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.

[Psychogenic amenorrhoea and sexed body]

Psychogenic amenorrhoea turns a life event into a body event, for the simple reason that the sexed body cannot be reduced to an organism ruled by physiological laws. In addition to being a datum of life, the body, which is dedicated to "jouir", is also a construction both created by the imaginary and dissolved by the symbolic. This element accounts for the sensitivity of a bodily symptom to speech. As an illustration, the relation of a clinical case will show how, in the course of psychogenic amenorrhoea, the body undergoes a process of "jouissance" that translates into a kind of "organ paralysis", along with the dormant state of one physiological function and the whole body. Psychotherapy enabled one of the subjects to awaken her inhibited body after she had unrolled the significant elements of her desire. Addressing to the Other of language allowed her to create a social link and thus, undo the symptom.

Approach to adolescent polycystic ovary syndrome (PCOS) in the pediatric endocrine community in the U.S.A

OBJECTIVE

Polycystic ovarian syndrome (PCOS) is the most common endocrinopathy in adult women, and is emerging as a common cause of menstrual disturbances in the adolescent population. Insulin resistance, which is considered one of its underlying causes, has increased substantially in the past decade, putting more adolescent girls at risk for PCOS and its complications. Our objective was to survey pediatric endocrinologists' approach to diagnosis and treatment of PCOS in the adolescent population, as there is presently no structured recommended approach to this emerging problem.

DESIGN/METHODS

A questionnaire survey was sent to 839 members of the Lawson Wilkins Pediatric Endocrine Society (LWPES). A total of 176 (21%) responses was received and analyzed. REDULTS: The majority of the participants would consider initiating work-up in an adolescent with oligomenorrhea or secondary amenorrhea 12-24 months after menarche. The following work-up was selected as a baseline for a teenager with oligomenorrhea or secondary amenorrhea by more than 50% of participants: LH and FSH, total and free testosterone, prolactin, 17-OH-progesterone, DHEAS and glucose/insulin measurements. For treatment of PCOS, the majority of surveyed endocrinologists suggested estrogen/progesterone combination. Metformin was considered appropriate treatment in the general adolescent population with PCOS by 30% and in obese teenagers with PCOS by 68% of surveyed endocrinologists.

CONCLUSIONS

Our findings indicate the trend among pediatric endocrinologists towards earlier work-up of menstrual irregularities in adolescents--unlike the traditional practice of waiting for 2 years after menarche. Most pediatric endocrinologists would consider evaluation for insulin resistance using glucose/insulin measurement, but only a small percentage considers performing OGTT in these patients. Even though using estrogen/progesterone combination is the preferred therapeutic approach, 30% of surveyed endocrinologists consider metformin therapy for the general adolescent population with PCOS, and 68% would consider using it in obese adolescents with PCOS.

Altered Hypothalamic-Pituitary-Ovarian Axis Function in Young Female Athletes

Young women have become increasingly active in athletics during the 20th century. Those involved in sports that emphasize lean body type are at high risk for the development of menstrual dysfunction, including amenorrhea. This is mediated by an alteration in function of the hypothalamic-pituitary-ovarian (HPO) axis, with loss of normal secretion of luteinizing hormone, and subsequent lack of estrogen production. Disruption of the HPO axis appears to be dependent on the body's recognition of an energy imbalance, which may be due to a lack of compensatory caloric intake in the face of significant energy expenditure. Other pituitary hormones, such as triiodothyronine, growth hormone, and insulin-like growth factor-1 may also be affected. These metabolic changes have an impact on bone mineralization during a critical period in the development of bone mass. Recognition by physicians of the so-called 'female athlete triad', consisting of disordered eating, amenorrhea, and osteoporosis, may allow therapeutic intervention. Diagnosis of eating disorders and decreased bone mineral density can have significant impact on the health of the young athlete. Treatment is aimed at restoring normal menstrual function by increasing caloric intake to balance the increased energy demands of athletic participation. Concurrent treatment of the hypoestrogenemic state using estrogen replacement is controversial, but may aid in alleviating further loss of bone mass.

The genetics, diagnosis and treatment of amenorrhea

The menstrual cycle is regulated by complex feedback interactions between the ovaries, pituitary and hypothalamus. A disruption at any point in one of these pathways may lead to irregularities in the menstrual cycle. In particular, amenorrhea, the cessation of menstrual functioning, serves as an indicator of ovarian, pituitary and/or hypothalamic dysfunction. Historically, diagnosing and treating amenorrhea presented medical professionals with numerous practical difficulties. In recent years, however, studies of amenorrhea have yielded new understandings and new treatments of the disorder. This paper synthesizes these current methodologies for diagnosing, treating and understanding both primary and secondary amenorrhea.

Managing anovulatory infertility

Around one in six couples wishing to have children have problems conceiving, and in a fifth of these, the cause is identified as an ovulatory disorder. Here we describe the management of women with infertility who present in general practice with amenorrhoea or oligomenorrhoea, often the first indication of possible anovulatory infertility.

The female athlete triad. A growing health concern

The number of female athletes participating at the high school, collegiate, and elite levels has increased nearly 10-fold since the passage of Title IX. President Nixon signed title IX into law in 1972. It required that all schools receiving federal funding provide equal opportunities for men and women. With this large increase in high-level female athletes comes a special set of medical and orthopaedic issues. One of the most important is the female athlete triad. The triad consists of disordered eating, amenorrhea, and premature osteoporosis. Currently, this problem is largely unrecognized. The purpose of this article is to help to educate orthopaedic nurses about this important issue so that we can detect the triad early and help address this growing national health issue.

The female athlete triad: an emerging role for physical therapy

Over the last thirty years, participation by girls and women in organized athletics has increased dramatically. This presents unique challenges in the area of sports medicine, orthopaedics, and pediatrics. While the benefits of participation in sports and exercise vastly outweigh the risks of permanent injury, an evolving concern is the number of stress fractures in active women. The female athlete triad ("triad") describes the coexistence of 3 distinct medical conditions that may occur in athletic girls and women. Originally, the triad included eating disorders, amenorrhea, and osteoporosis. Presently, it includes eating disorders/disordered eating behavior, amenorrhea/oligomenorrhea, and decreased bone mineral density (osteoporosis and osteopenia). Briefly, when coupled with inadequate nutrition, the high caloric expenditure of exercise training resultsin a sustained negative caloric balance or low energy availability, which is exquisitely sensed by the hypothalamus, initiating a complex neuroendocrine adaptive cascade. This cascade is associated with changes in the hypothalamic-pituitary-ovarian axis, such that estrogen levels are decreased, resulting in reproductive dysfunction that may include amenorrhea, oligomenorrhea, or anovulation. Low estrogen in otherwise young healthy women, like menopause, is associated with decreased bone mineral density and increased risk of fractures. The triad is not an inevitable consequence of participation in sports or physical activity at any level, however, exercise may contribute to the disruption of caloric balance. The triad is a complex disorder that requires intervention by a multidisciplinary team. Physical therapists bring a unique expertise to the team. The present review summarizes each component of the triad, component linkage, and the role of physical therapy in prevention, assessment, and intervention.

Menstrual disorders in adolescence: investigation and management

Menstrual disorders in adolescence may present diagnostic and management challenges for the gynaecologist. This review will describe the common and uncommon menstrual disorders that may arise in early reproductive life, together with guidance on their investigation and management.

Adolescent girls, the menstrual cycle, and bone health

In adolescent girls, amenorrhea is sometimes viewed as a variant of normal; in fact, however, during the first gynecologic year, the 95th percentile for cycle length is 90 days. Although early menstrual cycles are frequently anovulatory and may be somewhat irregular, girls with menses coming less frequently than every 90 days may have significant pathology associated with hypoestrogenism. Hypoestrogenism is a known risk factor for the development of osteoporosis. Causes of oligomenorrhea and amenorrhea include the relatively common conditions of hyperandrogenism, eating disorders, and exercise-induced amenorrhea, as well as uncommon conditions such as pituitary tumor, gonadal dysgenesis, and premature ovarian failure. Even functional hypothalamic oligomenorrhea has been linked to reduced bone density. Attention to menstrual irregularity and the earlier diagnosis of conditions causing it may lead to interventions that will benefit life-long bone health.

Amenorrhoea revealing an arteriovenous uterine malformation, and recovery of menses after embolization

A case is reported of secondary amenorrhoea related to an arteriovenous malformation (AVM) successfully treated with embolization, with a recovery of menstrual cycles. A 28-year-old woman presented with secondary amenorrhoea as the only clinical symptom. Although she had an eugonadic status, there was no genital withdrawal bleeding upon cessation of an oral contraceptive. Pelvic transvaginal ultrasonography revealed a pelvic mass but magnetic resonance imaging (MRI) clearly showed an AVM. Classical angiography was performed with endovascular embolization. Partial thrombosis of the lesion was assessed by magnetic resonance angiography. Recovery of menses occurred 2 months later. It is speculated that blood stolen from the endometrium by the uterine AVM could have been responsible for the amenorrhoea. It is a very unusual cause, and it can be successfully treated with embolization.

V. Uterine fibroid embolization: management of complications

Fortunately, the number of complications reported after uterine fibroid embolization (UFE) is extremely low. Angiographic mishap or drug reaction are probably more common than purely UFE-related complications. However, the possibility of infection or necrosis of the uterus, with their significant attendant morbidity, is a sobering reminder that embolotherapy can have a powerful impact on the target organ(s). Knowledge of the expected time course for symptom resolution and the often confusing imaging findings shortly after UFE are critical for avoiding unnecessary delay in surgical intervention or, perhaps more important, an inappropriate rush to surgery when antibiotics alone will suffice. Other complications include alteration of uterine physiology, which may disrupt sexual function, and menstrual irregularity and even premature menopause.

The female athlete triad: a terrible trio implications for primary care

PURPOSE

To describe the components of the female athlete triad, including definitions and clinical criteria for diagnosis, methods of screening, and treatment options.

DATA SOURCES

Selected scientific literature; standard diagnostic guidelines.

CONCLUSIONS

The female athlete triad is a cascading event consisting of disordered eating, amenorrhea, and osteoporosis. This disorder can occur in any sport but is seen most often in events that emphasize thinness and appearance such as gymnastics, ballet, and diving. It can often go unrecognized and result in irreversible bone loss and possible death.

IMPLICATIONS FOR PRACTICE

Primary care nurse practitioners (NPs) may be the first health care professionals encountering these females; they need to recognize the risk factors and institute a multidisciplinary approach to treatment. The treatment team should be composed of the patient, the NP, a dietitian, a psychologist, psychiatrist, or psychiatric nurse specialist, and the patient's family, coaches, and trainers.

Ovulation induction with pulsatile gonadotropin-releasing hormone (GnRH) or gonadotropins in a case of hypothalamic amenorrhea and diabetes insipidus

Hypothalamic amenorrhea is a treatable cause of infertility. Our patient was presented with secondary amenorrhea and diabetes insipidus. Cortisol and prolactin responded normally to a combined insulin tolerance test (ITT) and thyrotropin-releasing hormone (TRH) challenge, while thyroid-stimulating hormone (TSH) response to TRH was diminished, and no response of growth hormone to ITT was detected. Both luteinizing hormone (LH) and follicle-stimulating hormone (FSH) levels increased following gonadotropin-releasing hormone (GnRH) challenge. No response of LH to clomiphene citrate challenge was detected. Magnetic resonance imaging findings demonstrated a midline mass occupying the inferior hypothalamus, with posterior lobe not visible and thickened pituitary stalk. Ovulation induction was carried out first with combined human menopausal gonadotropins (hMG/LH/FSH) (150 IU/day) and afterwards with pulsatile GnRH (150 ng/kg/pulse). Ovulation was achieved with both pulsatile GnRH and combine gonadotropin therapy. Slightly better results were achieved with the pulsatile GnRH treatment.

The female athlete triad

The female athlete triad, a syndrome of disordered eating, amenorrhea, and osteoporosis, is now clearly recognized in selected populations of elite athletes. It is often seen in the sports that have an emphasis on "thinness," including gymnastics, figure skating, and ballet. Components of the triad are linked pathophysiologically, leading to significant morbidity and, on occasion, mortality. The disorder is difficult to treat and requires a multidisciplinary approach with intense psychological counseling as the primary focus of attack.

Resumption of luteinizing hormone pulsatility and hypogonadotropic hypogonadism after endoscopic ventriculocisternostomy in a hydrocephalic patient

OBJECTIVE

To study gonadotropin pulsatility before and after surgical cure of hydrocephalus.

DESIGN

Case report.

SETTING

Department of Endocrinology and Centre d'Investigations Cliniques, Necker Hospital, Paris, France.

PATIENT(S)

A 29-year-old woman who presented with secondary amenorrhea.

INTERVENTION(S)

The patient underwent an endoscopic ventriculocisternostomy that led to restoration of normal menses and resolution of hypogonadism.

MAIN OUTCOME MEASURE(S)

A gonadotropin pulse study was performed before and 2 and 5 months after surgery.

RESULT(S)

No LH pulse was observed before surgery. Emergence of pulsatility was observed 2 months after surgery, and pulses became clearly individualized after 5 months.

CONCLUSION(S)

This observation strongly suggests that amenorrhea, in case of chronic hydrocephalus, is indeed due to a hypothalamic dysfunction of the GnRH pulse generator.

[The female athlete triad]

This review offers some basic information on a syndrome described in 1992 as the female athlete triad. The increasing participation of women in competitive sports has led to significant accumulation of knowledge about potential pathological conditions due to strenuous exercise. Participation in sports that emphasize specific body image, psychological constitution of young female athletes and significantly lower daily calory intake cause the development of disordered eating, especially anorexia nervosa. Anorexia in combination with intensive training induces menstrual disorders, exercise-associated amenorrhea being the most important one. Low serum estrogen concentrations, as well as insufficient daily calcium intake have negative influence on bone mineral density, and the athletes have greater risk of developing osteoporosis and stress fractures. We described the diagnostic and therapeutic procedures necessary to detect and treat this syndrome. Education of physicians, female athletes and their coaches, as well as the screening during the annual examination, remain the most important measures of prevention.

Diagnosis and care of patients with anorexia nervosa in primary care settings

Anorexia nervosa is a psychiatric disorder characterized by abnormal eating behaviors that results in weight loss and has serious potential medical consequences. Most of these complications are readily treatable if diagnosed and attended to early in the course of the illness. In caring for patients with anorexia nervosa, the primary care physician has several critical roles. Because patients deny the severity of their illness, they delay seeking psychiatric treatment. The primary care physician must be skilled in recognizing this disorder, as well as in diagnosing and effectively treating the medical complications while educating the patient about them. The primary care physician is also involved with arranging and coordinating a comprehensive and multidisciplinary program, including dietary and mental health treatment. The multidisciplinary team is responsible for ensuring safe weight restoration and a judicious refeeding treatment plan. In addition to establishing the diagnosis and treating the multiple medical complications associated with anorexia nervosa, the primary care physician plays a central role in maintaining continuity of care despite the fact that successful care may require a variety of treatment settings. Factors that foster good prognoses for this increasingly common and often protracted eating disorder include early diagnosis and skilled medical intervention to prevent the inexorable physical decline that marked weight loss can cause.