Amenorrhea: Condition Information

What is amenorrhea?
Amenorrhea is the absence of a menstrual period. Amenorrhea is sometimes categorized as: Primary amenorrhea. This describes a young woman who has not had a period by age 16. Secondary amenorrhea. This occurs when a woman who once had regular periods experiences an absence of more than three cycles. Secondary amenorrhea includes pregnancy. Having regular periods is an important sign of overall health. Missing a period, when not caused by pregnancy, breastfeeding, or menopause, is generally a sign of another health problem. If you miss your period, talk to your health care provider about possible causes, including pregnancy.

What are the symptoms of amenorrhea?

Missing a period is the main sign of amenorrhea. Depending on the cause, a woman might have other signs or symptoms as well, such as: Excess facial hair Hair loss Headache Lack of breast development Milky discharge from the breasts Vision changes

Who is at risk?
According to the American Society for Reproductive Medicine, amenorrhea that is not caused by pregnancy, breastfeeding, or menopause occurs in 3% to 4% of women during their lifetime.1 Secondary amenorrhea is more common than primary amenorrhea. The risk factors for amenorrhea include:2 Excessive exercise Obesity Eating disorders such as anorexia nervosa A family history of amenorrhea or early menopause Having a certain version of the FMR1 gene, that also causes fragile X syndrome3

What causes Amenorrhea?

Amenorrhea can happen for many reasons. It most often occurs as a natural part of life, such as during pregnancy or breastfeeding, but it can also signal a more serious condition.

What causes primary amenorrhea?

There are three main causes of primary amenorrhea: Chromosomal or genetic abnormalities can cause the ovaries to stop functioning normally. Turner syndrome, a condition caused by a partially or completely missing X chromosome, and androgen insensitivity syndrome, often characterized by high levels of testosterone, are two examples of genetic abnormalities that can delay or disrupt menstruation.1 Hypothalamic (pronounced hahy-poh-thuh-LAM-ik) or pituitary (pronounced pi-TOO-i-ter-ee) problems in the brain and physical problems such as problems with reproductive organs can prevent periods from starting. Excessive exercise, eating disorders, extreme physical or psychological stress, or a combination of these factors can delay the onset of menstruation.

What causes secondary amenorrhea?

Secondary amenorrhea can result from various causes, such as: Natural causes. Pregnancy is the most common cause. Other natural causes include breastfeeding and menopause. Medications and therapies. Certain birth control pills, injectable contraceptives, and intrauterine devices (IUDs) can cause amenorrhea. It can take a few months after stopping birth control for the menstrual cycle to restart and become regular. Some medications, including certain antidepressants and blood pressure medications, can increase the levels of a hormone that prevents ovulation and the menstrual cycle.2 Chemotherapy and radiation treatments for hematologic cancer (including blood, bone marrow, and lymph nodes) and breast or gynecologic cancer can destroy estrogen-producing cells and eggs in the ovaries, leading to amenorrhea. The resulting amenorrhea may be short-term, especially in younger women.3 Sometimes scar tissue can build up in the lining of the uterus, preventing the normal shedding of the uterine lining in the menstrual cycle. This scarring sometimes occurs after a dilation and curettage (D&C), a procedure in which tissue is removed from the uterus to diagnose or treat heavy bleeding or to clear the uterine lining after a miscarriage,4 a cesarean section, or treatment for uterine fibroids. Hypothalamic amenorrhea. This condition occurs when the hypothalamus, a gland in the brain that regulates body processes, slows or stops releasing gonadotropin-releasing hormone (GnRH), the hormone that starts the menstrual cycle.5 Common characteristics of women with hypothalamic amenorrhea include:6 Low body weight Low percentage of body fat Very low intake of calories or fat Emotional stress

Strenuous exercise that burns more calories than are taken in through food Deficiency of leptin, a protein hormone that regulates appetite and metabolism Some medical conditions or illnesses Gynecological conditions. Unbalanced hormone levels are common features of certain conditions that have secondary amenorrhea as a main symptom. These can include: Polycystic ovary syndrome (PCOS). PCOS occurs when a woman's body produces more androgens (a type of hormone) than normal. High levels of androgens can cause fluid-filled sacs or cysts to grow in the ovaries, interfering with the release of eggs (ovulation). Most women with PCOS either have amenorrhea or experience irregular periods, called oligomenorrhea (pronounced ol-i-goh-men-uh-REE-uh). Fragile X-associated primary ovarian insufficiency (FXPOI). The term FXPOI describes a condition in which a woman's ovaries stop functioning before normal menopause, sometimes around age 40. FXPOI results from certain changes to a gene on the X chromosome. As many as 10% of women who seek treatment for amenorrhea have FXPOI.7 Thyroid problems. The thyroid is a small butterfly-shaped gland at the base of the neck, just below the Adam's apple. The thyroid produces hormones that control metabolism and play a role in puberty and menstruation.8 A thyroid gland that is overactive (called hyperthyroidism) or underactive (hypothyroidism) can cause menstrual irregularities, including amenorrhea.9 Pituitary tumor. Noncancerous tumors in the pituitary gland in the brain, which regulates the production of hormones that affect many body functions, including metabolism and the reproductive cycle, can interfere with the body's hormonal regulation of menstruation.10

How is Amenorrhea diagnosed?

A health care provider will usually ask a series of questions to begin diagnosing amenorrhea, including:1 How old were you when you started your period? What are your menstrual cycles like? (What is the typical length of your cycle? How heavy or light are your periods?) Are you sexually active? Could you be pregnant? Have you gained or lost weight recently? How often and how much do you exercise?

Primary Amenorrhea
If you are older than 16 and have never had a period, your health care provider will do a thorough medical history and physical exam, including a pelvic exam, to see if you are experiencing other signs of puberty. Depending on the findings and on your answers to the questions above, other tests may be ordered to determine the cause of your amenorrhea.

Secondary Amenorrhea
If you are sexually active, your health care provider will likely order a pregnancy test. He or she will also perform a complete physical exam, including a pelvic exam. You should contact your health care provider as soon as possible after you miss a period. Other tests you may need include:2 Thyroid function test. This test measures the amount of thyroidstimulating hormone (TSH) in your blood, which can help determine if your thyroid is working properly. A thyroid gland that is overactive (hyperthyroidism) or underactive (hypothyroidism) can cause menstrual irregularities, including amenorrhea. Ovary function test. This test measures the amount of follicle-stimulating hormone (FSH) or luteinizing hormone (LH)hormones made by the pituitary glandin your blood to determine if your ovaries are working properly. Your health care provider may also evaluate the level of antiMullerian hormone (AMH), which is produced by the ovarian follicles. Higher levels of AMH may be associated with polycystic ovary syndrome.3 Low or undetectable amounts of AMH may be associated with menopause or primary ovarian insufficiency. Androgen test. Androgens are sometimes called "male hormones" because men need higher levels of these hormones than woman do for overall health. However, both men and women need androgens to stay healthy. Your health care provider may want to check the level of male androgens in your blood. Hormone challenge test. With this test, you will take a hormonal medication for seven to 10 days in an effort to trigger a menstrual cycle. Results from the test can tell your health care provider whether your periods have stopped because of a lack of estrogen. Screening for a permutation of the FMR1 gene. Changes in this gene can cause the ovaries to stop functioning properly, leading to amenorrhea.4 Chromosome evaluation. This test, also known as a karyotype, involves counting and evaluating the chromosomes from cells in the body to identify any missing, extra, or rearranged cells. Results from this evaluation can help determine the cause of the chromosomal abnormality causing primary or secondary amenorrhea. Ultrasound. This painless test uses sound waves to produce images of internal organs. This test can help determine if your reproductive organs are all present and shaped normally. Computed 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 detailed images of soft tissues within the body. Your health care provider may order an MRI to check for a pituitary tumor or to examine your reproductive organs. Hysteroscopy. In this procedure a thin, lighted camera is passed through your vagina and cervix to allow your health care provider to look at the

inside of your uterus.1 Your health care provider might use several of these tests to attempt to diagnose the cause of amenorrhea. In some cases, no specific cause for the amenorrhea can be found. This situation is called idiopathic (pronounced idee-uh-PATH-ik) amenorrhea.5

What are the treatments for Amenorrhea?

The treatment for amenorrhea depends on the underlying cause, as well as the health status and goals of the individual. If primary or secondary amenorrhea is caused by lifestyle factors, your health care provider may suggest changes in the areas below: Weight. Being overweight or severely underweight can affect your menstrual cycle. Attaining and maintaining a healthy weight often helps balance hormone levels and restore your menstrual cycle. Stress. Assess the areas of stress in your life and reduce the things that are causing stress. If you can't decrease stress on your own, ask for help from family, friends, your health care provider, or a professional listener such as a counselor. Level of physical activity. You may need to change or adjust your physical activity level to help restart your menstrual cycle. Talk to your health care provider and your coach or trainer about how to train in a way that maintains your health and menstrual cycles. Be aware of changes in your menstrual cycle and check with your health care provider if you have concerns. Keep a record of when your periods occur. Note the date your period starts, how long it lasts, and any problems you experience. The first day of bleeding is considered the first day of your menstrual cycle. For primary amenorrhea, depending on your age and the results of the ovary function test, health care providers may recommend watchful waiting. If an ovary function test shows low follicle-stimulating hormone (FSH) or luteinizing hormone (LH) levels, menstruation may just be delayed. In females with a family history of delayed menstruation, this kind of delay is common.1 Primary amenorrhea caused by chromosomal or genetic problems may require surgery. Women with a genetic condition called 46, XY gonadal dysgenesis have one X and one Y chromosome, but their ovaries do not develop normally. This condition increases the risk for cancer developing in the ovaries. The gonads (ovaries) are often removed through laparoscopic surgery to prevent or reduce the risk of cancer.2 Treatment for secondary amenorrhea, depending on the cause, may include medical or surgical treatments or a combination of the two.

Medical Treatments for Secondary Amenorrhea

Common medical treatments for secondary amenorrhea include: Birth control pills or other types of hormonal medication. Certain oral contraceptives may help restart the menstrual cycle. Medications to help relieve the symptoms of PCOS. Clomiphene citrate (CC) therapy is often prescribed to help trigger ovulation.3 Estrogen replacement therapy (ERT). ERT may help balance hormonal levels and restart the menstrual cycle in women with primary ovarian

insufficiency (POI) or fragile X-associated primary ovarian insufficiency (FXPOI).4 Women with FXPOI often experience symptoms of menopause, such as hot flashes and night sweats. ERT replaces the estrogen a woman's body should be making naturally for a normal menstrual cycle. In addition, ERT may help women with FXPOI lower their risk for the bone disease osteoporosis.5 ERT can increase the risk for uterine cancer, so your health care provider may also prescribe progestin or progesterone to reduce this risk. In general, medications are safe, but they can have side effects, some of which may be serious. You should discuss side effects and risks with your health care provider before deciding on any specific medical treatment.

Surgical Treatments for Secondary Amenorrhea

Surgical treatment for amenorrhea is not common, but may be recommended in certain conditions. These include: Uterine scarring. This scarring sometimes occurs after removal of uterine fibroids, a cesarean section, or a dilation and curettage (D&C), a procedure in which tissue is removed from the uterus to diagnose or treat heavy bleeding or to clear the uterine lining after a miscarriage.6 Removal of the scar tissue during a procedure called a hysteroscopic resection can help restore the menstrual cycle.7 Pituitary tumor. Medications may be recommended to shrink the tumor. If this does not work, surgery may be necessary to remove the tumor. Pituitary tumors are not cancerous, but they can cause problems as they grow. Pituitary tumors can put pressure on surrounding blood vessels and nerves such as the optic nerve and may result in loss of vision. Most of the time, pituitary tumors are removed through the nose and sinuses. Radiation therapy may be used to shrink the tumor, either in combination with surgery or, for those who cannot have surgery, by itself.

Reference
Practice Committee of the American Society for Reproductive Medicine (PCASRM). (2008). Current evaluation of amenorrhea. Fertility and Sterility, 90, S219225. Retrieved April 6, 2012, from http://www.asrm.org/uploadedFiles/ASRM_Content/News_and_Publications/ Practice_Guidelines/Educational_Bulletins/Current_evaluation(1).pdf (PDF 146 KB) [top] Master-Hunter, T., & Heiman, D. L. (2006). Amenorrhea: Evaluation and treatment. American Family Physician. 73, 13741382. Retrieved April 6, 2012, from http://www.aafp.org/afp/2006/0415/p1374.html [top] PC_ASRM. (2008). Current evaluation of amenorrhea. Fertility and Sterility, 90, S219225. Retrieved June 6, 2012, from http://www.asrm.org/uploadedFiles/ASRM_Content/News_and_Publications/ Practice_Guidelines/Educational_Bulletins/Current_evaluation(1).pdf (PDF 146 KB). Pascal, P., Leprieur, E., Zenaty, D., Thibaud, E., Polak, M., Frances, A.M., et al. (2010). Steroidogenic factor-1 (SF-1) gene mutation as a frequent cause of primary amenorrhea in 46,XY female adolescents with low testosterone concentration. Reproductive Biology and Endocrinology, 8(28): 1-6. Lin, K & Barnhart, K. (2007). The clinical rationale for menses-free contraception. Journal of Women's Health, 16(8), 1171-1180. [top] La Torre, D., & Falorni, A. (2007). Pharmacological causes of hyperprolactinemia. Therapeutic and Clinical Risk Management, 3, 929951. Retrieved May 14, 2012, from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2376090/ [top] American College of Obstetricians and Gynecologists (ACOG). (2011). ACOG Committee Opinion: Primary ovarian insufficiency in the adolescent. Retrieved May 14, 2012, from http://www.acog.org/Resources_And_Publications/Committee_Opinions/Com mittee_on_Adolescent_Health_Care/Primary_Ovarian_Insufficiency_in_the_A dolescent [top] ACOG. (2012). Dilation and curettage. Retrieved June 6, 2012, from http://www.acog.org/~/media/For%20Patients/faq062.pdf?dmc=1&ts=201206 06T1418144478 [top] Gordon, C. M. (2010). Functional hypothalamic amenorrhea. New England Journal of Medicine, 363, 365371. [top] Hormone Health Network. (n.d.). Amenorrhea. Retrieved May 14, 2012, from http://www.hormone.org/Reproductive/amenorrhea.cfm [top] ACOG. (2011). ACOG Committee Opinion: Primary ovarian insufficiency in the adolescent. Retrieved May 14, 2012, from http://www.acog.org/Resources_And_Publications/Committee_Opinions/Com mittee_on_Adolescent_Health_Care/Primary_Ovarian_Insufficiency_in_the_A dolescent [top] U.S. Department of Health and Human Services Office of Women's Health. (2010). Thyroid disease fact sheet. Retrieved May 27, 2012, from http://womenshealth.gov/publications/our-publications/fact-sheet/thyroiddisease.html [top] Master-Hunter, T., & Heiman, D. L. (2006). Amenorrhea: Evaluation and treatment. American Family Physician. 73, 13741382. Retrieved April 6, 2012, from http://www.aafp.org/afp/2006/0415/p1374.html [top] Master-Hunter, T., & Heiman, D. L. (2006). Amenorrhea: Evaluation and treatment. American Family Physician. 73, 13741382. Retrieved April 6, 2012, from http://www.aafp.org/afp/2006/0415/p1374.html [top]