it can be caused by a tubercular endometritis with the subsequent death of a basal layer of an endometria, an injury of a basal layer during a scraping of a cavity of the uterus at abortion or after the delivery, and also after vnutrpmatochny administration of cobalt, radium or iodine.
The amenorrhea in connection with dysfunction of a thyroid gland can be caused at a hyperthyroidism by suppression not only thyritropic, but p gonadotropic function of a hypophysis, and also the accelerated removal of gonadotrophins and estrogen therefore gonadotrophins do not manage to carry out a promoting effect on ovaries, and are oestrogenic on an endometria. Also partial destruction of the circulating ovarian hormones is possible. At a myxedema And. it is observed very seldom.
The amenorrhea in connection with an adrenogenital syndrome is caused by the excess maintenance of AKTG which reduces gonadotropic function of a hypophysis, causes a secondary hypogonadism and a hyperplasia of bark of adrenal glands. Purpose of Prednisolonum reduces secretion of AKTG. At the same time gonadotropic function of a hypophysis is recovered that leads to recovery of menstrual function.
Differential diagnosis of an amenorrhea
Because And. the hypothalamus — a hypophysis — ovaries — a uterus can be a symptom of different diseases and a consequence of various pathological changes in system, questions of differential diagnosis become particularly important since depending on the level of defeat treatment And. variously. During the carrying out the differential diagnosis it is necessary to proceed from features of a clinical picture of a disease and data of hormonal and special inspection of the patient.
Diagnosis uterine And. it is easily specified by normal indicators of tests of functional diagnosis and excretion of estrogen and pregnandiol.
Gnpotalamichesky form A. more often than functional character, pituitary And. has, as a rule, organic character with involvement in pathological process of other systems and bodies and often is followed by emergence of the symptoms characteristic of a tumor (headaches, vomiting, a vision disorder, etc.). Most idiosyncrasy of these And. the central genesis the expressed decrease in secretion of gonadotrophins is that gives the chance to otdifferentsirovat them from other types And.
Before starting treatment And. the central genesis, it is always necessary to exclude carefully existence of a tumor of a brain by means of a X-ray analysis of bones of a skull, an electroencephalography, a research of an eyeground and fields of vision, and also special neurologic methods of a research. Ovarian forms A. pl are generally genetically caused connected with existence of the masculinizing tumors which often happen the small sizes. Definition of excretion of gonadotrophins helps with differential diagnosis, edges, as a rule, there are higher than 100 PIECES at 24 o'clock at all types of inborn ovarian insufficiency. The diagnosis sclerocystic a yaichnikor is specified by the definitions of excretion of 17 ketosteroids and testosterone given to a rentgenopelvigrafiya and decrease in the raised excretion 17-ke-tosteroidov after conducting test with Infecundinum (10 days on 2 tablets). These rentgenopelvigrafiya and definition of the raised excretion of androgens, especially testosterone help with diagnosis of the masculinizing tumors of an ovary.
In certain cases for an exception of adrenal genesis of virilescence test with dexamethasone is carried out (on 2 mg within 2 days), edges always happens negative at patients to the masculinizing tumors of an ovary, excepting lipidokletochny tumors.
For clarification of level of defeat at And. test with progesterone, estrogen and progesterone is carried out (see the scheme): enter 1% Solutio oleosa of progesterone on 1 ml intramusculary within 6 days. Emergence at And. menstrualnopodobny reaction will point to existence in an organism of the patient of enough estrogen.
Lack of reaction to test with progesterone indicates the low content of estrogen. In these cases it is necessary to carry out the test with estrogen entering cyclic hormonal therapy (ethinylestradiol of 0,1 mg daily within 15 days, then progesterone on 10 mg of 6 — 8 days). Lack of reaction to performing cyclic hormonal therapy speaks about existence of a uterine form A.
In cases of positive test with progesterone the progesteronoterapiya within 6 days, in 8 days prior to the expected periods, within 6 months is shown.
At positive test with estrogen it is necessary to carry out cyclic therapy (ethinylestradiol of 0,1 mg daily within 15 days, then progesterone on 10 mg of 6 — 8 days) 4 — 6 months. At full death of an endometria treatment of a uterine form A. it is in most cases useless since change of an endometria seldom is effective. For treatment of ovarian forms A. at inborn inferiority of ovaries it is possible to use replaceable cyclic hormonal therapy. In the absence of complaints of treatment it is not required. In the presence of sclerocystic ovaries their wedge-shaped resection is shown, and at the masculinizing tumors — an oncotomy.
At pituitary And. because of a panhypopituitarism (Shikhen's syndrome, Simmonds's disease) replacement therapy is shown by small doses of steroid hormones, Thyreoidinum and glucocorticoids.
At And., the caused existence of tumors of a hypophysis, Itsenko's disease — Cushing, to an acromegalia showed a roentgenotherapy of area of the Turkish saddle or operational treatment. Hormonal therapy is contraindicated.
Various forms which are most often found in clinical practice gipotalamnchesky And., as a rule, happen functional character. These forms of an amenorrhea demand various methods of treatment.
At psychogenic And., the false pregnancy, psychological anorexia needs first of all psychotherapeutic treatment. At And. because of exhaustions and intoxication it is necessary to carry out the treatment directed to elimination of a basic disease, and fortifying therapy.
If these methods do not help, then it is necessary to combine them with the stimulating therapy by steroid hormones. At moderate oppression of gipotalamo-pituitary system carrying out 3 — 4 discontinuous courses of treatment 2 — 3 months with the subsequent interval in treatment for 2 months is effective. Steroid hormones (it is oestrogenic 45 days and progesterone of 6 — 8 days) or synthetic progestins like Infecundinum, Bisecurinum, an eslyuton (from the 5th day of a conditional cycle on 1 tablet a day within 21 days with the subsequent break for 7 days).
At long And. the central genesis use of synthetic progestins does not give the stimulating effect. These types And. it is better to treat the drugs having ability directly to stimulate an ovulation. Clomifene and gonadotrophins belong to these drugs synthetic drug.
Treatment by clomifene should be begun with 5 — the 6th day after a scraping of a cavity of the uterus at patients, at K-rykh excretion of estrogen is not lower than 10 — 20 mkg at 24 o'clock. Treatment is carried out within 5 — 7 days on 50 — 100 mg daily. Clomifene is most effective at treatment And. central genesis. So, at patients with psychogenic And. or And. the small duration (it is less than 1 year), including p after long reception of hormonal contraceptives, efficiency of treatment on an ovulation makes 60 — 80%.
At And. it is lower than 10 mkg of central genesis with excretion of estrogen at 24 o'clock treatment by clomifene ineffectively. It is better to carry out treatment by gonadotrophins (follicle-stimulating hormone on 500 — 1000 PIECES intramusculary every other day in the beginning — only 4000 — 10000 PIECES, and then horiogoniny on 3000 PIECES daily or every other day — only 9000 PIECES).
Treatment at And., Kiari caused by a syndrome — Frommelya — see. Kiari — Frommelya a syndrome ]].
The beam amenorrhea
the Beam amenorrhea arises after direct action of ionizing radiation on ovaries of the woman. Doses over 700 p call firm A.
Obychno beam And. beam is a consequence castrations (see) or radiation therapy. At uniform general irradiations a rack And. it is not observed.
At many women who endured atomic explosion in Hiroshima and Nagasaki it was noted temporary A.
Izvestna also descriptions temporary And., arisen owing to an acute radiation injury in laboratory and working conditions.
At hron. action of small doses of external radiation and at incorporation of radioactive materials A. practically it is not observed.
Principles of treatment beam And. the same, as at And. ovarian origin.
See also Menstrual cycle .
Bodyazhina V. I. and Crimean M. L. Questions of diagnosis and treatment of patients with a secondary amenorrhea, Akush. and ginek., La 8, page 58, 1970; Kvater E. I. Hormonal diagnosis and therapy in obstetrics and gynecology, page 107, M., 1967; The Factors influencing fertility under the editorship of. To. R. Austen and D. S. Perry, lane with English, page 171, M., 1970, bibliogr.; Duront-Lesomrte of J. Examen d'une amenorrheique, Lille med., t. 14, p. 362, 1969; Haller J. Ovulationshemmung durch Hormone, Stuttgart, 1970; Israel S. L. Diagnosis and treatment of menstrual disorders and sterility, N. Y., 1961, bibliogr.; Marchant D. J. Amenorrhea, Clin. Obstet. Gynec., v. 12, p. 692, 1969; &Szont##225;gh F. E. Mechanism of action of oral progestogens, p. 78, Budapest, 1970.
Bodyazhina V. I., etc. Influence of ionizing radiation on gonads, pregnancy and pre-natal fruit, page 15, 138, M., 1962, bibliogr.; Verbenko A. A., Chusova V. N. and Gorbarenko N. I. About menstrual and generative function of the women who had an acute radiation injury, Akush. and ginek., No. 2, page 52, 1971; Studying of effects of nuclear explosions, the lane with English, under the editorship of A. I. Burnazyan and A. K. Guskova, M., 1964; The multivolume guide to obstetrics and gynecology, under the editorship of L. S. Persianinov, t. 4, book 1, page 167, M., 1963; Effects of explosion of an atomic bomb in Hiroshima, Peg», with English, under the editorship of G. A. Zedgenidze, M., 1960.
I. A. Manuylova: A. A. Verbenko (I am glad.), author of the scheme and tab. S. M. Kamenker.