Physiological amenorrhea

Introduction Amenorrhea, which occurs during development, pregnancy, lactation, and menopause, is called physiological amenorrhea and is a normal phenomenon. The maintenance of the normal menstrual cycle depends on the coordination of the hypothalamic-pituitary-ovarian function and the periodic response of the endometrium to sex hormones. Any problem in any of the above steps may cause amenorrhea. The majority of amenorrhea patients have no ovulation and therefore cannot be pregnant. Except for physiological amenorrhea (see prepubertal girls, postmenopausal women, and pregnant women), other amenorrhea is pathological.

Cause

In the early stage of puberty, in the second or third year of the first menstrual period, the ovarian function is still unstable, and the menstrual cycle is often irregular. After the conception, the ovarian corpus luteum produces a large amount of lutein, which stimulates the endometrium to proliferate without falling off. Therefore, it will not come to menstruation; after childbirth, ovarian function recovery takes a certain time, combined with breast-feeding inhibition of the ovary, menstrual recovery is later; after the age of 40, due to the gradual decline of ovarian function, menstruation often several months until menopause . This amenorrhea, which occurs during development, pregnancy, lactation, and menopause, is called physiological amenorrhea and is a normal phenomenon.

an examination

Related inspection

Luteinizing hormone estrogen withdrawal test progesterone test progesterone blood withdrawal test luteinizing hormone (LH)

Clinical manifestations of physiological amenorrhea

(1) Pre-puberty amenorrhea: girls 6 to 9 years old can detect dehydroepiandrosterone (DHEA) and its sulfate from the urine, which rises rapidly at the age of 10, which is the first appearance of adrenal function, derived from the adrenal gland. Androgen promotes the appearance of pubic hair and mane, and the body grows rapidly, because the hypothalamic-pituitary-ovarian axis has yet to be further developed, the estrogen level is still low, the endometrial proliferation is poor, and bleeding is not caused, so the menstrual period is delayed. . At this stage before menarche, there is no physiological phenomenon in menstrual cramps. Some girls have a menstrual flow for a period of one and a half years after menarche, and it is normal for anovulatory menstruation.

(2) Lactation amenorrhea: Breastfeeding women who are weaned at any time often return to menstruation 2 months after weaning.

(3) Menopausal transition period and postmenopausal amenorrhea: uterine bleeding may occur in the menopausal transition period for several months. After menopause, the reproductive organs gradually shrink and the uterus shrinks.

Diagnosis can be based on the above clinical manifestations.

Differential diagnosis

Clinical manifestations of pathological amenorrhea

(1) Uterine amenorrhea and cryptography:

1 non-porous hymen: clinical symptoms gradually appear, initially can feel cyclical lower abdominal bulge, pain, progressive aggravation, hematoma compression of the urethra and rectum, can cause urination and defecation difficulties, suprapubic pain, anal bulge, frequent urination, Urgency, dysuria, and even drips. When the uterine cavity has a large amount of blood, it can cause the ureter to shift, twist, accumulate water, and even hydronephrosis. When the blood flows back into the pelvis, it can stimulate the abdominal membrane to produce severe abdominal pain. Abdominal examination can be accompanied by a painful mass, deep tenderness, a small number of patients may have mild muscle tension, rebound tenderness. During the gynecological examination, the hymen was thinned and bulged, without openings, and the surface was purple-blue. Anal examination can touch the vaginal hematoma, the uterus is enlarged and tender, and the double attachment is a sausage-like strip and tenderness. The elderly with the disease may have irregular thickening and varying degrees of tender nodules. B-mode ultrasound or CT examination can detect solid vaginal barrel-like masses, uterine cavity and effusion in the fallopian tube.

2 congenital absence of vagina: this disease is often due to puberty does not come to menstruation, or periodic pain in the lower abdomen, or difficulty in sexual intercourse after marriage, or infertility, check at the time of treatment. The breast, secondary sexual characteristics and external genital development were normal, ovarian function was normal; basal body temperature (BBT) was biphasic, and blood reproductive hormone was measured periodically in women of childbearing age. If accompanied by a uterus absent or primordial uterus, it can be asymptomatic; if there is a functional endometrium of the uterus, there may be periodic abdominal pain due to progressive aggravation of uterine hemorrhage. During the gynecological examination, the vulva can be found without a vaginal opening. If the patient is treated for a long time after marriage, it can be found that there is a shallow fossa formed in the vestibular area due to sexual intercourse. Most patients have a cord-like uterus in the pelvic cavity. If the patient has a functional endometrium, the patient is younger and a small uterus can be found when the patient is examined, or a normal or enlarged painful uterus can be touched, sometimes with a salami-like thickening of the fallopian tube. Imaging studies such as B-ultrasound and CT can confirm the above findings and can detect urinary system malformations.

3 vaginal diaphragm: incompletely separated, because the menstrual blood can flow through the small hole, so no amenorrhea. Complete obscuration due to menstrual discharge disorder, the emergence of primary amenorrhea, periodic lower abdominal pain and other performance. In the complete vaginal and upper splanchnic gynecological examination, a lower length of the vagina can be found with a certain length and width. The top end is closed and touches a diaphragm with a fluctuating sensation. The vaginal dilation above it seems to be sexy. The lower part of the vagina is sometimes difficult to distinguish from vaginal atresia. Careful gynecological examination combined with posterior cavity puncture is an effective method of identification.

4 vaginal atresia: clinical manifestations of primary amenorrhea, periodic lower abdominal pain. Gynecological examination showed genital dysplasia, hymen no hole, but the surface color is normal, no outward bulging sign, anal diagnosis can be found in the vaginal cystic mass above the rectum about 3cm, the pain of the block during abdominal pain Big. Transabdominal or transrectal B-ultrasound can detect a cystic mass in the upper 3~4cm from the anus. Under the guidance of B-ultrasound, the puncture can be puncture through the vulva, and the old dark red blood or chocolate-like paste can be extracted. Type II patients have complete vaginal atresia, and the clinical manifestations are primary amenorrhea and periodic lower abdominal pain. Gynecological examination has a mass of 4 to 8 cm in diameter on one side or higher part of the pelvis, which is a deformed uterus or an attachment mass.

5 Cervical atresia: If the patient has no endometrium, only the primary amenorrhea, if there is endometrium, its clinical manifestations are similar to congenital absence of vagina.

6 congenital absence of uterus: clinical manifestations of primary amenorrhea, anal abdominal examination can not reach the uterus, B-ultrasound, CT and MRI can not detect the presence of the uterus.

7 primordial uterus: patients with primary amenorrhea, anal examination and B-ultrasound and other imaging examinations can be found a small uterus, only 2 ~ 3cm long, a solid flat, 0.5 ~ 1cm thick when laparoscopic or laparotomy Uterus traces.

8 Miller tube hypoplasia syndrome: manifested as primary amenorrhea, genital defects include congenital absence of vagina, uterus can be normal, but also various developmental malformations, including double-horned uterus, single-horned uterus, primordial uterus , the residual uterus, double uterus, etc., rarely congenital without uterus. The ovarian development and function of the patients were normal, so the secondary sexual characteristics developed normally. About 34% of patients have urinary tract malformations, 12% have skeletal malformations, 7% have inguinal hernias, and 4% have congenital heart disease. If it is a double uterus, a double horn or a single uterus, a residual uterus, it does not cause amenorrhea.

9 traumatic intrauterine adhesions: clinical manifestations and adhesion sites and degrees have a certain relationship, but the two are not completely consistent. Less menstrual flow, shortened menstruation, amenorrhea, infertility, abortion and obstetric complications are the main clinical symptoms. Reduced menstrual flow or amenorrhea after intrauterine surgery, especially in the endometrial regeneration at 1 week postpartum, after the curettage or abortion surgery, it is easy to damage the intima or hydatidiform mole after several consecutive uterine operations. Some patients have periodic abdominal pain, double-diagnosis can get a slightly larger or normal uterus, mild tenderness and tenderness in the double attachment area. Most patients with intracervical adhesions are amenorrhea after artificial abortion. Some patients may have abdominal pain due to intrauterine hemorrhage and menstrual blood flow into the abdominal cavity. Cervical pain, uterine body enlargement and tenderness, and vaginal posterior iliac puncture draws dark red. Blood clotting fluid, which behaves like an ectopic pregnancy. Intrauterine probe examination can find the internal occlusion or stenosis of the cervix. When the probe advances along the direction of uterine flexion and the axial direction of the uterine cavity, the adhesion may be lighter and enter the uterine cavity after being blocked. At the same time, there may be a small amount of dark red. Thick blood flows out. For intrauterine adhesions, the probe feels restricted after entering the uterine cavity. If the internal cervix is severely adhered, the probe can not enter the internal mouth. It is necessary to perform cervical sphincter under continuous anesthesia of the sacral nerve block. This severe intrauterine adhesion can also occur in patients with non-pregnant uterus for cervical laser or electricity. When burning, the surgery hurts the endocervix and the internal orifice of the cervical canal.

(2) Ovarian amenorrhea:

1 Turners syndrome: A. 16 years old still no menstrual cramps; B. short stature, secondary sexual dysplasia, sickle neck, shield chest, elbow valgus; C. high gonadotropin, hypogonadotropin; D. The karyotype is 45, XO; 46, XX; 45, XO; 45, XO; 47, XXX.

2 congenital gonadal dysplasia: karyotype and height of normal, secondary sexual development is generally normal. Yu Tong Turner's syndrome.

3 premature ovarian failure: A. 40 years before menopause; B. high gonadotropin and hypogonadotropin; C. about 20% have karyotypic abnormalities; D. about 20% with other autoimmune diseases; E. pathology Examination showed no follicles in the ovary or very few primordial follicles; F. laparoscopic ovarian atrophy; G. history of iatrogenic damage to the ovaries; H. no response to endogenous and exogenous gonadotropin stimulation I. clomiphene test, from the fifth day of the cycle, oral clofibrate 50 ~ 100mg, once / d, a total of 5 days. Serum FSH was measured on days 3 and 10 of the cycle, respectively. If the FSH value was >20 U/L on day 10, it suggested that ovarian function was low.

4 resistance syndrome: A. primary or secondary amenorrhea; B. high gonadotropin and hypogonadin; C. pathological examination showed that there are many primordial follicles and immature follicles in the ovary; D. laparoscopic ovary Normal size, but no growth follicles and ovulation marks; E. No response to endogenous and exogenous gonadotropin stimulation.

5 polycystic ovary syndrome: clinical manifestations of menstrual thinning, amenorrhea, infertility of chronic anovulation; hairy, acne and acanthosis nigricans and other high androgen blood phenomenon; obesity.

(3) Pituitary amenorrhea:

1 pituitary tumors and hyperprolactinemia: clinical manifestations of amenorrhea or irregular menstruation; lactation; such as pituitary tumors can cause headaches and visual impairment; such as empty sella syndrome can have pulsatile headache; exclusion of medication caused Hyperprolactinemia.

2 pituitary failure: clinical manifestations of postpartum hemorrhage or pituitary surgery history; weight loss, fatigue, chills, pale, postpartum no milk secretion, no sexual desire, no follicular development, reproductive tract atrophy; check for low levels of sex hormones and thyroid function Symptoms and signs of low and adrenal insufficiency.

(4) Central and hypothalamic amenorrhea:

1 Single gonadotropin-releasing hormone is low: A. Primary amenorrhea, follicles are present but not developed; B. Some patients have different degrees of secondary sexual developmental disorders; C. Kallmann's patients with olfactory loss; D. FSH, LH and E2 were both low; 5 responded to GnRH treatment; KL gene defect of 6X chromosome (Xp22.3).

2 functional hypothalamic amenorrhea: A. amenorrhea or irregular menstruation; B. common in adolescence or young women, more diet, mental stress, strenuous exercise and irregular life history; C. more thin and thin; D. TSH level Normal, T3 and T4 are lower; E.FSH and LH are lower or near normal, E2 level is lower; F. Ultrasound examination indicates normal ovarian size, multiple small follicles are scattered, and medullary reflex is not enhanced.

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