AMENORE- What does it mean that menstrual bleeding never starts or is delayed afterwards, how is it managed?
This article has been written with the aim of providing descriptive basic information on irregularity of menstrual cycles, non-starting or cessation of menstrual bleeding, and summarizing the associated clinical pictures as easily and understandably as possible. The reader’s information here, www.drkutaybiberoglu.com, doctorsite / facebook / instagram / youtube Biberoglu links, which I wrote earlier, “14-year-old breast development has not started, menstruation is an adolescent girl. February 23, 2020”, “16-year-old girl not having first menstrual bleeding now – Primary amenorrhea. February 9, 2020” and “Unusual vaginal bleeding in women of reproductive age – May 31, 2021”.
Physiology of menstrual cycles – basic information
The functions of organs and tissues in the body somehow require the harmonious operation and control of different centers in the brain (Figure 1).
Menstrual bleeding every month is also an indication that the upper centers, glands that secrete hormones, ovaries containing egg cells, in short, reproductive hormones, internal and external female sexual organs work in harmony with each other. There are systematic menstrual cycles in healthy women (Figure 2).
However, menstrual irregularities, especially the absence of menstrual bleeding, is an important health problem. Amenorrhea means absence of menstruation in Latin. Primary (primary) amenorrhea, that is, the condition of not starting menstruation at all, is the situation where the first menstruation still does not start even though 15 (at the latest 16) years of age have been completed in a girl or 3 years have passed from the onset of breast development. Secondary (secondary) amenorrhea is the situation where menstrual bleeding is delayed for at least 6 months (even if it is irregular, for at least 3 menstrual cycles) while there are menstrual cycles. Women are amenorrhoeic before puberty, during pregnancy and after menopause, that is, they do not menstruate, and this is completely physiological and normal.
Puberty onset age for girls is 8 years old. Stimulating hormones made in the hypothalamus (GnRH) and pituitary (FSH and LH) in the brain in adolescent girls stimulate the egg cells in the ovaries to secrete estrogen hormone. In 80 percent, rapid lengthening occurs first, followed by pubic hair growth on the breast bud and external genitalia. Sometimes (20 percent) armpit and pubic hair starts before the chest. The hormone estrogen develops the uterus, the lining endometrium, and the breasts. The beginning of the development of the first breast bud shows itself in the middle of 7-12 years. After 2-2.5 years, the first menstruation begins. When the first menstruation begins (13-16 years), breast development is almost complete and the adult breast is fully developed (Figure 3). It may be considered normal for menstrual cycles to be delayed by up to 90 days in the few years following puberty. This deadline may vary according to the history and clinical examination findings. Obesity plays a valuable role in both the early first menstrual period and the unsystematic menstrual cycles.
The fact that no breast development has started in a girl at the age of 14 should suggest that there may be a problem in the hormonal connection system between the brain and the ovary or in the development of the ovaries (such as premature ovarian failure) (Figure 4).
On the contrary, the fact that menstruation has not started despite breast development is due to a developmental abnormality in the internal and external sexual organs of the girl (uterus/vagina absence-RHCM syndrome or androgen insensitivity syndrome-testicular feminization-AIS) rather than hormonal. (Figure 5).
The possibility of getting pregnant without having a natural menstrual period or the fact that untreated tuberculosis disease has destroyed the uterine lining, although very prominent, should be kept in mind. These are extreme examples. To avoid confusion, I suggest you forget about these two situations.
The onset of the first menstrual bleeding of adolescents at a late age or the absence of menstrual bleeding also cause systemic health problems. Since there is no estrogen, weakness in the bones and increased risk of fracture should be taken into account at young ages, when the bones are most strengthened. Congenital familial or genetic issues can lead to amenorrhoea (premature ovarian failure, ovarian dysgenesis) resulting in developmental disorders and cardiovascular diseases.
Clinical and laboratory evaluation
During menstrual bleeding, nutritional disorder and the use of certain medications should also be taken into account in the middle of the possible reasons for its cessation. In summary, the disruption of menstrual bleeding is a valuable health issue. The health background of the person and his family should be taken, social life, growth and development curves, the list of drugs used, nutrition, sports, mental health and sexual activity should be examined in detail.
A complete physical examination, vital signs such as blood pressure, pulse, respiration, weight, body mass index over length are the main evaluation indicators. In addition, body hair distribution, acne, skin oily conditions, breasts, clitoris and other external genitalia development should be examined.
Required laboratory and imaging tests after history and examination are critical in confirming or excluding unusual findings and making a definitive diagnosis. In terms of hormonal evaluation, follicle stimulating hormone (FSH), luteinizing hormone (LH), prolactin (PRL), thyroid stimulating hormone (TSH), human chorionic gonadotropin (HCG), which is secreted from the brain in the blood sample and which governs menstrual cycles, thyroid gland secreted from the glands in the body hormones (T3 and T4), estradiol (E2), progesterone (P), androgen hormones in case of unusual hair growth, such as testosterone (T), adrenal hormones dehydroepiandrosterone sulfate (DHEA-S), also cortisol (C), 17-hydroxyprogesterone (17 OHP), anti-mullerian hormone (AMH) reflecting the number of eggs in the ovaries, and finally, karyotype examination showing the chromosome structures may be required in some genetic diseases that may be related to reproduction. Brain magnetic resonance imaging (MRI) and ultrasound examination of pelvic organs are other evaluation systems that can aid in diagnosis. All these diagnostic tests are used to support or exclude possible causes of menstrual bleeding disorders found as a result of clinical evaluation. Without making a clinical evaluation and making a clinical prediction, it is not possible to make a diagnosis based on the test results, and even to determine which tests will be requested. Even if all tens of tests are done, clinical experience is needed to evaluate them. Many times, the history and clinical examination findings are so specific and decisive for diagnosis that no laboratory test is even necessary. As long as physiology is well known and the doctor is experienced. Many times, diagnostic laparoscopy is performed to look for causes of amenorrhea, which is completely wrong and unnecessary.
Story – Background examination
The most valuable stage in the diagnosis of amenorrhea is to learn the present and past history of the patient and their family by questioning them.
1. Primary amenorrhea –
Breast development in adolescence is the sole deciding factor in finding the cause of primary amenorrhea. Breast development occurs under the influence of estrogen hormone. The fact that the first menstrual bleeding still has not started 2 years after the breast development indicates a congenital uterine or vagina developmental disorder. On the other hand, the fact that breast development has not started despite the age of 14 indicates that the estrogen hormone is not secreted, the problem is that the ovaries are not normal from birth or that the hormones that stimulate the ovaries are not secreted from the brain centers. As described, diagnosing a girl presenting with primary amenorrhea is not complicated at all. A good clinical examination and a few hormone measurements in the blood sample give us the definitive diagnosis.
Examination of the external genitalia is key in the investigation of primary amenorrhea. The onset of genital hair growth and breast development follow a certain sequence and are related to another. It is an unexpected development that menstruation does not start despite the development of the breasts (the effect of the female hormone estrogen), the absence of hair in the genital area (male hormone-androgen effect secreted from the adrenal glands) or being very weak. This situation makes the diagnosis of “androgen insensitivity syndrome” or “testicular feminization syndrome”. In fact, the female-looking individual in front of us is genetically male, there are testicles in the abdomen or in the groin, but the secreted male hormone cannot show its effect (insensitivity) and the appearance occurs in the female direction. When viewed from the outside, these individuals are males with a long, female appearance, the vagina and uterus are not formed congenitally. The reason for not starting menses (primary amenorrhea) can be easily understood with a careful examination.
If there is breast development during puberty
a. if sexual activity has started, it is customary that pregnancy should be excluded first
b. Although there is pain in the lower abdomen as if there is menstrual bleeding every month, if the menstruation does not start, there is a congenital developmental defect that prevents the blood from coming out, for example, the hymen is closed (imperforated hymen), there is a curtain in the vagina (vaginal septum) (Figure 6).
c. The absence or thinness of hair in the external genitalia, together with breast development and long length, should suggest the diagnosis of “androgen insensitivity syndrome-AIS”, also known as “testicular feminization-RHCM” (Figure 5).
Adolescence signs/signs such as lengthening, no chest development (Figure 4)
a. The absence of FSH, LH hormones that stimulate the ovaries from the centers in the brain (hypothalamus, pituitary)
b. ovaries are underdeveloped (gonadal agenesis) or abnormally developed (gonadal dysgenesis)
2. Secondary amenorrhea – it is the rule that the possibility of everlasting pregnancy should be excluded with a pregnancy test (preferably by measuring beta hCG in a blood sample).
a. The development of adhesions in the uterine cavity (Ascherman’s syndrome) in case of cessation of menstruation or their obvious decrease after a previous pregnancy termination / curettage process or an operation performed by entering the uterine cavity (myoma removal)
b. Polycystic ovary syndrome, which is accompanied by increased facial and body hair, acne, hair loss and increased male hormone, less likely late-onset congenital adrenal hyperplasia, rarely and very rapidly deepening of the voice, enlargement of the clitoris with tumor in the ovary or adrenal glands.
c. elevation of prolactin hormone in the blood with milky secretion from the breast (hyperprolactinemia)
d. Anorexia nervosa (usually under 40 kg) accompanied by hypothalamic amenorrhea or severe weight loss and weakness (usually under 40 kg) after significant nutritional disorder, physical or mental tension, or during sportive, artistic, social activities that require heavy competition (marathon running, ballet, music, etc.).
e. In case of estrogen deficiency accompanied by hot flashes, night sweats, vaginal dryness, premature ovarian failure (gonadal insufficiency) or early menopause compared to the age of cessation of menstruation
f. major and chronic diseases such as diabetes, kidney failure, inflammatory bowel disease, head trauma etc. after the events
g. After using birth control pill, progestin (3-month injection, intrauterine device, subcutaneous implant), GnRH agonist injection, anti-psychotic, anti-depressant, opiate pain reliever, dopamine antagonist type drug for many years
Physical examination
a. If there is no estrogenic activity on examination, such as breast buds, feminine body lines, and the length is short (less than 152 cm), primary amenorrhea due to congenital maldevelopment of the ovaries (gonadal agenesis or dysplasia)
b. In case of severe weight loss with loss of adipose tissue and muscle in a short time (body mass index below 18.5 – weight in kg/square of height in meters) secondary amenorrhea due to anorexia nervosa or malnutrition (malabsorption)
c . Too much weight (body mass index of 25 and above) and obesity (body mass index of 30 and above) with delayed menstruation, especially excessive hair growth, polycystic ovary syndrome or late-onset congenital adrenal hyperplasia, or ovarian or adrenal hyperplasia in a more severe condition. tumor-induced secondary amenorrhea in glands
d. In case of underactive thyroid gland (hypothyroidism), dry, coarse, thin skin, low pulse rate, slowing of reflexes or, conversely, soft, warm and moist skin in case of overactive thyroid gland (hyperthyroidism), rapid pulse, clear eyes, tremor in hands, reflexes secondary amenorrhea
e. Velvety appearance with intense color on the skin of the neck, armpits, groin, under the breasts, metabolic disease, insulin resistance, secondary amenorrhea caused by type 2 diabetes
f. in case of milky liquid by squeezing from the nipple in the examination, secondary amenorrhea due to hyperprolactinemia
g. If the large enlargement of the clitoris and the appearance of the external genitalia make it difficult for us to understand whether the individual is a girl or a boy, it should be considered that male hormone is secreted more than usual from birth. The issue of intersex is very complex and requires detailed examination and laboratory evaluation. Genetic examination and hormone levels in blood samples give us a definitive diagnosis.
Evaluation of ovarian functions
The most common cause of menstrual irregularities, whether primary or secondary amenorrhea, is ovarian problems. Problems, hyperprolactinemia, abnormal congenital development of the ovaries or ovarian failure with congenital premature depletion of eggs, genetic inherited problems, the body’s perception of the ovaries as foreign tissue, radiation or drugs applied for cancer treatment, each of which can cause amenorrhea.
Estrogen measurement
Estrogen is a hormone that is secreted at different levels in the blood circulation even within a few minutes, so a single blood value can be deceiving. In spite of all the possible wrong interpretation possibilities, values of 40 pg/ml and above indicate that estrogen can be secreted from the existing egg cells in the ovaries, while it is understood that the more values below this average (for example, below 20 pg/ml) the less estrogen can be produced.
Clinical evaluation can help us understand estrogen stability. For example, clear, watery, snot-like vaginal discharge with a delay in menstruation and abundant vaginal discharge should suggest that the estrogen hormone is actually sufficient. The problem here is that although estrogen is made, there is no ovulation. However, we must keep in mind that not every woman will notice this slimy discharge even though it is present.
The most reliable way to understand whether the biological estrogen secretion is sufficient is to give progestin externally to a woman with a delayed period. For example, if a pure progestin such as Tarlusal (medroxyprogesterone acetate) is given one tablet a day in the morning and evening for 7-10 days and menstruation can be started 2-7 days after stopping it, then circulating estrogen production is sufficient. If no bleeding starts and the possibility of pregnancy is excluded, it should be considered that the estrogen hormone is no longer produced, the ovaries are depleted, and the ovaries are bankrupt. This clinical practice is much more reliable than measuring estrogen in the blood. If a spot-like bleeding has started, not the usual menstrual bleeding, it is understood that the blood estrogen levels are low but are not exhausted now.
Ultrasound examination
Endometrium (the covering that lines the uterine cavity, sheds out with menstruation if there is no pregnancy, thickens if there is a pregnancy and is a bed for the baby) stay in 3 lines on vaginal ultrasound (at least 6 mm – how thick) If it is good), it means that estrogen synthesis continues in this woman and menstrual bleeding can be started with the progestin pill to be given externally. This clinical information is also more practical and valuable than measuring estrogen in a blood sample.
Serum follicle stimulating hormone (FSH) and luteinizing hormone (LH)
If there is no estrogen production, in a puberty girl (primary amenorrhea), this will manifest itself with the breasts not developing. In adulthood, in a woman whose menstruation has stopped, bleeding will not start despite the externally given progestin drug. One of the tests that shows why the estrogen hormone is not done is the FSH measurement.
Ovarian function is indirectly measured by measuring the level of FSH secreted from the pituitary gland in a blood sample. Since the level of secretion will change from day to day during the menstrual cycle, it should be measured in the blood sample taken on an empty stomach on the 2nd or 3rd days of the menstrual cycle, which is the lowest. It should be evaluated according to the clinical picture, but if the level is less than 5 U/L, it is concluded that the ovaries are normal and the cause of amenorrhea is the insufficient level of stimulating the ovaries by the centers in the brain (hypothalamus and pituitary), and it is understood that the treatment can be done in an active form by giving the deficient stimulating hormones externally. If the FSH blood level is higher than 20 U/L, the problem is in the ovaries, there is either a congenital developmental abnormality or the eggs are depleted. If the blood cost is in the middle of 5-20 U/L, it is considered normal, where the cause of amenorrhea is determined according to the results of the clinical examination and other hormonal tests.
Another stimulus involved in ovarian function, which is administered by the hypothalamus and pituitary, is luteinizing hormone (LH). While the FSH hormone matures the egg cells, the LH hormone triggers ovulation. Together, these two govern regular menstrual cycles. FSH measurement is sufficient for the diagnosis of amenorrhea, separate measurement of LH is not useful in diagnosis.
In case of menstrual irregularities or when it is desired to test egg reserve, the test required in daily practice is FSH, LH and Estradiol measurements in fasting blood sample on the 2nd or 3rd day of menstruation.
Serum Antimullerian Hormone (AMH)
This hormone, which is secreted from small diameter follicles in the ovaries, is measured in the blood sample as an alternative to FSH in the measurement of egg reserve. It is preferred that it gives safer results than FSH and that it is measured on any day, regardless of the menstrual bleeding day. It can be used to distinguish whether the cause of amenorrhea is the developmental abnormality or depletion of the ovaries and egg cells (values with 1 or lower zero – ng/ml) or whether it is due to other reasons despite the presence of sufficient number of eggs in the ovaries (2 and above ng/ml values). In women with menstrual cycles, low AMH cannot be accepted as a cause of infertility and should not be considered as a sign of early menopause. AMH is a hormone that shows the number of eggs rather than egg quality. Low AMH is especially valuable in women who will undergo IVF treatment, in which a large number of egg cells increase pregnancy success rates. In other words, I would like to emphasize that in women with a low number of eggs, the chance of pregnancy naturally is higher if the cause of infertility is found and treated. In women whose only chance is in vitro fertilization, if AMH values are low, it would be beneficial to proceed to the process without delay.
Serum prolactin (PRL) and thyroid stimulating hormone (TSH)
Two hormones that should be strictly measured in fasting blood samples in cases of menstrual irregularity and amenorrhea are PRL and TSH. One of the most common causes of cessation of menses (secondary amenorrhea) is serum PRL elevation. The higher its level in the blood, the more obvious its negative impact on menstrual cycles and ovulation. Sometimes, although it is high in the blood, it may not cause any complaints or findings in the clinical picture and therefore no treatment is required. Although it causes clinical problems, especially in blood sample at 40 ng/ml and above, it is necessary to make an individual decision for each patient. At very high (100 ng/ml) values, it can be found with microadenoma in the pituitary gland, and even in this case, follow-up and treatment should be done within the framework of clinical monitoring. Although breast milk secretion may accompany the clinical picture, it does not require a different approach in treatment and follow-up.
Both underactivity (hypothyroidism) and overwork (hyperthyroidism) of the thyroid gland can cause amenorrhea. Clinical hypothyroidism (T3 and/or T4 values are low, TSH (mIU/L) values are 2 and above), subclinical hypothyroidism (T3 and T4 levels are normal but TSH (mIU/L) values are 2 and above) serum prolactin (ng / ml) may cause menstrual irregularities. In that case, if the cause of the high PRL is the thyroid gland, the treatment is not PRL suppressive drugs, but treatment with thyroid hormone, which in fact returns the PRL costs to normal.
Serum androgen levels
Polycystic ovary syndrome (PCOS) should definitely be excluded if it is seen together with hair growth, acne, skin oiliness, hair loss, overweight, irregularity in menstrual cycles and amenorrhea. Testosterone (total or free fraction), dehydroepiandrosterone sulfate (DHEA-S), 17-hydroxy-progesterone, and cortisol measurements in fasting blood samples help in the diagnosis. Diagnosis of polycystic ovary syndrome in the presence of excess egg cells through ultrasound imaging of the ovaries is deceptive. In this way, only the presence of excess egg cells can be identified. AMH costs are also high in these cases (5 ng/ml and above).
Genetic evaluation- karyotype determination
In case of abnormal congenital development of the ovaries or premature depletion of eggs, some genetic issues should be evaluated by looking at the karyotype. Special follow-up and treatment is vital in the presence of a missing Y chromosome, the absence of the second X chromosome, or other genetic deviations.
Screening for immune issues – autoimmune screening
The body’s perception of its own organs and tissues as foreign structures and production of adverse bodies called antibodies against them can lead to premature loss of function of the thyroid, adrenal glands, pancreas, and even ovarian tissues. can open. It is the external administration of the hormone that cannot be treated.
Imaging
In the case of amenorrhea, although rarely, the hypothalamus and pituitary glands may need to be examined with magnetic resonance imaging. Radiographic or ultrasonographic imaging systems of the ovaries, uterus, thyroid and adrenal glands may be helpful in diagnosing amenorrhea.
ADMINISTRATION PLAN
1. The occurrence of menstrual bleeding once a month (if the respite from the first day of menstruation in the middle of the first day of the next menstruation is roughly 21 to 35 -38 days in some sources), it is a sign that ovulation is an eternity. In other words, it is the proof that progesterone secretion is also present in addition to estrogen secretion. If it is shorter or longer, it should be considered that the estrogen hormone is secreted alone and progesterone is not synthesized. This is a health issue because estrogen can cause unwanted thickening (hyperplasia, atypia, even cancer) in the uterine lining (and mammary glands) because the progesterone hormone, which counters and balances the negative effects of estrogen, is not produced. It is not possible for women who want to have children to achieve their goals without ovulation, that is, without progesterone. Women who do not intend to become pregnant, and even those who prefer to have a period every 2-3 months rather than every month, should not allow unsystematic menstruation. These delays can be seen frequently during the transition to menopause and may even be considered natural by some, however, the facts reveal that this is an important health problem.
The recommended approach is to use 10 mg progestin per day, in pill form with a 10-day respite, if the menstrual bleeding has not started for 1.5 months (45 days) by keeping the calendar. Thus, it is ensured that the endometrium, which covers the uterus, is discharged with bleeding until 60 days at the latest, when tissue thickening will begin. The waiting period can be extended to 60 or even 90 days, depending on the level of estrogen secretion. When 3 months have passed, bleeding cannot be started with externally given progestin, that’s when the estrogen hormone cannot be produced anymore and menopause has taken place. In this case, the use of progestin is no longer necessary because the tissue-thickening estrogen secretion is depleted. In case of estrogen depletion before 50, which is the natural age of menopause, the management plan will completely change according to the evaluation of the physician.
2. Ovulation problems that occur with menstrual irregularity can be solved in line with the woman’s pregnancy request, but by treating the underlying problem. Ovulation treatment is not discussed here as it is out of our scope.
3. If the ovaries do not develop normally from birth or if the eggs are depleted afterwards, there will be no menstrual bleeding and amenorrhea will develop. Estrogen hormone is necessary for women’s health, apart from reproductive life, for cardiovascular system or bones. In this case, estrogen, which is necessary for the body until the physiological menopause age, should be given externally as a medicine. To mask the negative, tissue-thickening effect of estrogen alone, the progestin slant is vital.
4. If there is breast development in adolescence (there is estrogen production) and menstruation does not start until the age of 16, but if the lower abdominal pain is increasing every month in a systematic form, it means that there is bleeding but cannot come out of the vagina. If the hymen is congenitally closed (imperforated hymen), or there is a tissue curtain in the vagina (transverse vaginal septum), or if the cervix is underdeveloped (cervical atresia), the accumulation of blood that cannot flow out during the examination will form a tender mass and a mass that becomes more painful and growing every month. will be detected. The treatment is very easily, if the defect is removed by surgical intervention and the menstrual bleeding is started in the usual way. If the cessation of regular menstrual bleeding (secondary amenorrhea) or its decrease is following the curettage process for pregnancy termination, or if an infection has occurred in the membrane covering the uterine cavity after miscarriage, it means that adhesions have formed in the uterine cavity (Asherman syndrome). Similarly, a surgical attempt applied to the cervix (LEEP or cervical stenosis after conization) may lead to cessation of menstrual bleeding again. Its treatment is surgical removal of adhesions and cervical canal obstruction. Genital tuberculosis, which cannot be treated because it cannot be diagnosed, can also rarely cause primary or secondary amenorrhoea, depending on the age at which it was passed.
5. In cases where there is breast development in adolescence (there is estrogen production) and menstruation does not begin until the age of 16, if there are no symptoms such as pain and similar symptoms, as if menstrual bleeding will begin, congenital uterus and upper third of the vagina do not form (mullerian duct agenesis- RKHM syndrome) should be considered. Surgical opening of the vaginal cavity will allow normal vaginal sexual interests to begin. In order for the pregnancy to be carried, a uterus transplant must be performed from another woman. Dünya üzerinde başarılı biçimde rahim nakli yapılmış sayılı olaylar mevcuttur.
6. Göğüs ve kadınsı beden çizgileri gelişmiş ancak birinci adeti başlamamış (primer amenore) genç kızlarda “androjen duyarsızlık sendromu-AIS” yahut “testiküler feminizasyon sendromu” tanısı, uterus ve vajinanın gelişmemiş olması, overler yerine testislerin bulunması ve karyotip tahlilinin dişi yapıda (XX) değil, erkek tipinde (XY) olması biçimindedir. Tedavide cerrahi olarak testislerin çıkarılması ve yapay vajina oluşturulması bireyin bayan olarak yaşantısına devam etmesini sağlayacaktır.
7. Ergenlikte göğüs ve bayan beden çizgilerinin gelişmemesi ve adetlerin başlamaması durumunda (primer amenore) yumurtalıkların doğuştan olağan gelişmemiş olması (gonadal agenezi yahut disgenezi) olasılıklardan bir adedidir. Kan örneğinde FSH pahaları yüksek (20 mIU/ml ve üzeri), AMH bedelleri ve estradiol çok düşüktür. Dış ve iç genital organlar olağan gelişmiştir. Olağan vajinal cinsel alakada bulunabilir. Dışardan estrojen ve progestin verilerek beden sınırları büsbütün kadınsı yapılabilir ve adet kanamaları başlatılabilir. Lakin bu bayanların bebek sahibi olmaları fakat öteki bir bayanın yumurta hücrelerinin kullanılması şartıyla gerçekleşebilir. Tüp bebek formunda öteki bayanın yumurtalarıyla laboratuarda gelişen gebelik, kendi uterusuna yerleştirilerek kendisi tarafından doğurulabilir.
8. Ergenlikte göğüs ve bayan beden sınırlarının gelişmemesi ve adetlerin başlamaması durumunda (primer amenore) overlerin doğuştan olağan gelişmiş, lakin beyindeki merkezlerden uyarıcı hormonların yapılmamış olması (hipogonadotropik hipogonadizm) olasılıklardan bir başkasıdır. Kan örneğinde FSH pahaları (5 mIU/ml ve altı) ve estradiol (20 pg/ml) düşük, AMH bedelleri ise olağandır. Dış ve iç genital organlar olağan gelişmiştir. Olağan vajinal cinsel alakada bulunabilir. Dışardan estrojen ve progestin verilerek beden çizgileri büsbütün kadınsı yapılabilir ve adet kanamaları başlatılabilir. Bu bayanlar bebek arzuladıklarında yumurtalıkları uyaran FSH ve LH hormonları dışarıdan verilerek yumurtlatılabilir ve bebek sahibi olabilirler.
Sonuç
Amenore ve adet düzensizliği çok değerli sıhhat sıkıntılarıdır. Nedeni araştırılmadan ve altta yatan sebebi tedavi edilmeden, yalnızca projestin ilaçları ile yahut doğum denetim hapları ile yapay formda adet kanamasının söktürülmesi hakikat bir yaklaşım olmadığı üzere sakıncalı bile olabilir. Bebek sahibi olmak için yumurtlamanın verilen ilaçlarla başlatılması kâfi ve son derece başarılıdır. Yumurtlama ve adet düzensizliği meselelerinde tüp bebek en son baş vurulacak tedavi yaklaşımı olmalıdır.
Bu makalenin yazılma emeli, kesin olarak klinik kıymetlendirme yapılmadan dijital ortamda teşhis koymaya ve tedaviye yardımcı olmak değildir. Amacımız, sorunu olan bayanın kendi bedeni hakkında bilgi sahibi olmasını ve uygulanan teşhis ve tedavi sistemlerini izleyebilmesini sağlamaktır.
Tıbbi tabirlerin Türkçe karşılıkları
Over – yumurtalık
Uterus – rahim
Endometrium – rahimin içini örten zarı
Prematür over yetmezliği – yumurtalıkların erken iflası
Androjen – erkeklik hormonu
Prof. Dr. Kutay Biberoğlu
01.04.2022
Ankara
