Tuesday, 9 October 2018

AMENORRHOEA AND INFERTILITY

Amenorrhoea means “without menstruation”. There could be false Amenorrhoea in which menstruation is actually taking place but it is not revealed because the outflow is obstructed at the level of the cervix, vagina or vulva. This is hidden menstruation or CRYPTOMENORRHOEA. Amenorrhoea or True Amenorrhoea is one in which the menstrual function is suppressed from the brain machinery and the explanation may be physiological (acceptable) or pathological (abnormal)

Examples of physiological Amenorrhoea occur:
(1)       Before puberty (prior to Age 10-13 years)
(2)       During pregnancy
(3)       During breast feeding
(4)       After the menopause – when the periods are expected to stop.

PATHOLOGICAL AMENORRHOEA

The significance of pathological Amenorrhoea is in the fact that a woman who does not see a period may not have ovulation 2 weeks prior to the date of expected period i.e. 80% of women would experience periods after ovulation. The remaining 20%, although may have ovulated, will not experience the period due to other reasons beyond the scope of this discussion.
Certainty, there can be no pregnancy if there is no ovulation.

Therefore, the problem of pathological amenorrhoea is of great concern in a woman who desires pregnancy. Amenorrhoea can be primary or secondary. Primary is when a woman has never experienced menstruation while secondary amenorrhoea is when a woman who has previously experienced periods seizes to have one.

Menstruation can be regarded as a final reflection of activities of a system starting with control from the Brain i.e. Hypothalamus and the pituitary, then the ovaries and finally the womb (uterus).

Disturbances or diseases at any of these levels could result in disturbances in menstruation including amenorrhoea.

(A)  DISTURBANCES AT THE LEVEL OF THE HYPOTHALAMUS
This can be caused by
(1) Diseases or injuries
(2) Psychoses or electric convulsion
(3) Emotional upsets and
(4) Stresses.
(5) “False pregnancy” i.e. pseudo Cyesis – a condition in which a woman imagines that she is pregnant and she develops other symptoms of pregnancy such as nausea and vomiting, breast changes, weight increase and abdominal swelling. Pseudo-pregnancy or false-pregnancy results from fear of, or desire for pregnancy. It is mostly seen in women suffering from sterility and in those approaching the menopause who either see their last chance of conception disappearing.
       (6)       Anorexia nervosa – An abnormal desire to lose weight which results in unusual presentations including amenorrhoea
(7)       A condition called polycystic ovaries (P.C.O)
(8)       Drugs: - some drugs act and affect the brain to cause amonorrhoea i.e. the popular oral contraceptive pill sometimes cause this

(B)       DISTURBANCES AT THE LEVEL OF THE PITUITARY
This can be caused by
(1)       Tumor in this organ
(2)       Tissue destruction as in Sheehan’s syndrome, which sometimes occurs with severe blood loss after delivery.

(C)       DISTURBANCES AT THE LEVEL OF THE OVARY
            Examples are:
(1)       When ovaries are mistakenly removed at surgery or are exposed to radiation.
(2)       Turner’s syndrome:- This is an inherited chromosomal problem in which the ovaries are never fully developed or represented by streaks of tissue and therefore contain very few ova.
(3)       Hormone-producing cysts of the ovary. These cysts produce estrogen/progesterone continuously rather than intermittently. This continuous hormone production results in amenorrhoea. Some ovarian tumours producing male hormones will cause amenorrhoea.

(D)      DISTURBANCES AT THE LEVEL OF THE WOMB
This can result from in-born absence of the womb or if the womb has been removed at surgery. Sometimes the womb surface is adversely affected by diseases such as tuberculosis to the extent that no further menstruation occurs.  It can also occur after over-enthusiastic scrapping of the womb inner surface during abortion procedure

(E)       OTHER CAUSES
            One of the other causes is thyroid gland under or especially over-activity. Diabetes mellitus starting both in childhood and adolescence can result in amenorrhoea subsequently.

CUSHING SYNDROME OR THE USE OF SOME STEROID DRUG CAN CAUSE AMENORRHOEA
            General constitutional upset and disease
i.          Sudden (acute) illness chronic diseases. Examples of these are tuberculosis of the lungs
ii.         Nutritional problems i.e. alimentary system absorption
iii.        Starvation.
iv.        Anorexia nervosa has been mentioned above
 v.        Obesity.

Tests
The various causes of amenorrhoea listed above can be investigated by your doctor and medical treatment and advice offered.  Different tests would be required for the various problems and treatment would depend on confirmation of those results and clinical examination in each case.  These various test could range from hormone tests, blood tests for sugar, eye tests, electrolytes and chromosome tests.

Treatment
The treatment of amenorrhoea is largely the treatment of its cause. For example, pelvic tuberculosis requires anti-tuberculos drugs. Diabetes calls for treatment of diabetes mellitus e. t. c.

Anorexia nervosa is particularly difficult to treat successfully. If amenorrhoea persists even after nutrition has been improved, ovulation can be induced with menstruation ensuing, using special hormones called gonadotrophin. General treatment include diet improvement, weight reduction in obesity and the usage of leisures.

In Polycystic ovaries, the use of resection of part of the ovaries used to be very popular form of treatment. Nowadays, there are hormone preparations that are available to treat such problems.

Lastly, with advances in modern scientific methods and research, it is now possible not only to produce regular menstruation in a woman who has no ovaries or ovarian activities but such women would also be made to achieve pregnancy with assisted reproductive technology using donated eggs.

Conclusions
Amenorrhoea, especially the secondary types is not an uncommon condition.  Management should be carefully handled by an experienced gynaecologist who would try and precisely identify the cause and institute appropriate treatment to produce regular periods. If however the primary concern of the patient is infertility, ovulation induction techniques are available to achieve this. In cases of ovarian failure, assisted reproduction using donor eggs are available in some ART centers such as ours.

For more information on fertility treatment, contact the best fertility specialist in Nigeria, Dr. Michael Ogunkoya (+2348033069466). He was trained in the best medical schools in USA, London, Canada, Wales and Hungary. He is the medical director of The Hope Valley Fertility Clinic.
The Hope Valley Fertility Clinic
Plot 31, Block 113, Gbemileke Akinsonwon Street, Opposite Treasure Garden, By Ikate Roundabout, Lekki Phase 1, Lagos-Epe Express Way, Lagos.
+2348033069466