menorrhoea -its causes

 

1)        Secondary amenorrhoea –How to Investigate a case  of SA-Part A : History & clinical examination :-After exclusion of any abnormality  in detailed history (like H/o Pill intake leading to post pill amenorrhoea, surgical abortion, drug intake, antacid intake, psychiatry drug intake , Repeated curettage, Koch’s, prolonged lactation,) -   if no such clue is available  then  we have to examine her for nutrition and systemic diseases followings should be carried out in order. A) If uterus is of normal size and is of normal consistency and UPT is negative  then as a first stage one should initially try for withdrawal bleed by cheap drug ;like Medroxy progesterone 10 mg empty stomach for 10 days provided   ET is < 6 mm and Endo is not echogenic in USG (if affordable) . If one is in doubt about very early pregancy during the sec ameneo phase then it is always safer to try withdrawal bleed by Duphaston. Duphaston will not cause harm to very early pregancy if there be any and UPT report is misleading (technical error or poor quality of kit).

Duphaston , instead of Modus/Meprate/ Orgamed is more relevant  if in sec ameno phase  ET is > 6 mm and or echogenic endometrium all suggesting good amount of progestogenic effect which might be due to very early pregnancy .

 

Part B:-- Progesterone Challenge Test. May be negative even in absence of pregancy when? - we must remember that to have withdrawal bleed +ve- the serum level of E 2 will have to be at least 10 pg/ml, preferably > 20 pg/ml. Too low E 2 will not prime the Endometrium for action by Prog.

 

2)        If withdrawal bleed is negative then urgent to estimate FSH & always with E2 also: - at least on 2 occasions (better on 3 occasions)-  -> If high FSH &  also high  LH. Low E 2 à then daig is POF is almost certain. AMH is also supposed to be low. One can also order for  Inhibin B  and AMH in research settings only not in day to day clinical practice.

3)        If withdrawal bleeding fails it progesterone only then, if clinician is almost certain that concerned woman is  not pregnant  then one should add E2 exogenous to keep E2 near 50 pcg/ml not only to aid withdrawal bleed but also  to prevent osteoporosis.

4)        Additional Investigations if FSH is too high more so if her age is < 35 yrs then we the clinicians should try to exclude the possibility of any autoimmune diseases. -Complete haemogram(Autoimmune anemia-ESR),  ANF, Rheumatoid factor, Serum cortisol, Ca, PO4, ANF, Anti-ds DNA Ab, PPBS, 

5)        If below 30 yrsà karyotype too if cases of unexplained and long standing secondary amenorrhoea.,

6)        Sella  Evaluation.MRI more so if PRL is > 100

7)        Estimate Bone Density- an often duty  on the part of gynecologists in POF cases and menopausal women too .

 Diseases which are  associated with POF.

GRS (Gonadotrophin Resistance Syndrome, Rheumatoid arthritis, Pernicious anemia, GLO. Nephritis, Graves Disuse, Hashimotos thyroiditis, Adrenal failure, Vitiligo-Leukoplakia, Lichen Planus, DM, M gravis, Hemolytic anemia. Anticardiolipin Ab.

How best to treat Sheehan’s Syndrome.(Postpartum partial ant pituitary necrosis due to sudden severe loss  of blood  during atonic PPH (secondary to thrombosis of big sinuses of Hypothalamo Pit plexus of blood vessels).

Treatment:-

1)                  Wysolone-5 mg.(OMNACORTIL) :  1 tab after breakfast, later  TDSPC

2)                  Eltroxin:- 50mcg for  7 days.; later 100 mcg for 15 days, 150mcg OD.

3)                   Calcium Tab  500 mg daily.