ABSENT AND IRREGULAR MENSES: TREATMENT

CONTENT

-INTRODUCTION

-ENSURING A REGULAR MENSTRUAL FLOW

-HORMONE REPLACEMENT THERAPY

-TREATMENT OF ASSOCIATED INFERTIITY

-TREATMENT OF SPECIFIC CAUSES OF HPO AXIS DISORDER

-MANAGEMENT OF COMPLICATIONS OF SPECIFIC CAUSES OF HPO AXIS DISORDER

 

INTRODUCTION

Although, following diagnosis, the treatment of absent and irregular menses is usually by the treatment of the specific disorder of the HPO axis, unfortunately, in some instances, an actual cure may not be possible. This may be due to an irreversible damage by either the disease process to the hypothalamus, the pituitary gland or the ovary, or by an irreversible damage caused by the treatment process itself. Thus, at treatment, the general considerations are the need to ensure a regular menstrual flow, the hormone replacement treatment of women to prevent the complications associated with low oestrogen level found in all disorders of HPO axis except PCOS, the treatment of associated infertility and the management of specific complications associated with the specific disorder of the HPO axis.

 

ENSURING A REGULAR MENSTRUAL FLOW

Because it is important as a sign of feminity for most women to see their regular monthly cycle, the cyclical use of combined oral contraceptive pills (COCP) can be given in most cases of absent and irregular menses to achieve a 28 days regular menstrual cycle. But even more importantly, women with PCOS are exposed to prolonged high levels of oestrogen hormone, in contrast to all other causes of HPO axis disorder, and are at an increased risk of prolonged irregular and erratic heavy menstrual bleeding that can lead to anemia, a future risk of endometrial hyperplasia and endometrial cancer. Thus, such women if not desirous of pregnancy must be on monthly COCP or cyclical progesterone tablets every 21 days from the beginning of the last menstrual flow to ensure a regular cyclical menstrual blood flow till the disorder (PCOS) is well under control.

 

HORMONE REPLACEMENT THERAPY

This refers to the external supply or use of hormones to replace the deficiency in a hormone normally produced in the body in other to maintain some specific functions of these hormones in the body. The main female sex hormone, oestrogen, produced by the ovary is often low in all cases of disorders in the HPO axis except PCOS. This can result in varying effects of oestrogen deficiency, similar to what is seen at menopause. A particular worrisome effect of prolonged oestrogen deficiency is an increased risk of bone fractures due to an increased rate of absorption of calcium from the bones, a condition also known as osteoporosis. Other hormones may also be deficient and may require replacement depending on the affected organ in the HPO axis. For example, women with disorders of the hypothalamus may require the replacement of the GnRH, for the management of infertility. Similalry, lesions affecting most or all part of the pituitary gland will in addition to hormone replacement of FSH and LH for the treatment of infertility, require the replacement of the thyroid hormones and adrenal hormones, as these hormones are normally produced under the influence of two other hormones produced or secreted by the pituitary gland (TSH and ACTH), whose absence following damage to the pituitary gland will eventually result in deficiency of the thyroid and adrenal hormones.

 

TREATMENT OF INFERTILITY

The management of infertility is a major cause of concern in all patients with disorders of the HPO axis due to the obvious absence of ovulation. The use of ovulation induction agents +/- the use of metformin tablets have been shown to achieve a very good result in women with PCOS. The use of drugs such as cabergoline or bromocriptine (dopamine agonists) to prevent the secretion of prolactin by the pituitary gland will restore ovulation in many women with hyperprolactinaemia, while thyroid  hormone replacement in women with hypothyroidism will reverse the high prolactin level associated with hypothyroidism. For women with lesions within the hypothalamus that are preventing the normal secretion of the GnRH, pulsatile injection of GnRH can stimulate the secretion of FSH and LH by the pituitary gland which in turn will stimulate the ovaries to produce follicles and undergo ovulation. Irreversible pituitary gland disease such as, Sheehan's syndrome, tumor and irradiation of the pituitary gland are usualy treated with FSH and LH injection, usually given as HMG for ovulation induction. Women with POF, are usually resistant to ovulation induction, but IVF with egg or ovum donor is an excellent means of conception. Perhaps in the nearest future, donation of ovarian tissue as a form of organ transplant, may help reshape how POF is managed.

 

TREATMENT OF SPECIFIC CAUSES OF HPO AXIS DISORDER

Exercise related amenorrhea and stress related amenorrhea can be treated basically by lifestyle modifications and a reduction in daily exercises. Amenorrhea due to weight loss, can be treated by maintaining the BMI above 19. This is because about 22% of the body mass must contain fat in order for ovulation to occur. Anorexia nervosa, is an extreme form of weight loss that requires co management with the mental health team or psychiatrists. 

While a brief but detailed information on the treatment of absent and irregular menses is given above to cover most of the disorders of the HPO axis, PCOS remains the commonest cause of absent and irregular menses and will be discussed in detailed in articles dedicated to it’s management. For more information on management of individual disorders of ovulation, kindly CHAT WITH OUR CONSULTANTS.

 

MANAGEMENT OF COMPLICATIONS OF VARIOUS CAUSES OF HPO AXIS DISORDER

For women with a tumour within the hypothalamus such as a glioma, compression of nearby tissues may result in headache and visual disturbances that may require surgery and in some cases, radiotherapy. Similalry, a prolactinoma and many other pituitary gland tumors may also present as above. While it is possible to keep in check the growth of many small prolactinomas with drugs like cabergoline (a dopamine agonist), large prolactinomas and other large pituitary tumours may require surgery. Bearing in mind that both the tumours and their treatment may damage the hypothalamus and or the pituitary gland, hormone replacement therapy may be needed after treatment.

PCOS as mentioned above, may be associated with aneamia from irregular but heavy and profuse menstrual bleeding. There is also a future risk of endometrial hyperplasia, endometrial cancer and type 2 diabetes mellitus (DM). Regular menstrual bleeding with the use of COCP and cyclical progesterone can be used to prevent the first three, while regular screening of blood sugar levels and appropriate life style modifications may be used to prevent the development of diabetes mellitus and its complications. Women with anorexia, a condition associated with chronic malnutrition, must be given adequate replacement of lost nutrients and vitamins especially thiamine before commencement of high glucose containing infusions or diet. This is important to prevent the sudden development of a characteristic form of psychosis associated with thiamine deficiency which may be precipitated by sudden glucose infusion into the blood that may result in utilization of the remaining thiamine in the blood following metabolism of the infused glucose.

 

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