Systemic disorders causing secondary amenorrhoea

Chronic disease may result in menstrual disorders as a consequence of the general disease state, weight loss or by the effect of the disease process on the hypothalamic-pituitary axis. Furthermore, a chronic disease that leads to immobility such as chronic obstructive airways disease, may increase the risk of amenorrhoea associated osteoporosis.

Some diseases affect gonadal function directly. Women with chronic renal failure have a discordantly elevated LH [42], possibly as a consequence of impaired clearance [43]. Prolactin is also elevated in these women, due to failure of the normal inhibition by dopamine. Liver disease affects the level of circulating sex hormone binding globulin, and thus hormone levels, thereby disrupting the normal feedback mechanisms. Metabolism of various hormones including testosterone, are also liver dependent; both menstruation and fertility return after liver transplantation [44].

Endocrine disorders such as thyrotoxicosis and Cush-ing's syndrome are commonly associated with gonadal dysfunction [45]. Autoimmune endocrinopathies may be associated with premature ovarian failure, because of ovarian antibodies. Diabetes mellitus may result in functional hypothalamic-pituitary amenorrhoea [46].

Management of these patients should concentrate on the underlying systemic problem and on preventing complications of oestrogen deficiency. If fertility is required, it is desirable to achieve maximal health and where possible to discontinue teratogenic drugs.

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