Amenorrhea

Overview

Abnormal absence or suppression of menstruation Primary amenorrhea: No menses by age 15 in the presence of normal growth and secondary sexual characteristics. Secondary amenorrhea: Cessation of menses for more than three cycles or 6 months in women who have had menses previously

Nursing Considerations-Nursing Diagnoses

Anxiety Deficient fluid volume Delayed growth and development Disturbed body image Imbalanced nutrition: Less than body requirements Risk for situational low self-esteem

Treatment-General

Based on cause

Overview-Causes

Chromosomal abnormalities Hypothalamic hypogonadism Imperforate hymen Agenesis of the uterus and upper two-thirds of the vagina Turner syndrome Constitutional delay

Overview-Primary Amenorrhea

Chromosomal abnormalities Hypothalamic hypogonadism Imperforate hymen Agenesis of the uterus and upper two-thirds of the vagina Turner syndrome Constitutional delay

Assessment-Physical Findings

Dependent on cause of amenorrhea: may include hirsutism, acne, abdominal mass, signs of malnutrition, and galactorrhea Evidence of congenital anomalies

Overview-Complications

Endometrial adenocarcinoma Estrogen deficiency syndrome Infertility Osteoporosis

Assessment-History

Failure to menstruate in a woman age 15 Absence of secondary sex characteristics Absence of menstruation for three cycles in a previously established menstrual pattern Change in menstrual pattern Dependent on cause of amenorrhea: May include headaches, hot flashes, nausea, weight gain or loss, emotional upset, trauma, extreme exercise, prolonged use of hormonal contraceptives

Nursing Considerations-Associated Nursing Procedures

Intake and output assessment Nutritional screening Oral drug administration Transvaginal ultrasound Vaginal examination Venipuncture Weight measurement

Treatment-Activity

Moderate exercise Reduction of activity level by 25% to 50% if overtraining is suspected

Diagnostic Test Results-Other

Pelvic examination reveals anatomic abnormalities.

Overview-Secondary Amenorrhea

Pregnancy (most common cause) Corpus luteal cyst Breast-feeding Suppression of the hypothalamic-pituitary axis Pituitary gland disease Uncontrolled endocrine disorders, such as diabetes, hypothyroidism, and hyperthyroidism Polycystic ovary syndrome Chemotherapy Pelvic irradiation Endometrial ablation Intrauterine adhesions Drug therapy with systemic steroids, danazol, antipsychotics, oral contraceptives, or Depo-Provera Premature ovarian failure Female athleticism (triad of amenorrhea, osteoporosis, and disordered eating) Weight loss/anorexia

Diagnostic Test Results-Laboratory

Pregnancy test result is positive (when pregnancy is the cause). Pituitary gonadotropin levels may be elevated or low. Serum thyroid levels are abnormal (if thyroid disease is involved). Serum progesterone levels are abnormal. Serum androgen levels are abnormal. Urinary 17-ketosteroid levels are elevated, with excessive androgen secretions. Plasma follicle-stimulating hormone (FSH) level of 40 mIU/ml (depending on the laboratory) suggests ovarian insufficiency). FSH levels are normal or low (possible hypothalamic or pituitary abnormality, depending on the clinical situation).

Overview-Incidence

Primary amenorrhea occurs in less than 1% of women. Secondary amenorrhea (lasting for 3 months) occurs in approximately 5% to 7% of menstruating women yearly.

Treatment-Medications

Progesterone replacement with medroxyprogesterone (Provera) Estrogen replacement with conjugated estrogen (Premarin), estradiol (Estrace) Oral contraceptive agents Calcium supplement (if cause is hypoestrogenism) Clomiphene citrate (may induce ovulation in women with amenorrhea caused by gonadotropin deficiency, polycystic ovarian disease, or excessive weight loss or gain) FSH and human menopausal gonadotropins for women with pituitary disease Metformin (Glucophage) (if cause is insulin resistance caused by polycystic ovary syndrome) Bromocriptine mesylate (if cause is hyperprolactinemia)

Nursing Considerations-Nursing Interventions

Provide reassurance and emotional support. Encourage the patient to verbalize concerns and questions. Answer questions honestly; assist with positive coping strategies. Give prescribed drugs, keeping in mind that hormone replacement therapy is typically used as a short-term treatment. Assist patient with scheduling activities and ways to avoid over-exercise. Encourage a well-balanced diet that supplies the patient with adequate calories and protein. Enlist the aid of a dietician to assist with meal planning and food choices.

Patient Teaching-Discharge Planning

Refer the patient for psychological counseling, if appropriate. Refer the patient to local community support groups for infertility or pregnancy, as appropriate.

Treatment-Surgery

Removal of tumor or obstruction and lysis of adhesions Hymenectomy if the cause is an imperforate hymen

Nursing Considerations-Monitoring

Signs and symptoms Intake and output Laboratory test results Emotional status and coping Signs and symptoms of possible thrombosis

Overview-Secondary Amenorrhea

The endometrium is sufficiently scarred and no functional endometrium exists.

Overview-Pathophysiology

The hypothalamic-pituitary-ovarian axis is dysfunctional due to a genetic or anatomic abnormality. Anatomic defects of the central nervous system cause the ovary not to receive the hormonal signals that normally initiate the development of secondary sex characteristics and the beginning of menstruation.

Overview-Primary Amenorrhea

The hypothalamic-pituitary-ovarian axis is dysfunctional due to a genetic or anatomic abnormality. Anatomic defects of the central nervous system cause the ovary not to receive the hormonal signals that normally initiate the development of secondary sex characteristics and the beginning of menstruation.

Diagnostic Test Results-Diagnostic Procedures

The progesterone challenge test indicates chronic anovulation if withdrawal bleeding occurs. Cervical mucus shows ferning on microscopic examination (an estrogen effect). Vaginal cytologic examination rules out carcinoma. Endometrial biopsy rules out endometrial hyperplasia or carcinoma.

Treatment-Diet

Well-balanced diet as tolerated Intake based on correction of underweight or overweight status

Diagnostic Test Results-Imaging

X-rays identify ovarian, adrenal, and pituitary tumors. Ultrasonography may show congenital abnormalities, cysts, and the absence or presence of a uterus.

Patient Teaching-General

disorder, diagnosis, and treatment, including prescribed medications medication regimen, including drug name(s), dosage(s), frequency of administration, and possible adverse effects underlying cause of the disorder and expected duration, whether temporary or permanent method for keeping an accurate record of menstrual cycles to aid in early detection of recurrent amenorrhea importance of follow-up appointments signs and symptoms of possible thrombosis related to hormone therapy and the need to notify a practitioner if any occur use of hormone replacement therapy for approximately 6 months, with discontinuation to assess spontaneous resumption of menses effect of condition on fertility and long-term consequences of not treating amenorrhea, such as osteoporosis and vaginal dryness contraceptive measures (because fertility returns before menses) available support if there is a reduction in or loss of fertility.

Nursing Considerations-Expected Outcomes

verbalize feelings of anxiety and fear maintain adequate fluid balance express understanding of norms for growth and development verbalize feelings about changed body image consume required caloric intake voice feelings related to self-esteem.