A small uterus

Q: Dear Dr Mitchell,

My sister did not get any periods in her life and now she is 33 years old. She married when she was 26 years old. The doctors told us that her uterus size is too small and that is why she did not got her periods. Is there any treatment to increase the uterus size?

A: The fact that your sister has never had a menstrual period at age 33 years old is significant. This could be due to a defect in the brain (pituitary or hypothalamus) or defect in the uterus or ovaries. Some women have a condition called premature ovarian failure where the eggs that they are born with rapidly degenerate and the ovaries become devoid of any follicles (eggs). This causes the ovaries to be very small and resemble that of a woman who is her post-menopausal period. The uterus stays small and infantile since there is no significant production of oestrogen and progesterone to promote growth and development of the uterus. In severe cases there is no period at all, while in mild cases the period may start at the usual age and then stop prematurely in the early 20s or 30s.

A woman who has never had a menstrual period is considered to have primary amenorrhoea. This may be due to a condition called Panhypopituitarism, which is failure of the pituitary gland to produce the usual hormones such as leutinizing hormone(LH) and follicle stimulating hormone (FSH) which are necessary for stimulation of the ovaries to cause maturation of egg follicles and subsequent ovulation. In this case the ovaries can be stimulated by the use of drugs to induce ovulation and pregnancy can be achieved if so desired. Disorders in thyroid hormone production (hyper/hypothyroidism) may cause failure to menstruate.

In severe cases hypothyroidism (where the thyroid gland underproduces thyroid hormones) can prevent the menstrual period from starting. This condition is usually suspected if the menstrual period is absent, there is weight gain, and low energy levels. This results because of the decreased metabolic rate associated with the low level of thyroid hormones.

Your sister should have a complete hormone profile done. This should include checking the pituitary hormones (LH and FSH), thyroid hormone, prolactin level and baseline oestrogen level.

In premature ovarian failure, the FSH and LH levels are usually very high and resemble that of post-menopausal women. In this situation hormones can be given to stimulate the lining of the uterus to shed and initiate the menstrual period. However, pregnancy cannot be achieved unless in-vitro fertilisation is done with donor eggs. Hypothyroidism can be readily treated by taking thyroxine tablets and increasing the circulating thyroid hormone levels. This is also effective in establishing regular periods and improving fertility. High levels of prolactin can be treated by using drugs to suppress production in the pituitary gland and these also improve fertility and establish a regular menstrual period.

Other causes of failure to menstruate include polycystic ovarian disease, chromosomal problems, stress, strenuous exercise and weight loss as is seen in anorexia nervosa. Polycystic ovarian disease is usually associated with excessive weight gain, acne, and excessive hair growth on the body, irregular or absent menstrual periods, and inability to conceive. This condition can be successfully treated with weight loss and the use of drugs such as metformin and clomiphene citrate to induce ovulation.

Karyotyping can be done to determine if there is an underlying chromosomal abnormality causing the absent menstrual periods

It is important for you sister to be investigated and treated even if fertility is not desired, since primary amenorrhoea can be associated with increased risk of cardiovascular problems and osteoporosis due to low oestrogen levels in women who do not ovulate.

Consult your gynaecologist who will advise you further.

Dr Sharmaine Mitchell is an obstetrician and gynaecologist. Send questions via e-mail to allwoman@jamaicaobserver. com; write to All Woman, 40-42 1/2 Beechwood Ave, Kingston 5; or fax 968-2025. Dr Mitchell cannot provide personal responses.

DISCLAIMER: The contents of this article are for informational purposes only and must not be relied upon as an alternative to medical advice or treatment from your own doctor.