Amenorrhea

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Definition of Amenorrhea

Amenorrhea is the name given to the condition when a woman fails to have menstrual periods. The condition is known as "primary amenorrhea" when the woman has never menstruated; and "secondary amenorrhea" if her periods cease after having been regular for months or years.

Description of Amenorrhea

If you are reaching the age of 16 years without ever having menstruated, the chances are that you are developing normally, but a little later than most girls. If you are very athletic or quite thin, menarche could be delayed.

However, because there is a small possibility that you have a hormonal abnormality, consult a physician, especially if other sexual changes also have been delayed - if your breasts and pubic hair have not yet begun to grow, for example.

If you have been menstruating for years and suddenly miss periods for a few months, you have secondary amenorrhea. Many women of reproductive age experience this at some point in their lives. There are several possible explanations for this.

You might be pregnant, perhaps you lost a lot of weight rather quickly or have been exercising a lot, or you may have been under stress. Very obese women sometimes fail to menstruate. You also could be taking a medication that suppresses menses as a side effect.

If you just quit taking oral contraceptives, you may not have a period for several months. In addition, breastfeeding can delay menstruation, and if you are reaching the age of menopause, it would be normal to begin skipping periods.

Secondary amenorrhea due to the above causes is quite common. More serious problems, such as tumors or disorders of the pituitary gland, also can cause amenorrhea, but they are rare.

Failure to resume menstruation after childbirth, particularly if lactation does not take place, may mean that the pituitary gland failed either partly or completely at the time of delivery, a condition called postpartum pituitary necrosis.

If you have been menstruating regularly and your period is more than two weeks late, you may want to see a physician to find out if you are pregnant. However, if you are sure that you are not pregnant and you have no other symptoms, there is generally no harm in waiting several months before consulting a physician. Keep in mind that even if you are not menstruating, you could still become pregnant if you do not take precautions.

Causes and Risk Factors of Amenorrhea

The most common cause of amenorrhea is pregnancy, and this is always excluded before other possible causes are considered.

Female ballet dancers, female joggers and women involved in vigorous sports frequently find they skip menstrual periods or stop menstruating altogether. This is more likely to happen if you are young, especially if your cycle is generally irregular. In fact, teenagers who train heavily are often in their late teens before they actually have their first menstrual period.

Medical experts believe that several factors are involved, including stress, and perhaps the ratio (proportion) of fat cells in your body to other cells. Going on a crash diet and losing a large amount of weight very rapidly also can interfere with menstruation. In both cases, you stop menstruating because your ovaries do not produce enough estrogen in the cyclic manner that causes the uterus lining to thicken and then shed.

If you reduce your exercise schedule or gain weight, you probably will begin to menstruate again. If that does not work, or if you do not want to exercise less or gain weight, your physician may suggest that you take estrogen in low doses.

Some medications such as phenothiazines (used for psychiatric disorders) and some narcotics can cause amenorrhea. So can anorexia nervosa, Cushing’s disease and other conditions related to pituitary insufficiency or thyroid problems. A thorough medical history can usually reveal the cause of amenorrhea in about 85 percent of cases .

Treatment of Amenorrhea

Your physician may prescribe various types of hormones to see whether your ovaries are functioning normally.

Provided no underlying disorder is causing the amenorrhea, treatment is generally unnecessary. However, because women who are not menstruating seem susceptible to osteoporosis, your physician may suggest that you take estrogen and a calcium supplement.

If an underlying disorder is to blame for either primary or secondary amenorrhea, the treatment will depend on the nature of the disorder.

Questions To Ask Your Doctor About Amenorrhea

Do any tests need to be done for diagnosis and to determine the cause?

What is the cause?

What treatment do you recommend?

Will you be prescribing any medication?

What are the side effects?

What's likely to happen if no treatment is undertaken?

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Amenorrhea Overview

Amenorrhea is the absence of menstrual bleeding and may be primary or secondary.

• Primary amenorrhea is the absence of menstrual bleeding and secondary sexual characteristics (for example, breast development and pubic hair) in a girl by age 14 years or the absence of menstrual bleeding with normal development of secondary sexual characteristics in a girl by age 16 years.


• Secondary amenorrhea is the absence of menstrual bleeding in a woman who had been menstruating but later stops menstruating for 3 or more months in the absence of pregnancy, lactation (the ability to breastfeed), cycle suppression withsystemic hormonal contraceptive (birth control) pills, or menopause.

For a woman to have regular menstrual cycles, her hypothalamus, pituitary gland (seeAnatomy of the Endocrine System), ovaries, and uterus should all be functioning normally. The hypothalamus stimulates the pituitary gland to release follicle-stimulating hormone(FSH) and luteinizing hormone (LH). FSH and LH cause the ovaries to produce the hormones estrogen and progesterone. Estrogen and progesterone are responsible for the cyclical changes in the endometrium (uterine lining), including menstruation. In addition, a woman’s genital tract should be free of any abnormalities to allow the passage of menstrual blood.

Amenorrhea Causes

Amenorrhea can result because of an abnormality in the hypothalamic-pituitary-ovarian axis, anatomical abnormalities of the genital tract, or functional causes.

Hypothalamic causes

• Craniopharyngioma (a brain tumor near the pituitary gland)


• Teratoma (a tumor made up of a mixture of tissues)


• Sarcoidosis (a chronic disease of unknown cause characterized by the formation of nodules in different parts of the body)


• Kallmann syndrome (deficiency of gonadotropins, which are hormones capable of promoting growth and function of reproductive organs)


• Nutritional deficiency


• Low body weight

Pituitary causes

• Prolactinemia (high blood levels of prolactin, a hormone that stimulates secretion of milk from the breasts during breastfeeding) - Possibly caused by prolactinoma (a tumor of the pituitary gland secreting the hormone prolactin)


• Other pituitary tumors (for example, Cushing syndrome, acromegaly, or thyroid-stimulating hormone)


• Postpartum pituitary necrosis (death of pituitary cells after a woman delivers a baby)


• Autoimmune hypophysitis (cells of the pituitary gland destroyed by the body’s own defense system)


• Pituitary radiation


• Sarcoidosis

Ovarian causes

• Anovulation (lack of the release of an egg)


• Hyperandrogenemia (high blood levels of male hormones)


• Polycystic ovary syndrome (hormonal disorder affecting women of reproductive age)


• Premature ovarian failure


• Turner syndrome (a genetic disorder characterized by underdeveloped ovaries, absence of menstrual onset, and short stature)


• Pure gonadal dysgenesis (defective development of the ovary)


• Autoimmune oophoritis (cells of the ovaries destroyed by the body’s own defense system)


• Fragile X premutation


• Radiation or chemotherapy


• Galactosemia (an inherited disorder in which galactose, a type of sugar, accumulates in the blood)


• Anatomical abnormalities of the genital tract


• Intrauterine adhesions (the opposing surfaces of the uterine cavity stick together)


• Imperforate hymen (a hymen in which there is no opening, the membranecompletely closes off the vagina)


• Transverse vaginal septum (a dividing wall or membrane in the vagina)


• Aplasia (absence of an organ or tissue) of the vagina, the cervix, or the uterus

Functional causes

• Anorexia/bulimia


• Chronic diseases (for example, tuberculosis)


• Excessive weight gain or weight loss


• Malnutrition


• Depression or other psychiatric disorders


• Recreational drug abuse


• Psychotropic drug use (drugs prescribed to stabilize or improve mood, mental status, or behavior)


• Excessive stress


• Excessive exercise


• Cycle suppression with systemic hormonal contraceptive (birth control) pills

Amenorrhea Symptoms

Amenorrhea is a symptom of an underlying disorder. Additional symptoms may be present depending on the associated condition.

• Galactorrhea (breasts produce milk in a woman who is not pregnant or breastfeeding), headache, or reducedperipheral vision could be a sign of anintracranial tumor.


• Increased hair growth in a male pattern (hirsutism) may be caused by excessandrogen (a hormone that encourages development of male sex characteristics).


• Vaginal dryness, hot flashes, night sweats, or disordered sleep may be a sign of ovarian insufficiency or premature ovarian failure.


• Noticeable weight gain or weight loss may be present.


• Excessive anxiety may be present in women with associated psychiatric abnormalities.

When to Seek Medical Care

Consult a health care provider if a girl is 14 years old and her secondary sexual characteristics (for example, breast development and pubic hair) have not started to develop or a girl is 16 years old and has not had her first menstrual period.

For women who have already begun menstruating, they should see a health care provider if they have missed 3 consecutive menstrual periods.

Exams and Tests

A doctor may perform the following tests to determine the cause of the amenorrhea:

• Blood tests may be performed to determine the levels of hormones secreted by the pituitary gland (FSH, LH, TSH, and prolactin) and the ovaries (estrogen).


• Ultrasonography of the pelvis may be performed to assess the abnormalities of the genital tract or to look for polycystic ovaries.


• CT scan or MRI of the head may be performed to exclude pituitary and hypothalamic causes of amenorrhea.

If the above tests are inconclusive, additional tests may be performed.

• Thyroid function tests


• Determination of prolactin levels


• Hysterosalpingogram (x-ray test) or saline infusion sonography (SIS), both of which examine the uterus


• Hysteroscopy (visual inspection of the uterine cavity)

Amenorrhea Treatment

Self-Care at Home

• In some women, nutritional deficiencies induced by dieting can cause amenorrhea. Such women should eat a properly balanced diet.


• In some women, excessive body weight could be the cause of amenorrhea. These women should restrict the amount of fat in their diet, and they should exercise moderately to maintain an ideal body weight.


• More than 8 hours of vigorous exercise a week may cause amenorrhea. A moderate exercise program may restore normal menstruation.


• If amenorrhea is caused by emotional stress, finding ways to deal with stress and conflicts may help.


• Maintaining a healthy lifestyle by avoiding alcohol consumption and cigarette smoking is also helpful.

Medical Treatment

Treatment depends on the cause of amenorrhea. Once the cause is determined, treatment is directed at correcting the underlying disease, which should restore menstruation. In case of anatomical abnormalities of the genital tract, surgery may be indicated.

Dopamine agonists, such as bromocriptine (Parlodel) or pergolide (Permax), are effective in treating hyperprolactinemia. In most women, treatment with dopamine agonists restores normal ovarian endocrine function and ovulation.

Hormone replacement therapy, consisting of an estrogen and a progestin, is needed for women in whom estrogen deficiency remains because ovarian function cannot be restored. It is also required to maintain bone density in women whose underlying disease cannot be treated.

In some cases, oral contraceptives may be prescribed to restore the menstrual cycle and to provide estrogen replacement to women with amenorrhea who do not wish to become pregnant. Before administering oral contraceptives, withdrawal bleeding is induced with an injection of progesterone or oral administration of 5-10 mg ofmedroxyprogesterone (Provera) for 10 days.

Surgery

• Some pituitary and hypothalamic tumors may require surgery and, in some cases,radiation therapy.


• Women with intrauterine adhesions require dissolution of the intrauterine adhesions.


• Surgical procedures required for other genital tract abnormalities depend on the specific clinical situation.

Follow-up

Annual follow-up is required for women with amenorrhea caused by ovarian insufficiency. The follow-up is performed to monitor ovarian hormone replacement and to detect the development of associated conditions.

Prevention

By maintaining a normal weight, girls can prevent primary amenorrhea caused by excessive weight loss or weight gain.

Outlook

In most cases, amenorrhea is not a life-threatening condition. In most women, medications, lifestyle change, or surgery can correct amenorrhea.

Amenorrhea has been associated with reduced bone density and increased fracture rates.

For More Information

American College of Obstetricians and Gynecologists
409 12th St, SW
PO Box 96920
Washington, DC 20090-6920
(202) 638-5577

American Society for Reproductive Medicine
1209 Montgomery Highway
Birmingham, AL 35216-2809
(205) 978-5000

Web Links

MedlinePlus, Amenorrhea - primary

MedlinePlus, Menstruation - absent

Synonyms and Keywords

amenorrhea, absence of menstrual bleeding, absent menstruation, lack of menstruation, missed period, absent period, absent menses, menstrual dysfunction, primary amenorrhea, secondary amenorrhea, menstrual cycle,menarche, menstrual bleeding, delayed puberty, anatomical defects of the genital tract, abnormalities of the genital tract, ovarian disorders, anovulation, pituitary disorders, hypothalamic disorders, intrauterine adhesions, pituitary tumor, hypothalamic tumor, intracranial tumor, hyperandrogenemia, premature ovarian failure, polycystic ovary syndrome, prolactinemia, prolactinoma

Authors and Editors

Author: Lawrence M Nelson, MD, MBA, Head of Gynecologic Endocrinology Unit, Investigator, Section of Women's Health Research, Developmental Endocrinology Branch,

Editors: Suzanne R Trupin, MD, Clinical Professor, Department of Obstetrics and Gynecology, University of Illinois College of Medicine at Urbana-Champaign; Mary L Windle, Pharm D, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Pharmacy Editor, eMedicine.com, Inc; Lee P Shulman, MD, Professor of Obstetrics and Gynecology, Head, Section of Reproductive Genetics, Feinberg School of Medicine, Northwestern University, Chicago, Illinois.