Amenorrhea natural history, complications and prognosis
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Eiman Ghaffarpasand, M.D. [2]
Overview
If left untreated, patients with amenorrhea may progress to develop infertility and osteoporosis. Common complications of amenorrhea are based on underlying disorder that induce amenorrhea. Prognosis is generally excellent and the mortality rate of patients with amenorrhea is approximately less than 1%, generally in brain lesions.
Natural History, Complications, and Prognosis
Natural History
- The symptoms of puberty usually develop in the second decade of life, 12-13 years of age and usually before 15 years of age. The main symptom of puberty in female gender is menarche.[1]
- In primary amenorrhea:
- In secondary amenorrhea:
- Menstrual cycle is interrupted for at least 3 months, however menstrual cycles were regular before.[1]
- Menstrual cycle is interrupted for at least 6 months, however menstrual cycles were irregular before.[3]
- If left untreated, all patients with amenorrhea may progress to develop infertility and osteoporosis.
- The majority of amenorrhea cases are caused by four conditions, which include polycystic ovary syndrome, hypothalamic amenorrhea, hyperprolactinemia, and ovarian failure.
- In case of amenorrhea secondary to Asherman's syndrome, patients usually have a past medical history of uterine surgery and scarring.
- Polycystic ovary syndrome (PCOS), if left untreated can lead to heart disease from elevated cholesterol and increased levels of androgens. Long periods of not having menstrual cycles leads to unopposed exposure of endometrium to estrogen, can result in endometrial cancer.[4]
- In functional (hypothalamic) amenorrhea, the patient usually reports normal regular cycles in the past, with sudden interruption of menstrual cycles for more than 3 months. There is almost always a history of weight loss (severe), excessive exercise, or drastic emotional stress prior to cessation of menstruation.[5]
- Premature ovarian failure presents with menopause before the age of 40 and elevated levels of gonadotropins. In the age group of 41 to 44 years, it is called pre-menopause. Patients of Premature ovarian failure generally have a family history of ovarian failure.[6]
- Amenorrhea from hyperprolactinemia can be caused by prolactin overproduction or dopamine suppression, and is mostly seen in middle aged women. Idiopathic hyperprolactinemia is elevated serum prolactin level without any brain lesion or other pathologies.[7]
Complications
- Common complications of amenorrhea are based on the underlying disorder inducing amenorrhea.
- Common complications of amenorrhea from PCOS include:
- Hyperprolactinemia leads to galactorrhea, decreasing libido, and pregnancy complications. In case of prolactin-producing pituitary adenoma, massive enlargement of the tumor may influence vision and pituitary function. It can also cause osteopenia and osteoporosis in pre-menopausal women.[8]
- Common complications of premature ovarian failure are infertility, osteoporosis, depression/anxiety, cardiac disease, and dementia.[9]
- Patients with hypothalamic (functional) amenorrhea experience various complications, such as infertility, decrease in bone mineral density (BMD), increased risk for fracture along with cardiovascular and psychological problems.[5]
- The most important complication of premature ovarian failure is infertility, that is preventable to some extent with appropriate therapies. Bone loss and mental problems are other complications.[10]
Prognosis
- Prognosis is generally excellent and the mortality rate of patients with amenorrhea is approximately less than 1%.
- Among patients of androgen insensitivity syndrome there is an increased risk of testicular cancer, and surveillance should be done at appropriate intervals.
- Prognosis of polycystic ovary syndrome (PCOS) is generally good, long term diet and exercise along with metformin therapy decrease the cardiovascular and pregnancy problems in the future.[11]
- Long term (7 years) prognosis of hyperprolactinemia from microadenomas has 90-95% stability or gradual decrease in prolactin serum level. Whereas, one third of patients with idiopathic hyperprolactinemia are cured without therapy, two thirds of patients with macroadenomas and basal prolactin < 40 ng/mL. 40% of relapse within 5 years after surgery.[12]
References
- ↑ 1.0 1.1 Chiavaroli, Valentina; DAdamo, Ebe; Diesse, Laura; de, Tommaso; Chiarelli, Francesco; Moh, Angelika (2011). "Primary and Secondary Amenorrhea". doi:10.5772/17675.
- ↑ Herman-Giddens, M. E.; Slora, E. J.; Wasserman, R. C.; Bourdony, C. J.; Bhapkar, M. V.; Koch, G. G.; Hasemeier, C. M. (1997). "Secondary Sexual Characteristics and Menses in Young Girls Seen in Office Practice: A Study from the Pediatric Research in Office Settings Network". PEDIATRICS. 99 (4): 505–512. doi:10.1542/peds.99.4.505. ISSN 0031-4005.
- ↑ Fritz, Marc (2011). Clinical gynecologic endocrinology and infertility. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins. ISBN 978-0781779685.
- ↑ Palomba S, Santagni S, Falbo A, La Sala GB (2015). "Complications and challenges associated with polycystic ovary syndrome: current perspectives". Int J Womens Health. 7: 745–63. doi:10.2147/IJWH.S70314. PMC 4527566. PMID 26261426.
- ↑ 5.0 5.1 Meczekalski B, Katulski K, Czyzyk A, Podfigurna-Stopa A, Maciejewska-Jeske M (2014) Functional hypothalamic amenorrhea and its influence on women's health. J Endocrinol Invest 37 (11):1049-56. DOI:10.1007/s40618-014-0169-3 PMID: 25201001
- ↑ Vegetti W, Marozzi A, Manfredini E, Testa G, Alagna F, Nicolosi A, Caliari I, Taborelli M, Tibiletti MG, Dalprà L, Crosignani PG (2000). "Premature ovarian failure". Mol. Cell. Endocrinol. 161 (1–2): 53–7. PMID 10773392.
- ↑ Mattei AM, Severini V, Crosignani PG (1991). "Natural history of hyperprolactinemia". Ann. N. Y. Acad. Sci. 626: 130–6. PMID 2058949.
- ↑ Sanfilippo JS (1999). "Implications of not treating hyperprolactinemia". J Reprod Med. 44 (12 Suppl): 1111–5. PMID 10649820.
- ↑ "Premature ovarian failure - Symptoms and causes - Mayo Clinic".
- ↑ Nelson LM (2009). "Clinical practice. Primary ovarian insufficiency". N Engl J Med. 360 (6): 606–14. doi:10.1056/NEJMcp0808697. PMC 2762081. PMID 19196677.
- ↑ Hart R (2007). "Polycystic ovarian syndrome--prognosis and treatment outcomes". Curr. Opin. Obstet. Gynecol. 19 (6): 529–35. doi:10.1097/GCO.0b013e3282f10e22. PMID 18007129.
- ↑ "Hyperprolactinemia Follow-up: Further Outpatient Care, Complications, Prognosis".