Amenorrhea

If you don’t have your period for more than 3 cycles, it’s called amenorrhea. It can occur due to a variety of reasons. Sometimes it occurs as a natural part of life, or it can be caused by medications or a hormonal imbalance. Amenorrhea is not life threatening, and often the sign of a treatable condition.

Primary amenorrhea

Primary amenorrhea refers to the absence of menstruation, meaning it never started at puberty (usually by age 15).

Secondary amenorrhea

Secondary amenorrhea refers to missing 1 or more cycles when someone has experienced them in the past. This type is due to some physical cause and usually of later onset. Your periods were at one time normal and regular but become increasingly abnormal and irregular or absent.

What are the symptoms of amenorrhea?

The most obvious symptom of amenorrhea is missing your menstrual period for more than three months. Depending on the initial cause of amenorrhea, additional symptoms may include the following:

  • Abdominal bloating (if stress is the cause).
  • Acne.
  • Excess facial hair.
  • Hair loss.
  • Headaches.
  • Hot flashes.
  • Milky nipple discharge.
  • No secondary sexual characteristics developing, such as lack of breast growth (in those with primary amenorrhea).
  • Pelvic pain.
  • Vaginal dryness.
  • Vision changes.
Provider and patient having a discussion

What causes amenorrhea?

Amenorrhea can occur due to a variety of reasons. Sometimes it occurs as a natural part of life, or can be caused by medications or hormonal imbalance. Amenorrhea is not life threatening, and often the sign of a treatable condition. With treatment, menstruation can resume.

The following are the main causes of amenorrhea:

Natural occurrences

  • Pregnancy. When you are pregnant, you don’t ovulate, so your period stops temporarily. Pregnancy is the most common cause of secondary amenorrhea.
  • Breastfeeding.
  • Menopause.

Hormone imbalances

  • Hormone levels. When hormones are irregular, menstruation can be prevented. Irregular hormone levels are the most common cause of primary amenorrhea. Hypogonadotropic hypogonadism or functional hypothalamic amenorrhea s one of the most common types of secondary amenorrhea, when the sex organs produce too few hormones because of an issue with the hypothalamus or pituitary gland.
  • Ovulation problems. These are usually the cause of very irregular periods or frequently missed periods.
  • Pituitary tumor. A benign (non-cancerous) tumor in the pituitary gland can interfere with the hormone regulation of menstruation.
  • Polycystic Ovarian Syndrome (Polycystic Ovary Syndrome). Also known as PCOS, Polycystic Ovary Syndrome causes high and sustained levels of hormones, preventing fluctuation as in a normal menstrual cycle. People with Polycystic Ovary Syndrome need lifelong care to prevent health complications and to regulate cycles with treatment.
  • Premature menopause (primary ovarian Insufficiency). Menopause typically occurs after age 50, but some people younger than 40 experience ovarian insufficiency or premature ovarian failure, when the supply of eggs diminishes early and the menstrual cycle stops at a younger age.
  • Thyroid gland disorder. If you have an underactive thyroid (hypothyroidism) or an overactive thyroid (hyperthyroidism) your periods may stop.

Medications

Certain medications can stop the menstrual cycle, including

  • Allergy medications.
  • Antidepressants.
  • Antipsychotics.
  • Blood pressure medications.
  • Chemotherapy.

Contraceptives. Oral contraceptives such as the birth control pill can cause menstrual irregularity or even stop menses altogether. Even after stopping taking a birth control pill, regular ovulation and menstrual function may take a while to resume. Alternative contraceptive measures such as those injected or implanted as well as an IUD can cause amenorrhea.

Lifestyle factors

  • Eating disorders. If you have anorexia or bulimia, you may develop amenorrhea. This is because extreme weight loss makes your body weight too low to sustain a pregnancy. To protect the body, the reproductive system “shuts down” by interrupting hormone production and stopping ovulation because it’s severely malnourished. Excessively low body weight is classified as about 10% under normal weight.
  • Over-exercise or strenuous exercise. If you exercise a lot, your periods may stop due to low body fat content from weight loss, stress, and high energy expenditure.
  • Obesity. If you have experienced rapid weight gain or are overweight, you may have amenorrhea as a result of excess fat cells getting in the way of the process of ovulation.
  • Stress. Mental and physical stress can alter the hypothalamus function, resulting in the stop of ovulation and menstruation (known as hypothalamic amenorrhea). Regular cycles typically resume when stress decreases.

Defects or structural problems

If your period hasn’t started by age 16, it may be due to a birth defect, anatomical defect, or other medical condition.

  • Chromosomal abnormality. When chromosomes are missing or in excess, they can create defects such as Turner Syndrome, when one of the X chromosomes is missing. This prevents the ovaries from developing.
  • Missing reproductive organs. During fetal development, problems can arise and lead to birth defects such as mullerian agenesis (missing the uterus), cervix, vagina, or other elements of the reproductive systems. Because of the lack of a fully-developed reproductive system, menses will not occur later in life.
  • Structural abnormalities of the vagina. Any obstruction of the vagina may prevent visible menstrual bleeding or hinder menses. Sometimes a membrane within the vagina blocks the blood flow from the uterus and cervix.
  • Uterine scarring. A condition known as Asherman’s syndrome can cause scar tissue to build in the lining of the uterus. Uterine scarring prevents the normal buildup and shedding of uterine tissue. It can be caused by uterine fibroids, or sometimes a cesarean section or dilation and curettage.

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Diagnosing amenorrhea

Diagnosis starts with a medical history and a complete physical exam, including a pelvic exam to check for any problems with your reproductive organs. Your healthcare provider will want to rule out other menstrual disorders, medical conditions, or medicines that may be causing or aggravating the condition. A diagnosis of amenorrhea means that you miss at least 3 periods in a row, without being pregnant.

Young women who haven’t had their first menstrual period by age 15 should be evaluated promptly. Making an early diagnosis and starting treatment as soon as possible is very important.

Amenorrhea can indicate a complex set of hormonal problems. Finding the underlying cause can take time and may require more than one kind of testing. Your doctor may recommend one or more of the following:

Blood Tests

A variety of blood tests may be necessary to test for hormonal insufficiency.

  • Pregnancy tests are used first to rule out or confirm a possible pregnancy.
  • Thyroid function tests measure the amount of thyroid-stimulating hormone (TSH) in the blood and determine if the thyroid is working correctly.
  • Ovarian function tests measure the amount of follicle stimulating hormone (FSH) in the blood to check for ovarian failure or ovarian insufficiency, meaning the ovaries are not working correctly.
  • Prolactin tests check that your levels of the hormone prolactin are normal or not. A low level of prolactin can indicate problems with the pituitary gland such as a pituitary gland tumor.
  • Male hormone tests check the amount of male hormones in the blood. If you have increased facial hair and lowered voice, it may indicate a hormone imbalance and that there is excess Testosterone being produced.

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Imaging tests

Depending on your symptoms and the results of your bloodwork, your doctor may also recommend some imaging tests to differentiate your diagnosis. These tests may include:

Magnetic resonance imaging (MRI), which uses radio waves to produce detailed images of the body’s soft tissues. This test is usually used if your doctor suspects a pituitary tumor may be the cause of your amenorrhea.

An ultrasound, which uses sound waves to make images of the internal organs. This is usually recommended for those who have never had a period, so your doctor can check for any reproductive organ abnormalities.

Hormone challenge test

Your doctor may suggest you take a 7-10 day regimen of hormone therapy to trigger menstruation. This can help your doctor learn if your amenorrhea is caused by a lack of estrogen.

Scope tests

If the above tests do not indicate what may be causing your amenorrhea, a hysteroscopy may be recommended.

In this test, a slim camera and light are passed through the vagina and cervix to examine the inside of the uterus to check for complications such as uterine fibroids.

Possible complications of amenorrhea

Untreated amenorrhea can lead to other conditions.

Left untreated, amenorrhea can lead to the following possible complications:

  • Cardiovascular disease. A lack of estrogen can also cause cardiovascular problems, making someone at increased risk of heart attack or problems with the heart muscle and blood vessels.
  • Infertility. Amenorrhea prevents ovulation, which in turn means you cannot get pregnant. The hormone imbalances that cause amenorrhea also increase the likelihood of a miscarriage or other complications with pregnancy.
  • Osteoporosis. Hormonal problems that cause amenorrhea such as a lack of Estrogen can cause osteoporosis, the weakening of bones. The decreased bone density and bone loss can make you more likely to get hip and wrist fractures, as well as make it more difficult to perform general activities.
  • Ovarian cancer. Those with irregular cycles that are older are twice as likely to develop ovarian cancer in their 70s that those without problems like amenorrhea.
  • Pelvic pain. If an anatomical abnormality is causing amenorrhea, it can also cause pelvic pain
  • Psychological stress. Young women who are going through puberty can experience stress if they do not get their period, especially when compared to their peers.
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Treatments depend on the cause

Treatment for amenorrhea depends on the underlying cause of it, and whether it is primary amenorrhea or secondary amenorrhea.

  • In some instances, hormone therapy or birth control may be recommended to restart the menstrual cycles.
  • If weight issues are the cause, losing weight through dieting and exercise (for those overweight) or gaining weight through an individualized diet plan (for those with eating disorders) can restart your menstrual cycle.
  • Amenorrhea that is caused by a pituitary or thyroid disorder can be treated with medications.
  • Surgery may be necessary to treat amenorrhea caused by a tumor or structural blockage.

How can amenorrhea be prevented?

Living a healthy lifestyle can help prevent some causes of secondary amenorrhea.

The following preventative lifestyle measures include:

  • Getting an appropriate amount of sleep.
  • Getting regular gynecological appointments, including pelvic exams and PAP tests when recommended.
  • Keeping track of your menstrual cycle and any abnormalities.
  • Maintaining a healthy weight, exercising the appropriate amount, and eating a healthy diet.