Major gynaecological issues in female largely due to no menstruation

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This is a very multi divisional topic as it encompasses various aspects of female gynaecological issues. Amenorrhoea is not a disease but it is a symptom of a disease. It is absence of menstrual periods primarily or secondarily. The former occur when the female is 14 years due to the absence of growth or development of the secondary sexual characteristics; absence of menstruation can also occur at age 16. The latter is absence of menstruation for a period of six months or more in a woman who previously had regular menstruation or for 12 months in a patients with history of oligomenorrhoea(menstrual cycle occurring at 35 days or more but less than 6 months) or polymenorhoea i.e menstral cycle occurring at intervals less than 21 days or hypermenorrhoea which is excessive and prolonged menstruation of over 80mls in regular intervals of 21 to 35 days.Women with amenorrhoea present in various ways.

Developmental defects of the lower genital tract
• Uterine agenesis and others
• Embryological abnormalities
• Developmental defects of the upper genital tract
• Uterine and endometrial causes
• Ovarian failure
• Ovarian Tumour and other ovarian abnormalities
• Non-gonadal Endocrine Diseases ( cushing’s syndrome,Congenital adrenal hyperplasia)
• Hypothalamic

Developmental defects of the lower genital tract

In an adequately developed girl, a history of monthly recurring cramps in the lower abdomen and a bulging bluish membrane in the introtus may be present. A more complex problem is when the vagina is partly absence. There may be shallow vagina, but a transverse septum occupies a large part of the vagina lumen. The internal structures are present and functioning. This condition may be noted early in life since vagina and uterus become distended by watery or mucoid fluid. Alternatively the patient might present shortly after menarche with complains similar to those of the patient with imperforate hymen. In most case of the absent vagina the uterus is only rudimentary, but grossly abnormal uterine tubes and ovaries may be found on rectal examination.

Uterine Agenesis

This accounts for the substantial causes of primary amenorrhoea. Patients are usually small at birth, grow slowly, fail to have pubertal growth spurt and end up at a mean final height of about 142cm.

Ovarian Failure

Female in this group have hypergonadotrophism in which the FSH/LH ratio exceeds unity. The presence of secondary sexual characteristics indicates that there has been some ovarian activity in the past.
Ovarian Tumour and other Disorders
Several types of hormone producing ovarian tumours can disrupt the ovarian cycle, with amenorrhoea as one manifestation. Usually these tumours are evident on physical and pelvic examination. Other symptoms associated with virilising ovarian tumour are infertility, defeminisation, baldness and breast atrophy.

Polycystic Ovary Syndrome (PCOS)

PCOS is recognised as a complex of signs consisting of amenorrhoea, hirsutism and obesity.
Risk Factors to Amenorrhoea
• Too Short/overweight and obese
• Chronic disease
• Thyroid disease
• Observe body hair distribution
• High blood pressure
• Masses in the abdomen and striae on the abdomen or trunkal obesity
• Clitoris size
• Clitoromegally
• Masculinisation
• Adnexal masses
• Uterine size
• Breast sizes
• Family history of amenorrhea
• Previous operation such as oophorectom,hysterectomy etc
• Previous radiation treatment
• Psychiatric illness and administration of psychogenic drugs
• Previous treatment with cytotoxin drugs
Over eating or under eating
• Increase or reduction in weight
• Hormone replacement therapy
• Engagement in sport activities

For normal menstruation to occur,an individual must have intact hypothalamo-pituary-ovarian uterine axis with or without an associated organic lesion. The role of ovarian hormones as well as prolactin, thyroid hormones are very important. This account for the diversity causes of amenorrhoea. Treatment options of amenorrhoea vary from drugs to minimal or major surgery once the cause is identified then treatment can be done accordingly.

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