Amenorrhea refers to the complete absence of menstrual periods during the reproductive years of women. Periods start at puberty and continue until menopause (natural cessation of periods). Amenorrhea usually happens during pregnancy and while breastfeeding, and it is normal in these conditions. Otherwise, skipped periods or continuous absent menstruation signify some serious health problems.
In this article, we will break down what this condition is, why it happens, and what it means for women’s health in easy-to-understand terms.
What are the types of amenorrhea?
The two main types of amenorrhea are:
Primary amenorrhea
Primary amenorrhoea is the absence of the initiation of periods or failure to reach menarche by the age of 16 years, despite normal growth and the development of secondary sexual characteristics. Menarche, or the onset of periods, is a hallmark of puberty.
The normal range during which periods start is 9 to 15 years. If a girl has not started periods by the age of 16 years, it is diagnosed as primary amenorrhoea. It is caused by various reasons, including genetics, hormonal issues, and other structural abnormalities.
Secondary amenorrhea
Secondary amenorrhea is defined as the cessation of periods in menstruating women. Clinically, it is diagnosed when periods are absent consecutively for 3 months in women with a regular menstrual cycle, or for 6 months in women with irregular periods.
While primary amenorrhea occurs in girls who never had periods, secondary amenorrhea occurs in menstruating females. There are multiple causes of secondary amenorrhoea, including hormonal imbalance, lifestyle factors, and underlying diseases.
What are the symptoms of amenorrhea?
The main symptom of amenorrhea is the absence of periods. However, other symptoms may appear depending on the cause; these include:
- Pelvic pain
- Excessive facial hair
- Headache
- Milky nipple discharge
- Hair loss
- Vision defects
- Vaginal dryness
- Hot flashes
- Change in breast size.
What causes primary amenorrhea?
Primary amenorrhoea is caused by the following:
Chromosomal abnormalities and anatomical defects
Various chromosomal abnormalities and anatomical defects can lead to primary amenorrhea.
- Turner syndrome: Normally, a female has two X chromosomes (XX). But in turner syndrome, there is a complete or partial absence of one X chromosome, so females with turner syndrome have only one sex chromosome (X0). It results in multiple physical and developmental abnormalities, including underdeveloped or complete absence of ovaries leading to primary amenorrhea.
- Kallmann syndrome: It is a rare genetic disorder characterized by the association of hypogonadotropic hypogonadism (decreased or absent function of the gonads) with a reduced sense of smell. In Kallmann syndrome, there is a disruption in the normal functioning of the hypothalamus and pituitary gland. So, GnRH is not sufficiently produced, resulting in a failure to stimulate the release of FSH and LH. Ovulatory dysfunction and a lack of ovulation cause amenorrhea.
- Congenital adrenal hyperplasia: In this condition, there is an absence of enzymes required to synthesize two important hormones, cortisol and aldosterone. Consequently, the adrenal glands produce an increased amount of androgens (male hormone). The excess androgens interfere with the normal development of the ovaries and the subsequent regulation of the normal menstrual cycle.
- Mullerian agenesis: It refers to the absence or underdevelopment of reproductive organs (uterus, fallopian tubes, upper vagina). This causes primary amenorrhea since females do not have a functional uterus or vagina.
- Androgen insensitivity syndrome (AIS): It is a genetic disorder causing XY individuals to have partial or complete insensitivity to androgens. They are born with external genitalia that appear typically female or ambiguous. Complete AIS leads to primary amenorrhea, as the absence of a functional uterus results in the inability to menstruate. On the other hand, those with partial AIS might experience irregular menstrual cycles.
- Imperforate hymen: It is a congenital condition where the hymen, a thin membrane that partially covers the opening of the vagina, does not have an opening. It results in the obstruction of blood flow as a girl approaches puberty, causing primary amenorrhea.
- Transverse vaginal septum: A transverse vaginal septum is a congenital condition in which tissue forms horizontally across the vaginal canal, dividing it into two separate compartments. This septum can partially or completely block the passage of menstrual blood, leading to primary amenorrhea.
- Swyer syndrome: Also known as 46 XY gonadal dysgenesis. It causes primary amenorrhea in individuals with 46 XY chromosomes. Although such individuals have male chromosomes, they have female external genitalia and are typically raised as females until puberty. Due to underdeveloped or undifferentiated gonads, they do not undergo menstruation or develop normal reproductive function.
- Cervical stenosis: The cervix is the passage that connects the uterus with the vaginal canal. In cervical stenosis, the cervical canal is narrowed, resulting in an obstruction to the outflow of menstrual blood, causing primary amenorrhea.
Hormonal causes
The menstrual cycle is under the influence of hormones released from the hypothalamus, pituitary gland, and ovaries. Other body hormones, such as thyroid and stress hormones, also affect the production and release of reproductive hormones. So any defect in this whole process can lead to the cessation of menstruation.
- Hypothalamic dysfunction: If the hypothalamus is not fully developed, or there is any tumor that impacts its functioning, it will affect the production and release of GnRH. The hypothalamus is also affected by stress, eating disorders, and weight fluctuations. So, inadequate GnRH causes primary amenorrhea.
- Pituitary dysfunction: Just like the hypothalamus, any developmental defect, trauma, or tumor affecting the pituitary gland can disturb the release of FSH and LH that govern the menstrual cycle leading to amenorrhea.
- Elevated FSH: Gonadal dysfunction can cause elevated FSH levels, which may be a cause of primary amenorrhea.
- Congenital GnRH deficiency: Sometimes there is a congenital deficiency of gonadotropin-releasing hormone (GnRH). A less-than-required amount of GnRH fails to stimulate the release of FSH and LH, resulting in primary amenorrhea.
- Hyperprolactinemia: It refers to the increased levels of prolactin hormone in the blood. Increased prolactin levels can inhibit the secretion of GnRH, ultimately stopping the menstrual cycle.
What causes secondary amenorrhea?
Secondary amenorrhea is caused by the following reasons:
Hormonal imbalance
- Pregnancy: One of the most common reasons a woman might miss her period is pregnancy. When a woman becomes pregnant, her body starts producing different hormones to support the growing baby. These hormonal changes stop the monthly menstrual cycle. So, if a period is missed, pregnancy is often the first thing to think of.
- Polycystic ovary syndrome: It is characterized by multiple ovarian cysts and hyperandrogenism, causing anovulation, hirsutism, and other menstrual irregularities. Excess androgen and insulin resistance disturb the delicate balance of hormones, leading to amenorrhea in some cases.
- Thyroid disorders: The thyroid gland produces T3 and T4 hormones, which impact almost all body functions, including the menstrual cycle. So, hyperthyroidism or hypothyroidism can disturb the hormonal balance, causing secondary amenorrhea.
- Pituitary gland tumors: They can directly affect the secretion of FSH and LH from the pituitary gland. Tumors can interfere with the normal functioning of the pituitary cells that produce these hormones, leading to reduced levels of FSH and LH, resulting in secondary amenorrhea.
- Premature ovarian failure: Also known as primary ovarian insufficiency, it is a condition in which the ovaries stop working before the age of 40. Ovaries do not have the ability to form eggs and ovulate; hence there is no menstruation.
- Hyperprolactinemia: Prolactin is the hormone responsible for breast milk production. Increased prolactin levels in non-pregnant and non-nursing females inhibit the production and release of gonadotropin-releasing hormone (GnRH), ultimately stopping the menstrual cycle.
- Cushing syndrome: It is a condition marked by high levels of cortisol. Increased cortisol levels diminish the production and release of GnRH, FSH, and LH leading to irregular menstruation.
Lifestyle factors
- Intense exercise: Strenuous and vigorous exercise can suppress the production of certain hormones like GnRH, FSH, and LH, leading to hormonal imbalances that affect the menstrual cycle.
- Stress: Chronic stress disturbs the hypothalamic ovarian axis, which controls the release of hormones involved in the menstrual cycle. A disturbed hypothalamic-ovarian axis can change the menstrual pattern, often causing secondary amenorrhea.
- Malnourished diet: A poor diet lacking much-needed nutrients and essential minerals can decrease the production of hormones, leading to secondary amenorrhea.
- Sleep: Inadequate sleep, irregular sleep patterns, and poor sleep quality can negatively impact hormone regulation and lead to amenorrhea. Proper sleep is essential for maintaining hormonal balance and overall health.
- Alcohol consumption and excessive caffeine intake: Alcohol and caffeine can disrupt the hormonal balance, causing secondary amenorrhea.
- Weight changes: Sudden and extreme weight changes, either weight loss or weight gain, can cause secondary amenorrhea.
Structural defects
There are some structural defects in the reproductive organs of females that have the potential to cause secondary amenorrhea. They include:
- Ashermann’s syndrome: Intrauterine adhesions or scar tissue in the uterus can result from previous surgeries or infections, leading to secondary amenorrhea.
- Uterine anomalies: Some uterine abnormalities can interfere with menstruation and cause amenorrhea. They include:
- Uterine adhesions
- Uterine fibroids
- Uterine septa.
Other causes include cervical stenosis and fallopian tube blockage.
Medications
Some medicines have side effects that negatively impact the menstrual cycle. They interfere with hormonal levels, causing secondary amenorrhea. These drugs are:
- Anti-allergic
- Anti-hypertension
- Anti-psychotics
- Chemotherapy
- Anti-depressants
- Birth control pills
- Injectable contraceptives
Hypothalamic amenorrhea
It is a type of secondary amenorrhea that is caused by a disturbance of the hypothalamic-pituitary-ovarian axis that regulates the menstrual cycle. All the factors that impact the hypothalamus and pituitary glands can cause hypothalamic amenorrhea. Some of the factors affecting the hypothalamus and causing hypothalamic amenorrhea are:
- Emotional shock
- Anxiety
- Fear
- Psychotropic drugs
- Injury to the midbrain.
What are the complications caused by amenorrhea?
If amenorrhea is not treated, it can lead to various complications and health risks. Some of them include:
- Fertility issues: Fertilization requires the release of an egg and a normal menstrual cycle; anovulation in amenorrhea decreases the chance of conceiving and poses difficulties in getting pregnant.
- Osteoporosis: Reduced estrogen levels can decrease bone density. Decreased bone mineralization and density cause osteoporosis.
- Premature ovarian failure: Amenorrhea often results from a deficiency in the hormones required for normal ovulation. These imbalances can disrupt the regular functioning of the ovaries and their ability to ovulate. Chronic hormonal imbalances can, over time, lead to premature ovarian failure, which is the stoppage of ovarian function before the age of 40.
- Excessive body and facial hair: Amenorrhea resulting from excessive androgens causes hirsutism or excessive facial hair growth.
- Acne: Increased androgens stimulate sebum production, which can clog pores and increase acne formation.
- Vision problems: Amenorrhea itself does not directly cause vision problems. However, underlying conditions leading to amenorrhea, such as hormonal imbalances, thyroid issues, or pituitary tumors, can potentially affect vision. Nutritional deficiencies associated with amenorrhea may also impact eye health.
- Cardiovascular diseases: Decreased estrogen linked to amenorrhea increases the risk of cardiovascular diseases.
How to diagnose amenorrhea?
Diagnosing primary and secondary amenorrhea requires a comprehensive evaluation by a healthcare professional. The diagnosis is carried out through these steps:
Medical history
The doctor requires a detailed medical history. This includes information about the age of onset of menarche, duration and length of the menstrual cycle, family history of menstrual disorders, previous surgeries, any medicines you are using, and details about your lifestyle such as eating habits, sleep schedule, and exercise routine.
Pelvic examination
The history is followed by a physical examination of the pelvis, which will help identify any structural abnormalities.
Laboratory tests
To pinpoint the exact cause of amenorrhea, various laboratory tests are conducted. These include:
- Pregnancy test
- FSH, LH, prolactin hormonal profile test
- Thyroid function test
- Ovarian function test
- Androgen and testosterone test.
Imaging studies
These help visualize any structural defects, blockages, or other causes of amenorrhea. Imaging studies include:
- Ultrasound of the pelvis
- MRI and CT scans of the brain and adrenal glands
- Hysteroscopy.
Genetic testing
If genetic conditions, such as turner syndrome or androgen insensitivity syndrome (AIS), are suspected, genetic testing may be recommended.
How to manage amenorrhea?
Treating and managing amenorrhea requires proper medications, lifestyle modifications, and more importantly, treating the underlying conditions.
Hormone therapy
In cases where primary or secondary amenorrhea is due to hormonal imbalances, hormone replacement therapy may be prescribed. The specific hormones prescribed depend on the underlying cause. For example, estrogen, progesterone, or progestin may be given to induce menstrual bleeding and regulate the menstrual cycle.
Lifestyle modifications
When amenorrhea is caused by a poor lifestyle, managing lifestyle changes can help to improve amenorrhea. This includes having a properly balanced diet with adequate nutrition and minerals, drinking plenty of water, exercising moderately, and sleeping well.
Reducing stress
Stress greatly contributes to amenorrhea. So reducing stress levels with relaxation techniques, cognitive behavioral therapies, and meditation helps to eliminate menstrual irregularities.
Medications
Certain medicines are available to treat the causes of amenorrhea. These include:
- GnRH agonists
- Dopamine agonists
- Androgen blockers
- Thyroid medications
- Oral contraceptives.
Surgical interventions
When necessary in anatomical defects, surgical interventions can be done to treat underlying conditions. These include:
- Myomectomy to remove uterine fibroids.
- Hysteroscopic adhesiolysis to remove uterine adhesions and scarring in ashermann’s syndrome.
- Transsphenoidal surgery to remove pituitary tumors.
- Hysterectomy to remove the uterus as a whole to eliminate uterine anomalies.
Treating underlying medical conditions
Treating the underlying conditions is crucial for resolving amenorrhea.
When to seek medical advice?
Having no period for one month is common and normal, but if you don’t have periods for several months and also experience certain symptoms, then it is recommended to get yourself checked by a healthcare professional. Seek medical advice immediately if:
- You are over 16 years old and have not experienced your first period.
- You previously had a regular menstrual cycle and now have no periods for three consecutive months.
- Your menstrual cycle was previously irregular, and now you have not had a period for six months.
- If you are experiencing some other symptoms along with a lack of periods, including acne, hirsutism, hot flashes, pelvic pain, mood swings, and headache.
Menstrual Portal also offers free online consultation, regarding all your menstrual health concerns.
Frequently asked questions
Can you get pregnant with amenorrhea?
Amenorrhea occurs when there is no menstruation, meaning that an egg is not formed at all, so it is not possible to conceive with amenorrhea. However, treatment of amenorrhea can restart the menstrual cycle, after which it is possible to conceive.
Can stress cause amenorrhea?
Yes, chronic stress can disrupt the hormonal balance in the body, leading to amenorrhea. The release of stress hormones can affect the functioning of the hypothalamus and pituitary gland, which play a crucial role in regulating the menstrual cycle.
Can amenorrhea affect fertility?
Yes, amenorrhea can affect fertility, especially if amenorrhea is caused by hormonal imbalances or other underlying conditions that impact ovulation. However, treatment of amenorrhea can reverse infertility.
