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 three or more months in the absence of pregnancy, lactation (the ability to breastfeed), cycle suppression with systemic hormonal contraceptive (birth control) pills, or menopause.
Amenorrhea is a symptom of an underlying disorder rather than a condition in and of itself. 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 reduced peripheral vision could be a sign of an intracranial tumor.
- Increased hair growth in a male pattern (hirsutism) may be caused by excess androgen (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.
Amenorrhea can result because of an abnormality in the hypothalamic-pituitary-ovarian axis, anatomical abnormalities of the genital tract, or functional 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 or growth delay
- 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
- 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
- galactose (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 membrane completely 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
- Chronic diseases (for example, tuberculosis)
- Excessive weight gain or weight loss
- 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
Tests and diagnosis
Amenorrhea can be a sign of a complex set of hormonal problems. Finding the underlying cause can take time and may require more than one kind of testing.
A variety of blood tests may be necessary, including:
- Pregnancy test. This will probably be the first test your doctor suggests, to rule out or confirm a possible pregnancy.
- Thyroid function test. Measuring the amount of thyroid-stimulating hormone (TSH) in your blood can determine if your thyroid is working properly.
- Ovary function test. Measuring the amount of follicle-stimulating hormone (FSH) in your blood can determine if your ovaries are working properly.
- Prolactin test. Low levels of the hormone prolactin may be a sign of a pituitary gland tumor.
- Male hormone test. If you’re experiencing increased facial hair and a lowered voice, your doctor may want to check the level of male hormones in your blood.
Hormone challenge test
For this test, you take a hormonal medication for seven to 10 days to trigger menstrual bleeding. Results from this test can tell your doctor whether your periods have stopped due to a lack of estrogen.
Depending on your signs and symptoms — and the result of any blood tests you’ve had — your doctor might recommend one or more imaging tests, including:
- Ultrasound. This test uses sound waves to produce images of internal organs. If you have never had a period, your doctor may suggest an ultrasound test to check for any abnormalities in your reproductive organs.
- Computerized tomography (CT). CT scans combine many X-ray images taken from different directions to create cross-sectional views of internal structures. A CT scan can indicate whether your uterus, ovaries and kidneys look normal.
- Magnetic resonance imaging (MRI). MRI uses radio waves with a strong magnetic field to produce exceptionally detailed images of soft tissues within the body. Your doctor may order an MRI to check for a pituitary tumor.
If other testing reveals no specific cause, your doctor may recommend a hysteroscopy — a test in which a thin, lighted camera is passed through your vagina and cervix to look at the inside of your uterus.
- 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.
- In women with anorexia nervosa or excessive weight loss, normal menstrual cycles can often be restored by undergoing treatment to restore and maintain a healthy body weight.
- 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.
Amenorrhea 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. Some causes of amenorrhea can be managed by medical (drug) therapy. Examples include the following:
- Dopamine agonists such as bromocriptine (Parlodel) or pergolide (Permax), are effective in treating hyperprolactinemia. In most women, treatment with dopamine agonists medications restores normal ovarian endocrine function and ovulation.
- Hormone replacement therapy consisting of an estrogen and a progestin can be used for women in whom estrogen deficiency remains because ovarian function cannot be restored.
- Metformin (Glucophage) is a drug that has been successfully used in women with polycystic ovary syndrome to induce ovulation.
- 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 of medroxyprogesterone (Provera) for 10 days.
- 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.
Can amenorrhea be prevented?
Amenorrhea is a symptom and not a disease in itself. Therefore, amenorrhea can be prevented only to the extent that the underlying cause can be prevented. For example, amenorrhea that results from genetic or inborn conditions cannot be prevented. On the other hand, amenorrhea that results from self-imposed stringent dieting or intensive exercise is typically preventable.
Lifestyle and home remedies
Some lifestyle factors — such as too much exercise or too little food — can cause amenorrhea, so strive for balance in work, recreation and rest. Assess areas of stress and conflict in your life. If you can’t decrease stress on your own, ask for help from family, friends or your doctor. Be aware of changes in your menstrual cycle and check with your doctor if you have concerns. Keep a record of when your periods occur. Note the date your period starts, how long it lasts and any troublesome symptoms you experience.
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