amenorrhea
Introduction
Introduction Amenorrhea is a common symptom in gynecological diseases and can be caused by a variety of different causes. Amenorrhea is usually divided into primary and secondary. Those who have not passed the age of 18 years old are called primary amenorrhea; after menarche, any time before normal menopause (except pregnancy or lactation), menstrual closure for more than 6 months is called secondary amenorrhea . This distinction is largely artificial, as the underlying factors that cause primary and secondary amenorrhea may sometimes be the same. However, this division is valuable when providing clues to etiology and prognosis, such as most congenital anomalies, including dysplasia of the ovary or Mullerian tissue, resulting in amenorrhea being included in primary amenorrhea, followed by Most of the amenorrhea is caused by acquired diseases and is easier to treat.
Cause
Cause
1. Disease:
It mainly includes consumptive diseases, such as severe tuberculosis, severe anemia, malnutrition, etc., and endocrine diseases such as "obesity reproductive incompetent malnutrition". The effects of some endocrine disorders in the body, such as the adrenal gland, the prostate gland, the pancreas and other dysfunction. The effects of these reasons may not come to menstruation. However, amenorrhea caused by these kinds of conditions, as long as the disease is cured, menstruation will naturally come.
2. Lower genital tract atresia:
Such as the cervix, vagina, hymen, labia, etc., there is a part of congenital atresia, or acquired damage caused by adhesional atresia, although menstruation, but menstrual blood can not flow out. This condition is called recessive or pseudo-menopause. The lower part of the reproductive tract is closed and can be cured by doctors.
3. The Department of Reproductive Organs is not sound or stunted:
Some people have congenital absence of ovaries, or ovarian malnutrition, or ovarian sputum, can not produce estrogen and progesterone, so the endometrium can not undergo periodic changes, there will be no endometrial shedding, so also There is no menstrual cramps. There are also congenital absence of uterus, or endometrial dysplasia, or endometrial damage, even if the ovarian function is sound, the secretion of estrogen and progesterone is normal, it will not come to menstruation.
4. Tuberculous endometritis:
This is because tuberculosis invades the endometrium, inflames the endometrium, and is damaged to varying degrees. Finally, scar tissue appears, resulting in amenorrhea. Therefore, tuberculous endometritis should be treated promptly and should not be delayed.
5. Pituitary or hypothalamic dysfunction:
The pituitary gland secretes gonadotropins. Gonadotropin has the effect of regulating ovarian function and maintaining menstruation. If the dysfunction of the pituitary gland, it will affect the secretion of gonadotropin, affecting the function of the ovary, and abnormal ovarian function will cause amenorrhea. In addition, abnormal hypothalamic function can also cause amenorrhea. There are many causes of hypothalamic dysfunction, such as mental stimulation, sad anxiety, fear, nervousness, and environmental changes, cold stimulation. Amenorrhea caused by the hypothalamus is more common.
Examine
an examination
Related inspection
Pregnancy test progesterone chromosome progesterone plasma dihydrotestosterone (DHT)
First, medical history
Including the history of parental marriage, family history, past history, personal development history and menstrual history, amenorrhea time, etiology, incentives and accompanying symptoms (such as galactorrhea, pelvic mass), marriage and childbirth (sex life, maternal birth, childbirth and lactation Situation) Family planning history, (using contraceptives and induced abortions), and outpatient treatment, with or without systemic diseases.
Second, physical examination
(1) General physical examination: mental, nutritional, physical and developmental status and sexual characteristics (such as posture, height, weight, finger distance, skin, hair and breast development), with or without gnomes, neck and acromosis, Mucous edema, galactorrhea, hirsutism and inguinal hernia.
(2) Gynecological examination: development of internal and external genital organs, presence or absence of deformity and tumors. Primary amenorrhea should pay attention to the presence or absence of genitourinary sinus deformity, clitoris hypertrophy and hermaphroditism.
Third, laboratory examination and hypothalamic-pituitary-ovarian-uterine axis hormone function test
(1) Laboratory inspection
1. Cytogenetic examination: including X, Y sex chromatin, chromosome nucleus.
2. Hormone determination: including 1 pituitary hormone: FSH, LH. PRL, TEH, GH, ACTH; 2 gonadotropins: E2, P, T0 hydronexin (DHT); 3 adrenocortical hormone: DHEA, DHEAS, 17 - Determination of ketosteroids (17-KS) hydroxysteroids and cortisol; 4 thyroid hormones: T3, T4, plasma protein-bound iodine (PBI) 5 insulin and insulin-like growth factor; (IGF-1); 5 sex hormone binding globulin Hu (SHBG).
3. Vaginal epithelial cell examination: vaginal epithelial cells are affected by ovarian hormones, and periodic changes occur. Therefore, continuous smear examination, l~2 times a week, can measure ovarian function to observe estrogen levels and periodicity. Variety.
4. Cervical and cervical fluid examination: the gland of the endocervix secretes cervical new fluid, and the amount, color, traits, new consistency and crystallization type of cervix of cervical cervix are affected by ovarian hormones, and the cycle is Sexual change. From the 6th to 7th day of the menstrual cycle, check 2-3 times a week to estimate ovarian function and estrogen levels.
5. Diagnostic curettage and endometrial pathology: curettage can understand the length and width of the uterine cavity, the endometrium of the uterus. Endometrial pathology, on the one hand can understand the function of the ovary, on the other hand can understand whether there is endometrial tuberculosis or other organic lesions.
(2) hypothalamic-pituitary-ovarian-uterine axis hormone function test
The aim is to monitor and assess the functional status of reproductive hormone target organs to determine amenorrhea partitions and causes.
1. Progesterone test: The purpose is to assess endogenous estrogen and endometrial reactivity to identify uterine and ovarian amenorrhea. Progesterone 20 mg / d intramuscular injection for 3 ~ 5 d. The withdrawal was observed to observe the withdrawal bleeding, and the blood withdrawal was positive, indicating endogenous estrogen secretion and good endometrial reactivity, and can exclude pregnancy and uterine amenorrhea. No blood withdrawal was negative, indicating that the internal reaction was poor or endogenous estrogen secretion was not enough to make the endometrium, so the estrogen test should be done after the exclusion of pregnancy.
2. Estrogen test: The purpose is to examine the endometrial reversal to identify uterine amenorrhea and ovarian amenorrhea. Diethylstilbestrol 1mg / d for 20d, or intramuscular injection of estradiol benzoic acid 1mg, 10 times a day, a total of 10 times, withdrawal of drugs to observe the withdrawal of blood can be used for progesterone withdrawal. There is a blood donor test positive, indicating lack; endogenous estrogen secretion and endometrial response is good, except for uterine amenorrhea and pregnancy, indicating amenorrhea at the ovarian level. No blood drop test was negative, indicating uterine amenorrhea.
3. Gonadotropin test: The purpose is to detect the responsiveness of the ovary to gonadotropin to identify the ovarian and pituitary. HMG 150 U / d intramuscular injection 10 ~ 14 d, or purified vesicle hormone (PFSH) 75 U / d, intramuscular injection 10 ~ 14 d, to observe the development of the bubble and hormone changes. Follicular development or ovulation is pituitary amenorrhea, and vice versa is ovarian amenorrhea. Repeat a large number of people who still have no follicular development as ovarian insensitivity syndrome.
4. Gonadotropin-releasing hormone: (GnRH) test pituitary stimulation test, the purpose is to detect the anterior pituitary gland responsiveness to GnRH-RH and LH (luteinizing hormone) two stock preparation and release function to identify hypothalamus and pituitary The normal response to amenorrhea was that the peak of LH release at the 15 min and 2 h after the GnRH at the resting point was 3 to 5 times the baseline value before the test; the normal reaction suggested that the pituitary function was normal, and amenorrhea was caused by hypothalamic metamorphosis. The slow or low level response is pituitary amenorrhea.
5. Chlorophenolamine test: The purpose is to examine the hypothalamic-pituitary-ovarian glaze positive and negative feedback mechanism of the brain juice and functional generation of evil to identify hypothalamic and pituitary amenorrhea.
6. Prolactin test: including: thyroid stimulating hormone releasing hormone (TRH) test, normal women once static registration 100 ~ 400 ug, 15 ~ 30 min prolactin (PRL) 5 to 10 times more than before injection. Pituitary tumors do not increase. In the chlorpromazine test, chlorpromazine was transfused by the recipient to suppress the absorption and conversion of norepinephrine and the function of dopamine to promote PRL secretion. In normal women, 20~50mg after intramuscular injection of 60~90min blood prolactin, 1~2 times higher than before injection, lasted 3h, no increase in pituitary tumors. In the bromocriptine test, the drug is a dopamine receptor agonist that strongly inhibits PRL synthesis and release. Normal women take 2.5-5mg orally, and PRL decreases 0.50 for 2~4 hours for 20~30h. Functional hyperprolactinemia (HPRL) T prolactin adenoma decreased significantly.
Fourth, equipment inspection:
(A) chest X-ray examination: to determine the presence or absence of pulmonary tuberculosis.
(B) basal body temperature measurement: basal body temperature curve of ovulation menstrual cycle is biphasic; basal body temperature curve of no ovulation menstrual cycle due to the absence of progesterone, it is a single-phase type. Therefore, it is widely used to estimate the presence or absence of ovulation, when to ovulate, and the development of the corpus luteum after ovulation.
(3) Medical imaging examination: including B/C type ultrasound, CT, MRI, hysterosalpingography, posterior peritoneal angiography, and ventricle and cerebral angiography.
(4) Endoscopy: including edema, hysteroscopy and laparoscopy.
(5) Exploratory laparotomy and gonadal biopsy.
Diagnosis
Differential diagnosis
It should be differentiated from the following symptoms:
1. Physiological amenorrhea: Physiological amenorrhea is a normal phenomenon.
2. Sports amenorrhea: Light female athletes, amenorrhea that occurs during sports competitions or intense training, is called "sports amenorrhea." Some young women may also have amenorrhea during their travels or intense work and study. The pathogenesis is similar to this disease, and can also be treated with reference to exercise amenorrhea. The disease is often associated with excessive mental stress, leading to endocrine dysfunction. Chinese medicine believes that due to excessive mental stress, the movement of air-conditioners is reversed, and the dysfunction of the rushing function is caused by the bloody sea.
3. Pituitary amenorrhea: pituitary amenorrhea: amenorrhea caused by pituitary tumors may be accompanied by headache, blurred vision, or lactation; amenorrhea in the anterior pituitary, occurs in postpartum hemorrhage, manifested as loss of libido, genital atrophy, fatigue Fear of cold, hair loss.
4. Uterine amenorrhea: The endometrium is periodically changed by the stimulation of sex hormones secreted by the ovaries. When the endometrium is peeled off, there is a menstrual cramp. Therefore, in the congenital absence of uterus or uterus dysplasia, endometrial damage Or hysterectomy cases, even if the ovarian function is sound, the secretion of sex hormones is normal, there is no menstrual cramps, the cause of this amenorrhea is in the uterus, it is also called uterine amenorrhea.
