ABSENT AND IRREGULAR MENSES: CLINICAL PRESENTATION

CONTENT

-HISTORY

-PHYSICAL EXAMINATION

 

HISTORY

Because it is possible to identify from the history the specific site of the disorder in the HPO axis in a significant percentage of women, a detailed clinical history will be taken from you at presentation. Starting from your bio data, relevant information will be documented and processed. Taking age as an example, a 35 year old woman who presents with complaints of irregular or absent menses along with some features of perimenopause will be suspected of having premature ovarian failure (POF) as against a 15 year old girl complaining of irregular menses who recently started menstruating and whose symptoms suggest an immaturity of the HPO axis. This is because, early in the reproductive years of young girls,the HPO axis undergoes some maturity, taking about a year or two, following the onset of menstruation before the whole process involved in orchestrating of the menstrual cycle by the HPO axis becomes stable, while the earliest cycles are mostly without ovulation.

1.  THE MENSTRUAL HISTORY

When was your last menstrual period (LMP)? This is to confirm your complaint. Remember oligomenorrhea and amenorrhea are defined based on how long you have missed your period.

How long did your last period flow? Because such menses are usually anovulatory, they are often abnormal. Hence, it is not unusual for the menstrual bleeding to be prolonged, lasting for many days to some weeks predisposing the woman to an increased risk of anaemia or in some other cases, scanty, barely lasting a day or two, although in many others, it may remain normal.

When was the first time you ever menstruated? Not only does this confirm that you have a secondary amenorrhea rather than a primay amenorrhea, it may also help to rule out immaturity of the HPO axis, granted it is more than two to three years that you have been menstruating regularly.

Have your periods ever been regular? If yes what was the cycle length and the duration of menstrual flow? This may also help to exclude immaturity of the HPO axis and confirm a secondary amenorrhea.

When was the first time you ever noticed a missed or skipped period and how often in the last one year have you had a missed period? This may give an idea of how long the disorder have started as well as the severity of the disorder.

2.  HISTORY TO EXCLUDE OTHER CAUSES OF SECONDARY AMENORRHEA

Are you sexually active and when did you have an unprotected intercourse last? This is important to exclude pregnancy which is an important cause of amenorrhea and of abnormal bleeding.

Do you have any pregnancy symptoms? symptoms of pregnancy such as nausea, vomiting, breast tenderness and fullness, loss of appetite just to mention a few will also be asked.

Did you have a recent D and C? A recent D and C either for an abortion or for an evacuation of retained products of conception following a miscarriage just bofore the onset of the complaint may suggest either an Asherman syndrome and or a cervical stenosis which are both possible complications of D and C and possible causes of secondary amenorrhea.

Do you have any cyclical lower abdominal pain especially at the time you are supposed to see your menses but with little or no menstrual flow? This if present, suggests cryptomenorrhea, which is moderate to severe lower abdominal pain with scanty or no menstrual bleeding. It does suggest the presence of a cervical stenosis or a vaginal gynaetresia in women who have developed an obstruction to the passage of menses along their genital tract.

Was there a history of insertion of herbs, creams and unorthodox drugs into the vagina prior to the onset of the complaint? This if true suggests an acquired vaginal gynaetrsia in women with cryptomenorrhea.

3.  HISTORY TO ASCERTAIN THE SPECIFIC SITE OF THE HPO AXIS DSIORDER

1)  HYPOTHALAMIC DISORDERS

Is there any history of recent excessive weight loss, excessive exercise or eating disorder? Significant weight loss and excessive exercise can switch off the hypothalamic secretion of GnRH, while eating disorders like anorexia nervosa, can manifest as absence of menses along with other signs and symptoms of malnutrition.

Are you psychologically distressed? Not unusual many young ladies facing intense exam pressure or those under severe psychological distress may present with missed periods and or secondary amenorrhea due to a shut down of their hypothalamus.

Is there a history of chronic head ache and or a defect in your visual field? A  chronic history of headache and a feeling of a veil covering a part of your visual field may suggest a tumor growing within the hypothalamus such as a glioma or a craniopharyngioma. These tumors compress the normal hypothalamic tissues, the surrounding tissues and the optic tracts thus preventing normal secretion of the GNRH and causing a chronic headache and visual disturbances due to the pressure effect of the tumors.

Are you on any medication such as contraceptives, hormone containing drugs, antipsychotics, steroids and any other drugs that may affect the function of the hypothalamus? Hormonal preparations such as contraceptives, some hormonal anti-cancer medications, androgens, steroids and GnRH agonist used for the medical treatment of endometriosis and fibroids just to mention a few can directly prevent the secretion of the GNRH hormone by the hypothalamus while drugs like antipsychotics, anti emetics (metoclopramide) and methyl dopa are notorious for preventing the release of dopamine from the hypothalamus which in turn raises the prolactin levels and cause anovulation, amenorrhea and galactorrhea. Similarly, many other drugs such as opiods and cimetidine can also directly increase the secretion of prolactin which then disrupt the normal pulsatile secretion of GnRH by the hypothalamus.

Others: Other questions you may be asked include a previous history of any chronic disease, a previous treatment of a chronic infection or inflammatory disease such as TB and sarcoidosis and a previous hsitory of head injury. Although uncommon, women with a past history of TB or sarcoidosis may develop infiltration of the hypothalamus with either of the disease. Chronic disease like renal failure may produce so much stress and weight loss that a switch off of the GnRH secretion by the hypothalamus may occur. Although, a direct effect of some of these diseases on the ovary is also possible. Finally, head injury involving damage to the hypothalamus may present with secondary amenorrhea upon recovery.

2)  PITUITARY GLAND DISORDERS

Do you have nipple or breast milk discharge? Excessive levels of prolactin produced by prolactin secreting cells of the pituitary gland may present as galactorrhea in addition to amenorrhea. Other drugs that may raise prolactin level and present as galactorrhea must also be excluded and include oestrogen containing drugs, opiods such as morphine, and centrally acting drugs such as methyl dopa and antipsychotics.

Do you have head aches and any visual field defects? Prolactinomas are the commonest tumor in the pituitary gland. Other than secreting high levels of prolactin hormone, they along with other pituitary gland tumours may present as head aches and visual field defects similar to hypothalamic tumours.

Did you experience profuse or excessive blood loss immediately after child birth necessitating massive blood transfusion? This would be asked if there was a failure to resume menses few months to years after delivery in order to exclude sheehan’s syndrome. Other questions that may confirm this include, how many pints of blood were you given? were you able to lactate or produce milk after delivery? Was there a history of cold intolerance and easy fatiguability after delivery? If yes to all these, then sheehan’s syndrome may be suspected. Sheehan’s syndrome refers to death of some or all of the cells of the pituitary gland following a sudden massive drop in blood pressure and blood flow to the brain due to excessive blood loss during child birth or delivery resulting in failure of the pituitary gland to secrete some or all its hormones including LH and FSH after wards. Usually blood transfusion is said to be massive when the whole blood volume is replaced within 24 hours (about 5 – 7 litres or 10 -14 pints of blood in a delivered mother) of delivery or more than 50% of the whole blood is replaced in just about 4 hours of delivery (2.5 – 3.5 litres or 5 to 7 pints of blood).

Is there a recent drop in your activity level, coupled with intolerance to a cold environment, a significant gain in weight and or the presence of neck swelling? Although, these symptoms suggest a thyroid problem, women with primary hypothyroidism, produces a high amount of TRH from their hypothalamus, in response to the low levels of thyroid hormones produced by the thyroid glands in the blood. The TRH in turn stimulates the pituitary gland to produce a high level of prolactin which subsequently disrupt the GnRH stimulation by the hypothalamus resulting in amenorrhea and infertiltiy. 

3)  OVARIAN DISORDERS

Do you have an excessive growth of hair on your chin, chest and tummy? This is referred to as hirsutism and may suggest the presence of PCOS or a tumor producing excessive male hormones in your body.

Do you experience symptoms of menopause, such as heat flushes, sweating, irritability, dry vagina and difficulty in getting wet? If this occurs at any age before 40 years, it may suggest POF. If yes, questions relating to specific causes of POF that will be asked include, have you ever had chemotherapy or radiotherapy for the treatment of cancer?

 

PHYSICAL EXAMINATION

A physical examination may also give clues to the possible causes of the condition. Your weight and height will be used to calculate your BMI. Obesity is commonly associated with PCOS and a low BMI is associated with abnormal functioning of the hypothalamus. Click on this link on the site to check your BMI

Testing the visual field in all cases sugestive of a tumor within the hypothalamus and the pituitary gland is compulsory as this may help confirm the pressure effect of the growing tumor in the brain. Galactorrhea when demonstrated may suggest hyperprolactinaemia and the presence of a neck mass may suggest a thyroid disorder. The presence of a moon face associated with abdominal striae and back lump may suggest cushing's syndrome, a hormonal disorder associated with prolonged exposure to high levels of steroid hormones and amenorrhea. PCOS may be suggested by the presence of excessive acne, male pattern of hair distribution and obesity. Examination of the vagina and the cervix may revealed a structural obstruction to the outflow tract such as vaginal gynaetresia  or demonstrate changes consistent with low oestrogen level similar to that seen in post menopausal states e.g dry vagina wall seen in women with premature ovarian failure (POF).

 

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