Amenorrhea

AMENORRHEA (from Greek a - negative particle, men-month and rheo-to flow), absence of menstruation. A. is a physiological phenomenon before the onset of sexual maturity, during the climacteric, during pregnancy, after childbirth during breastfeeding (not always). A. occurs more frequently in multiparous women, after difficult childbirth complicated by significant blood loss, infection. Depending on pathological causes, A. occurs with congenital absence of the uterus, with its underdevelopment, after hysterectomy, total and supravaginal amputation, and after removal or irradiation of the ovaries. Absence of menstruation can also be observed after desquamative metritis (metritis dissecans), after severe oophoritis, in tuberculosis of the genital organs, in ovarian neoplasms, although it should be noted that for their functioning, the presence of a very small part of the ovarian parenchyma is sufficient. Temporary, and sometimes permanent, A. is observed after vigorous curettage of the uterine cavity, especially of a pregnant uterus, after cauterization of the uterine mucosa (repeated instillation of iodine tincture into the uterine cavity, coating with a strong solution of zinc chloride, vaporization, etc.). Menstrual discharge is absent in atresias of the hymen, vagina, and cervical canal, when blood, finding no outlet, accumulates in the vagina or uterine cavity. The origin of A. is often also closely associated with ovarian insufficiency in various diseases when the menstrual function is lost. Therefore, A. occurs: 1) after severe infectious diseases (typhoid, cholera, malaria, severe form of joint rheumatism, croupous pneumonia, sepsis); in some such cases, A. is connected not only with weakening of the entire body but also with diffuse oophoritis and subsequent atrophy of the ovarian parenchyma; 2) in chronic tuberculosis of the lungs, bones, kidneys; examination of these organs is necessary in young women with amenorrhea; 3) in chronic poisonings (lead, phosphorus, morphine, cocaine, nicotine, alcoholism); 4) in blood diseases (severe form of secondary anemia, progressive pernicious anemia, etc.); 5) in chronic purulent processes; 6) in metabolic disorders - diabetes, starvation, etc.; 7) in severe kidney diseases, liver diseases, sometimes in decompensated heart defects; 8) after prolonged breastfeeding, when, apparently, impulses coming from the mammary gland and weakening of the entire body act suppressively on the ovary; 9) with excessive use of sun baths, sea bathing; 10) with dysfunction of the endocrine glands: hyper- and hypothyroidism, acromegaly, pituitary obesity (dystrophia adiposo-genitalis); 11) in early dementia (dementia praecox), epilepsy, when along with this there is ovarian inadequacy. The onset of A. is possible under the influence of mental shocks (fright, grief, fear of pregnancy) or with an excessive desire to have children ('false pregnancy'). The significance of nervous shocks is apparently associated with improper distribution of blood (vasomotor disorders, since menstrual discharge sometimes stops after cooling the feet and cold baths). It has also been established that strong nervous and mental shocks lead to an increase in adrenaline content in the blood (Cannon), which can have a braking effect on the ovary. In such cases, amenorrhea is called 'functional'. This is often noted in women with various constitutional deviations that allow for the presence of insufficiency and easy vulnerability of the ovary. Some cases of A., classified under the rubric of functional A., arise on the basis of general weakening of the body; for example, A. in peasant women during summer work, in students during exams, etc. The combination of causes is especially clear in A. of 'wartime', in which apparently not only lack of food and heavy labor but also psychological trauma play a role. It is not always possible to accurately establish the cause of A. For example, the existence of A. in urinary fistulas is poorly explainable. In some cases - with stagnant phenomena in the pelvis - A. is eliminated by bloodletting (scarification of the cervix, leeches to the coccyx), which suggests spastic contraction of the uterine muscles, the possibility of decreased ovarian function on the basis, probably, of chemically altered pelvic blood filling. Changes in the genital organs in A. vary. As an expression of a significant decrease in ovarian function, only primordial follicles are found in it; in cases where ovarian function is less impaired, a picture of incomplete follicle development with their partial atresia is observed, which microscopically is expressed in small-cystic degeneration of the ovary; at the same time, the corpus luteum is rarely found. Depending on the degree of decrease in ovarian function, objective data also differ from other genital organs. In some cases, the uterus is atrophic, the connective tissue surrounding it is somewhat shrunken. With a slight decrease in ovarian function, the uterus almost retains its usual size and position. In other cases, the tone of the uterus is reduced, and it is in a retroflexed position, which changes to an anteverted position with the cessation of A. The state of the endometrium also varies; it corresponds to either the climacteric or the resting period, in some cases there are indications of cyclic changes. The pregnancy observed in some cases of A. occurs either with the restoration of ovarian function or with relatively mild changes in it and in the uterine mucosa; it is possible that in such cases, sexual intercourse causes ovulation. In connection with the nature and degree of changes in the genital organs and ovary is the fact that A. in some cases is replaced by menstruation with a small amount of blood (hypomenorrhea) or menstrual discharge, in addition, appears after long intervals (oligomenorrhea). In such cases, it is not excluded that changes in the ovary can occur at a slowed pace, similar to the 'fluctuating life' in plants or animals during winter hibernation. From this point of view, A. in a woman of the far north during the polar night can be understood. The possible, though incomplete, cyclic changes in the ovary and uterine mucosa in A. confirm to a certain extent the hypothesis that menstruation, being the result of changes not only in pelvic organs but in the entire body, can be absent or scanty in cases when the body cannot produce to the proper degree that excess plastic material which usually accumulates during the intermenstrual period and is then expelled during menstruation. Symptoms are mostly absent where A. is associated with weakening of the entire body. In A. after removal of the ovaries, their irradiation, and in A. depending on various origins of primary ovarian insufficiency, symptoms characteristic of the climacteric period are usually observed. In some cases, they can also be observed in A. after removal of the uterus or too vigorous curettage of its cavity. In the latter case, sometimes at the time of menstruation, pains of considerable intensity appear in the lower abdomen, a feeling of heaviness and pressure, which usually disappear after the appearance of menstrual discharge. In diagnosis, pregnancy must first be excluded, and then the cause of amenorrhea established. It is necessary to carefully examine the entire body. Often, however, the main cause remains unclear. Treatment. In some cases, amenorrhea as such does not require special treatment, and, after eliminating the main cause, the menstrual function is restored. In long-lasting A., when atrophic changes occur, local treatment is necessary, which, however, does not always lead to a favorable result. Very often, depending on the cause of A., in its treatment it is necessary to pay the most serious attention to improving the general condition of the body, for which good nutrition, being in the fresh air, light non-tiring sports, various preparations of iron, arsenic, etc., are indicated. Local therapy consists in the cautious use of heat in the form of hot douches, hot-water bottles, mud cakes, diathermy. In some cases, congestive hyperemia of the cervix, gynecological massage, repeated probing of the uterine cavity, curettage of the uterus, electrification with galvanic or constant current are successfully applied. It is believed that any intrauterine therapy has a stimulating effect on the ovary. Doubtful success is given by remedies taken internally with the aim of causing hyperemia in the pelvic cavity; these include aloe, salipyrin, potassium permanganate in pills, api-ol, yohimbine, evmenol, etc. Organotherapeutic preparations are appropriate - ovarin, pituitary gland extract, hypophysin in cases of dystrophia adiposo-genitalis. Zondek experimentally proved that an extract from the anterior pituitary gland stimulates the ovary. According to observations by Sieppel, favorable results are achieved by transplantation of the ovary.

The use of small doses of X-rays is also suggested for the irritation and stimulation of the ovarian parenchyma. However, great caution is necessary in this case, as precise dosing is difficult and damage to the ovary from large doses is possible. It cannot be ruled out that the active principle in this method is, in essence, protein therapy, since under the influence of X-rays, tissue damage and the absorption of their breakdown products occur. Treatment of A. with parenterally administered protein TE1K2K6 was used, but with doubtful success; there is reason to believe that large doses and prolonged use of protein therapy can lead to a decrease in ovarian function.