Amenorrhea

Amenorrhea-lack of menstruation for 6 months or more. Distinguish between true and false amenorrhea. With true amenorrhea, there are no cyclic changes in the ovaries, endometrium and throughout the body. True physiological amenorrhea is observed in childhood, during pregnancy and lactation, during menopause. Pathological amenorrhea can be primary (menstruation has never been) and secondary (cessation of menstruation). Primary amenorrhea often occurs due to genetically determined pathology (gonadal dysgenesis) due to delayed sexual development (severe infectious diseases, intoxication). Secondary amenorrhea is observed in general infectious and somatic diseases (tuberculosis, rheumatism, typhus, heart disease, liver disease, etc.), severe intoxication (lead poisoning, mercury, alcoholism), nutritional disorders (malnutrition), neuropsychiatric disorders and hormonal Disorders (damage to the hypothalamus, pituitary, ovaries, adrenals, thyroid gland). With false amenorrhea, there are cyclic changes, but menstrual blood does not appear outward due to obstructions in the cervix, vagina, hymen.

Diagnosis presents significant difficulties. The diagnosis is based on data from a detailed history, general examination of the patient, gynecological examination, functional diagnostic tests (rectal temperature, cytology of the vaginal smear, pupil symptom), endometrial biopsy (diagnostic scraping), special research methods (EEG, study of color fields of vision, radiography (In the blood and urine of gonadotropins, zestrogens, gestagens, urinary concentrations of 17-ketosteroids, oxycorticosteroids, etc.), genetic methods (sex chromatin, karyotin). It is necessary to examine patients in a specialized gynecological hospital.

The leading role in the diagnosis of ovarian function disorders (one of the main causes of amenorrhea) belongs to tests of functional diagnostics. Basal (rectal) temperature is one of the most accurate tests for ovulation. In a normal (two-phase) cycle, the basal temperature during the first half of the cycle is below 37 g. C. Immediately after ovulation, the basal temperature rises by 0.4-0.6 g. C, and she remains at this level until the next menstruation. In the anovulatory cycle (often with various forms of amenorrhea), the basal temperature remains menophasic throughout the study period. Basal temperature is measured in the rectum every morning (before emptying the intestine and bladder) for 10 minutes. In parallel, the temperature in the axillary region is determined, with an increase in which the basal temperature test loses its diagnostic value.

Cytological examination of the vaginal smear gives an idea. Pb of estrogen saturation of the organism (hypoestrogenemia is observed in many forms of amenorrhea). Test smears are taken with a special pear or spatula from the posterior vaginal fornix (carefully!), Applied to a slide and stained with conventional dyes. At microscopy, count the number of different cells of the vaginal epithelium (keratinizing, intermediate, parabasal, basal) and calculate the karyopicnotic index (KPI). KPI indicators reflect the estrogen saturation of the body. In the normal menstrual cycle, CPI in the first phase of the cycle ranges from 30 to 40%, at the time of ovulation it is 50-60% and then decreases to 20-30%. In amenorrhea, CRI is usually low (5-10%), with a large number of parabasal and basal cells appearing in the smear, indicating an atrophic process in the vaginal epithelium. With a normal menstrual cycle from 5-6 to 20, an increase in the diameter of the external uterine pharynx, filled with clear mucus; When illuminated, the expanded uterine pharynx, filled with mucus, has some similarity with the pupil (pupil symptom). In the anovulatory cycles (often with amenorrhea), the pharynx opens slightly, and the amount of mucus is not enough (the pupil symptom is negative).

Treatment is aimed at eliminating the causes that caused the disease. Full nutrition, normalization of the work and rest regime, elimination of stressful moments, physical education, effective treatment of common infectious and somatic diseases, elimination of toxic compounds that have entered the body usually normalize the menstrual cycle without hormone therapy. In amenorrhea associated with hypofunction of the pituitary gland and ovaries, hormone therapy is used: estrogens in combination with progesterone (from 1 to 14 days of 5000-10 000 ED estrogen-folliculin, synestrol, estradiol propionate, etc., then during 6- 8 days of progesterone 10 mg per day). Effective action of combined estrogen-progestogen drugs (bisecurin 1 tablet per day) for 21 days. Treatment is based on the "phenomenon of recoil" and stimulation of the hypothalamic-pituitary system after its temporary blockade by combined estrogen-progestational agents. Cyclic hormone therapy does not always immediately lead to a menstrual reaction (rejection of the endometrium in response to the cessation of hormone administration), so such treatment should be repeated.

With primary amenorrhea and pronounced infantilism (conical neck, small uterus size, low estrogen saturation of the body), treatment begins with the administration of estrogens for several months under the control of functional tests.

Under the influence of these hormones, sexual organs and secondary sexual characters develop. For all amenorrhea of ​​the hypothalamic-pituitary genesis, preparations showing a direct effect on ovulation (gonadotropins, clostilbehyde) are shown. Initially, a pergonal is prescribed every other day (8-10 injections), then choriogonin at 3000 ED every other day for 6 days. Treatment with clostilbehyde begins 5-6 days after diagnostic curettage, inject 50-100 mg of the drug daily under the control of functional diagnostic tests. Increase in basal temperature indicates ovulation. In amenorrhea, associated with hyperproduction of prolactin by the pituitary gland, a parlodel is prescribed. Hormonal treatment is combined with physiotherapeutic procedures (endonasal electrophoresis, galvanic collar, abdominal-sacral diathermy, mud therapy).