Violations of the menstrual cycle can be one of the frequent manifestations of gynecological diseases or their causes. Despite the great adaptive abilities of the female body, in the last decade there has been a steady increase in reproductive disorders.
The variety of nosological forms of menstrual disorders due to its multi-stage regulation. Neurohumoral coordination of the menstrual function occurs as a result of the coordinated work of the cerebral cortex, specific sections of the hypothalamus, the pituitary gland, and their interaction with peripheral endocrine organs, along with a number of extrahypothalamic structures. As a rule, menstrual disorders are associated with changes in the system of regulation of reproductive function or in target organs.
Along with the symptoms that characterize one or another variant of menstrual disorders (amenorrhea, dysfunctional uterine bleeding, algomenorrhea), neuroendocrine syndromes that are most commonly encountered in practice — such as Cushing, Shereshevsky – Turner syndrome, polycystic ovaries, and premenstrual, posthysterectomy syndromes and syndrome after total oophorectomy (postcastration).
Amenorrhea – the absence of menstruation for 6 months or more, is a symptom of many gynecological diseases and syndromes. In addition to amenorrhea, there may be other changes in menstrual function, such as hypomenorrhea, opsymenorrhea and oligomenorrhea – respectively, scanty, short and rare menstruation. Distinguish physiological, pathological, false and iatrogenic amenorrhea.
Physiological amenorrhea – the absence of menstruation until puberty, during pregnancy, lactation and postmenopausal. Pathological amenorrhea is a symptom of gynecological or extragenital diseases; may be primary and secondary. Primary amenorrhea – the absence of the first menstruation after 16 years, secondary – the absence of menstruation for 6 months in previously menstruating women.
False amenorrhea – the absence of blood secretions from the genital tract due to disruption of their outflow due to atresia of the cervical canal or a malformation of the genitals; at the same time cyclic activity of ovaries is not broken.
Iatrogenic amenorrhea occurs after hysterectomy and total ovariectomy. It may also be associated with medication (gonadotropin agonists, anti-estrogen drugs). As a rule, after cessation of treatment, menstruation is restored. It is known that the neurohumoral regulation of the menstrual cycle occurs with the participation of the cerebral cortex, subcortical structures, the pituitary, the ovaries, the uterus and is a single whole. Violation in any link inevitably affects other links in the chain. Amenorrhea of any etiology (of any level of lesion, except for the uterine form) ultimately leads to hypoestrogenism and lack of ovulation. Hydestrogenesis, in turn, is associated with hyperandrogenism, the severity of which depends on the level of the lesion. Such an imbalance of sex hormones determines the mutation (virilism): the characteristic structure of the skeleton, excessive hair growth (hypertrichosis), male hair growth (hirsutism), coarsening of the voice, clitoral hypertrophy, underdevelopment of secondary sexual characteristics.
Depending on the predominant level of damage of one or another link of the neuroendocrine system, amenorrhea of central genesis (hypothalamic-pituitary), ovarian and uterine forms, amenorrhea, caused by adrenal and thyroid pathology, are distinguished. This conditional division is of great importance for the choice of treatment tactics. Damage to each of the levels of regulation of the menstrual cycle and the uterus can be either functional or organic, or the result of congenital abnormalities.
Amenorrhea Central Genesis
Amenorrhea of central genesis includes dysfunctions of both the cerebral cortex and subcortical structures (hypothalamic-pituitary amenorrhea). Violations of the hypothalamic-pituitary system can be functional, organic, and the result of congenital abnormalities. Amenorrhea of central Genesis is more often functional and, as a rule, occurs as a result of exposure to adverse environmental factors.
Disruption mechanisms are implemented through the neurosecretory structures of the brain that regulate the tonic and cyclic secretion of gonadotropins. Under the influence of stress, there is an excessive release of endogenous opioids that reduce the formation of dopamine, as well as a decrease in the formation and release of gonadoliberins, which can lead to amenorrhea. With minor violations, the number of anovulatory cycles increases, and the luteal phase deficiency appears.
The most common occurrence of central forms of amenorrhea is preceded by mental trauma, neuroinfection, intoxication, stress, and complicated pregnancy and childbirth. Amenorrhea is observed in every 3rd patient with schizophrenia and manic-depressive psychosis, especially in the period of exacerbation. Psychological stress and infectious diseases carried in childhood matter. Physical overloads associated with significant emotional-volitional stress can cause amenorrhea with mental, asthenoneurotic, astheno-depressive or asthenoipochondric disorders. Menstruation stops suddenly. Along with amenorrhea, irritability, tearfulness, headache, memory problems, health, sleep disorder are observed. During the war, due to the forced starvation, women became very thin, which led to a violation in the hypothalamic-pituitary area and to the so-called amenorrhea of wartime. This was facilitated by psycho-emotional stress.
Functional disorders of the hypothalamic-pituitary system lead to the development of anorexia nervosa, Shchenko-Cushing’s disease, gigantism, functional hyperprolactinemia. Causes of functional disorders of the hypothalamic-pituitary system:
• chronic psychogenic stress;
• chronic infections (frequent sore throats) and especially neuroinfections;
• endocrine diseases;
• taking drugs that deplete dopamine in the central nervous system (reserpine, opioids,
monoamine oxidase inhibitors) and affecting the secretion and metabolism of dopamine (haloperidol, metoclopramide). Anatomical disorders of the hypothalamic-pituitary structures, leading to Skien syndrome and hyperprolactinemia are as follows:
hormonally active pituitary tumors: prolactinoma, mixed prolactin and ACTH-secreting pituitary adenomas; damage to the pituitary stem as a result of injury or surgery, exposure to radiation; necrosis of the pituitary tissue, thrombosis of the pituitary vessels.
Congenital abnormalities of the hypothalamic-pituitary system can lead to adiposogenital dystrophy. Regardless of the causes of damage to the hypothalamic-pituitary region, there is a violation of the production of hypothalamic GnRH, which leads to a change in the secretion of FSH, LH, ACTH, GHTH, TSH and prolactin. This may disrupt the cyclical nature of their secretion. When the hormone-forming function of the pituitary gland changes, various syndromes occur. Reduced secretion of FSH and LH leads to disruption of follicular development and, consequently, insufficient ovarian production of estrogen. Secondary hypoestrogenism, as a rule, is accompanied by hyperandrogenism, which, in turn, contributes to the emergence of the viril syndrome, moderately expressed in hypothalamic-pituitary disorders.
Since the pituitary gland is also responsible for metabolic processes, with the defeat of the hypothalamic-pituitary region of patients, a characteristic appearance is distinguished: obesity, moon face, fat apron, stretch marks on the abdomen and hips, but excessive thinness with poorly expressed secondary sexual characteristics is also possible. Obesity and heavy weight loss as a result of disorders of the hypothalamic-pituitary area exacerbate the manifestations of hormonal dysfunction.
Amenorrhea in anorexia nervosa results in a sharp decrease in the secretion of glucose nerves. This is often observed with an insistent desire to lose weight and a rapid decrease in body weight by 15% or more. This pathology is common among adolescent girls who exhaust themselves with diet and exercise, and can be the beginning of a mental illness. The absence of menstruation is one of the first signs of the onset of the disease, which leads the girls to the gynecologist. On examination, a sharp decrease in the subcutaneous fatty tissue is noted with a female body type. Secondary sexual characteristics are developed normally. Gynecological examination reveals moderate hypoplasia of the external and internal genital organs. Continuing weight loss can lead to bradycardia, hypotension, hypothermia. Further, irritability, aggressiveness, cachexia with complete loss of appetite and aversion to food appear. The hypoestrogenic condition, along with the lack of nutrition, makes patients susceptible to osteoporosis.
The Itsenko – Cushing syndrome (disease) is characterized by an increased formation of the hypothalamus-corticoliberin. This causes activation of the adrenocorticotropic function of the anterior pituitary gland due to hyperplasia of basophilic cells and, as a result, hypertrophy and adrenal hyperfunction, excessive formation of glucocorticosteroids and androgens. Hypercorticoidism results in such hormonal disorders, which leads to hypokalemic acidosis, increased glyconeogenesis processes, an increase in blood sugar levels, and eventually to steroid diabetes. The disease is observed at any age. In children, Itsenko-Cushing’s disease is accompanied by the virilization of varying severity, in adults, amenorrhea is observed at the onset of the disease, and later signs of virilization appear. Disproportionate obesity is characteristic with the deposition of subcutaneous fat on the face, neck, upper half of the body. In patients, the face is rounded, cyanotic red.
The skin is dry, atrophic, with a marble pattern and areas of pigmentation and acne. On the chest, abdomen, thighs are crimson-red stretch bands. Gigantism also becomes a consequence of hyperplasia of eosinophilic pituitary cells with increased production of somatotropic and lactogenic hormones. With hyperproduction of growth hormone growth is excessively high, relatively proportional or disproportionate. An excessive increase in growth is usually noticed in the prepubertal and pubertal periods over a number of years. Over time, acromegaloid enlargement of facial features may develop. Hypogonadism, primary amenorrhea, or early cessation of menstruation have been noted since the onset of the disease.
Structural changes in the pituitary gland due to massive postpartum or post-abortion bleeding lead to Scien syndrome. At the same time, necrotic changes and intravascular thrombosis in the pituitary gland are detected. Ischemia of the pituitary also contributes to the physiological decrease in the release of ACTH in the postpartum period. Intravascular thrombosis also leads to changes in the liver, kidneys, and brain structures. The severity of the clinical manifestations of Skien syndrome depends on the size and localization of the pituitary gland and, accordingly, its insufficiency of gonadotropic, thyrotropic, adrenocorticotropic functions. The disease is often accompanied by a clinical picture of thyroid hypofunction or vascular dystonia of the hypotonic type (headache, increased fatigue, chilliness). A decrease in the hormonal function of the ovaries is manifested by oligomenorrhea, anovulatory infertility. Symptomatology of the total hypofunction of the pituitary gland is caused by severe insufficiency of gonadotropic, thyrotropic and adrenocorticotropic functions: persistent amenorrhea, hypotrophy of the genitals and mammary glands, baldness, loss of memory, weakness, weakness, slimming.
During the history taking, the connection between the onset of the disease and complicated labor or abortion is found out. The diagnosis can be clarified by reducing the blood levels of gonadotropins, TSH, ACTH, as well as estradiol, cortisol, T3 and T4. Hyperprolactinemia. The occurrence of hypothalamic-pituitary amenorrhea is often accompanied by excessive secretion of prolactin – hyperprolactinemia. Prolactin is the only hormone of the anterior lobe of the pituitary gland, whose secretion is constantly suppressed by the hypothalamus and increases dramatically after the pituitary gland is released from hypothalamic control. Physiological hyperprolactinemia is observed during pregnancy and lactation, in practically healthy women during sleep, after physical exertion, as well as during stress. Hyperprolactinemia is possible due to damage to the intrauterine receptors with frequent scraping of the mucous membrane of the uterus, manual examination of the uterine walls after childbirth.