Dear Dr Mitchell

I've been seeing a gynaecologist who told me after doing quite a few ultrasounds that my uterus was small. I even went to New York and did ultrasounds there. I don't have a regular period, I have to be taking contraceptives (the last one I was taking was Celetste), but whenever I give the pills a break for a while my period doesn't come. When I'm on the pills, my period comes regularly. I'm married now and I want to know, will I be able to have a child?

NW
Montego Bay

The fact that you do not have a period unless you take the contraceptive pills suggests that you do not ovulate. The small size of your uterus may also suggest a congenital problem which may be associated with abnormal ovaries and hence the absence of the periods. It is quite possible that what you have is premature ovarian failure. This is defined as cessation of ovarian function prior to the age of 40 years. It results in an end or pause in menstruation, the onset of menopausal symptoms and a decline in the production of oestrogen and eggs and subsequent infertility. With premature ovarian failure, up to 50% of women may ovulate once in any given year and 5 - 10% may become pregnant. It may also be associated with an autoimmune thyroid dysfunction.

This is a rare disorder and affects 10% of women by the age of 40 years. The average age of onset is 27 years. Women may experience hot flashes, infertility, absence of the menstrual periods, night sweats, irritability, sleep disturbances, decreased libido, hair coarseness, moodiness and vaginal dryness.

It may also manifest as intermittent ovarian failure with the period being missed for several consecutive months.
The cause of this condition is unknown, but up to 40% may be due to genetic causes. Environmental causes include pelvic surgery, cancer therapy (Chemotherapy and Radiotherapy) and viral infections of the ovary, Anorexia nervosa may also contribute to this.

Premature ovarian failure may go undetected for several years if patients are on the oral contraceptive pills which will usually mask the symptoms. Early indications of premature ovarian failure include menstrual cycles less than 21 days in length, infrequent or light menstrual periods and the absence or cessation of the menstrual period.

There may also be other causes of chronic anovulation such as disorders of the thyroid (Hypothyroidism), high prolactin levels, polycystic ovarian disorder, excessive exercise and weight loss.

You will need to have a detailed history taken, a physical examination and appropriate hormonal evaluation done to investigate your ovarian function. If the problem is due to an endocrine problem such as hypothyroidism, then this can be treated successfully and ovulation will resume. If the hormone evaluation shows that you have premature ovarian failure then the ovaries will not respond to fertility drugs. It is still possible to conceive but you will need to do in-vitro fertilisation (IVF) and obtain an egg from a donor. This will then be fertilised by your husband's sperm and reimplanted into your uterus. If your uterus is abnormally small and not suitable for carrying the fertilised egg, you may opt to use a surrogate to carry the pregnancy to term for you. Surrogacy and egg donation are not yet done in Jamaica but are being considered for the near future at the fertility unit at the University Hospital.

If the diagnosis is actually premature ovarian failure, then the chronic low levels of oestrogen may lead to oesteoporsis and cardio-vascular problems.

You need to consult your gynaecologist who will thoroughly investigate you and advise you about your options for fertility, and if this is not feasible then hormone replacement to counteract the low oestrogen levels is definitely indicated.
The diagnostic evaluation may reveal medical conditions which require treatment. This may include thyroid disease, diabetes mellitus, skin disorders and bleeding disorders.
Alternatives such as adoption should be considered if IVF and surrogacy are not feasible alternatives.

Best Wishes.

Dr Sharmaine Mitchell is an Obstetrician and Gynaecologist. Send questions or comments by e-mail to allwoman@jamaicaobserver.com, fax to 968-2025 or call 511-2502 to leave a 30-second voicemail message.

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