Chapter XIII., page 199), does not ordinarily have amenorrhea as a symptom, although rudimentary uterus, when associated with atresia of the vagina, generally does. Arrests of growth, on the other hand, — infantile uterus and congenital atrophy of the uterus, — are commonly attended by amenorrhea. Infantile uterus is a relatively common condition. The uterus is narrow in proportion to its length, has a long cervix and a short body, and is situated well back and high in the pelvis at the end of a long vagina. The cervix is conical and anteflexed, and the os a 'pin-hole os.' The patient's figure, breasts, hair, and voice are generally of the feminine type. Congenital atrophy of the uterus is a rare condition. Here all the dimensions of the uterus are reduced while the normal proportions are retained. The condition has been found in dwarfs and cretins, and in early tuberculosis and chlorosis. It is supposed that in these cases the uterus attained a proper growth to the virgin type, and that atrophy followed. Both of these conditions are generally associated with anomalies of the ovaries. (See Chapter XVII., p. 285.) Congenital absence of both ovaries is extremely rare. It is of course accompanied by absolute amenorrhea. Absence of one ovary does not affect menstruation. Faulty growth of the ovaries accompanies both infantile uterus and rudimentary uterus. The ovaries are small and amenorrhea may exist. (b) Atresia of the Hymen, or of the Vagina. — Cryptomenorrhea may be caused by imperforate hymen (see Chapter XXI., page 396), or by the different varieties of atresia of the vagina (see Chapter XX., pages 357, 359). In these cases the ovaries are functionally active. Menstrual molimina are present and may be attended by severe cramp pains, and there may be vicarious menstruation from the nose or other mucous-membrane-lined cavities. The menstrual fluid collects behind the obstruction, which may be situated anywhere from the hymen to the internal os, though it is usually in the vagina, and by distending first the vagina, then the uterus, and finally the tubes, causes the conditions known as hematocolpos, hematometra, and hematosalpinx, respectively. <Callout type="warning" title="Warning">Always consider pregnancy when evaluating amenorrhea.</Callout> SECONDARY AMENORRHEA 141 The patient, who has passed the usual time for puberty, presents a normal figure and has normal feminine breasts, hair, and voice. She complains of absence of menstruation and suffers with menstrual molimina— generally severe cramps in the lower abdomen. <Callout type="tip" title="Tip">Prolonged lactation may lead to amenorrhea due to ovarian atrophy.</Callout> 2. Secondary Amenorrhea. — The following causes besides the menopause may be enumerated as accounting for the cessation of menstruation after it has been established: — (a) pregnancy and lactation, (b) atrophy of the ovaries, (c) constitutional diseases. (d) exhaustion and shock, and (e) retention of menses from acquired atresia of the genital canal. Cessation of menstruation may be temporary or permanent; if the latter, it constitutes the menopause. <Callout type="important" title="Important">Always investigate for systemic disorders before concluding amenorrhea is due to local causes.</Callout> (a) Pregnancy and Lactation. — Pregnancy must be considered the chief cause of amenorrhea and the physician will do well to bear this constantly in mind, even in the cases where the probability of its being present seems to be small. It is to be remembered that menstruation may occasionally occur during pregnancy (see Chapter XXII., page 419). The menses are usually absent during lactation, though not always. Prolonged lactation may induce lactation atrophy of the ovaries with consequent amenorrhea. <Callout type="risk" title="Risk">Retained menstruation from imperforate hymen or atresia can lead to serious harm if not treated.</Callout> (b) Atrophy of the Ovaries. — Not much is known about the conditions which cause atrophy of the ovaries. When atrophy has taken place the oophoron of the ovary, the egg-bearing zone, is smaller and harder than normal, and becomes transformed into a layer of dense fibrous tissue. Ovarian atrophy has been reported in women who have nursed their children a very long time, and also in the following diseases: — the exanthemata, myxedema, marked anemia, and diabetes. We are justified in supposing that cessation of function of the ovaries is the direct cause of amenorrhea in the (c) Constitutional Diseases. — Whether demonstrable degenerative tissue changes occur ordinarily when amenorrhea is present we do not know. There is no doubt that the ovaries show a decrease in size under such conditions. Suddenly acquired obesity is often attended by amenorrhea, so also are the early stages of pulmonary phthisis. In the former case it is apparently due to anemia and over-nutrition, and in the latter to anemia and malnutrition. Other instances of the latter cause are: tuberculosis of the kidney, diabetes, chronic nephritis, malaria, chronic mercury, lead, or alcohol poisoning, leukemia, and the morphine habit. If amenorrhea is not directly dependent on the blood state it is related to the condition of the nervous system. (d) Mental overwork in schoolgirls is sometimes responsible for the absence of the menstrual flow. Sudden grief, worry, or fear, or grave hysteria, melancholia, or some of the other psychoses, are often attended by amenorrhea. <Callout type="beginner" title="Beginner">Amenorrhea can be caused by sudden emotional stress.</Callout> (e) Amenorrhea from retained menstruation due to atresia of the genital canal is comparatively rare. Necrosis of the vagina or cervix following prolonged and difficult labors, the wearing of neglected pessaries, or injury of the vagina from caustics, occasionally cause cicatricial stenosis to the extent that the secretions of the uterus are dammed up. In this event the absence of menstruation will be attended by crampy pains and menstrual molimina. If a girl does not menstruate after she has passed her sixteenth year, the physician should inquire into the state of her general health, making whatever physical examination is necessary to arrive at a diagnosis of systemic disorder. The blood should be examined both as regards the number of red corpuscles and the percentage of hemoglobin. Failing to find any constitutional cause for the amenorrhea, a local examination should be made, and except in the rare cases of phlegmatic girls of good sense, with the aid of an anesthetic. Should the patient experience menstrual molimina without a flow, local examination should be made without a previous inquiry into the constitutional state. Neglect to investigate has resulted in serious harm in the cases of retained menstruation from imperforate hymen or atresia, through dilatation of the uterus and tubes with rupture of the latter into the abdominal cavity. In women who have been exposed to sexual intercourse, pregnancy should always be in the physician's mind as a probable cause of amenorrhea, and after the fortieth year the possibility of the beginning of the menopause should be considered. In every case of amenorrhea the general physical condition of the patient should first engage the physician's attention, — the nervous system and the blood state being thoroughly investigated.
Key Takeaways
- Consider pregnancy as a primary cause of amenorrhea.
- Investigate for systemic disorders before concluding local causes.
- Prolonged lactation can lead to ovarian atrophy and amenorrhea.
Practical Tips
- Always perform a thorough blood test when evaluating amenorrhea, including checking hemoglobin levels.
- Use anesthetic if necessary during examinations of patients experiencing menstrual molimina without flow.
- Keep in mind that sudden emotional stress can cause amenorrhea in schoolgirls and other young women.
Warnings & Risks
- Retained menstruation from imperforate hymen or atresia can lead to serious harm if not treated promptly.
- Failure to investigate the constitutional state before performing a local examination can result in severe complications.
- Prolonged lactation may induce ovarian atrophy and amenorrhea, which should be considered during evaluations.
Modern Application
Understanding amenorrhea and its causes is crucial for modern survival preparedness, especially in emergency situations where medical resources are limited. While the specific conditions like congenital absence of ovaries or imperforate hymen may not be common today, the principles of thorough triage and systemic evaluation remain essential. Modern techniques have improved diagnostics but the importance of considering pregnancy as a primary cause has been preserved.
Frequently Asked Questions
Q: What are some causes of secondary amenorrhea mentioned in this chapter?
Secondary amenorrhea can be caused by factors such as pregnancy, atrophy of the ovaries, constitutional diseases (like tuberculosis or diabetes), exhaustion and shock, and retention of menses from acquired atresia of the genital canal.
Q: How does prolonged lactation affect a woman's reproductive health according to this chapter?
Prolonged lactation can lead to ovarian atrophy with consequent amenorrhea. This is due to the long-term nursing causing changes in the ovaries that reduce their function.
Q: What should be done if a patient does not menstruate after passing her sixteenth year?
The physician should inquire into the state of the patient's general health, make necessary physical examinations, and consider systemic disorders as potential causes for amenorrhea.