Definition

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 with
systemic hormonal contraceptive birth control pills, or menopause. All women
who enter menopause experience amenorrhea unless they receive hormone
replacement therapy. In younger women, amenorrhea unrelated to pregnancy
and lactation can be a distressing symptom. In addition to its psychologic
morbidity, amenorrhea may be the manifesting feature of a wide array of
anatomic and endocrine abnormalities. Amenorrhea results in impaired fertility.
When estrogen levels are low, changes in mineral, glucose, and fat metabolism
accompany amenorrhea. These metabolic changes affect bone and
cardiovascular health, increasing the risk of osteoporosis and coronary heart
disease in later life.
 Pathophysiology

Menstruation is the cyclic, orderly sloughing of the uterine lining, due to the interactions
of hormones produced by the hypothalamus, pituitary, and ovaries. Hypothalamus,
pituitary and ovaries form a functional endocrine axis, known as HPO axis with
hormonal regulations and feedback loops.

The hypothalamic central nervous system discharges gonadotropin-releasing hormone

(GnRH), which is transported to the anterior pituitary, where it stimulates the
gonadotrophs. In response to stimulation, these cells in turn secrete the gonadotropins
follicle-stimulating hormone (FSH), and luteinizing hormone (LH). Furthermore, these
tropic hormones stimulate the gonads to synthesize and secrete sex steroids. Hormone
release in the hypothalamus-pituitary-ovarian (HPO) axis is regulated by a negative
feedback on gonadotrophs in the anterior pituitary and by indirect inhibition at the level
of the hypothalamus. Stimulation and negative inhibition complete the pathway between
the hypothalamus, pituitary, and ovaries. Any disruption in this axis may result in
amenorrhea. A systematic approach to understand pathophysiology of amenorrhea
involves defining the level of primary dysfunction.

Hypothalamic amenorrhea

Hypothalamic dysfunction results in decreased or inhibited GnRH secretion, which

affects the pulsatile release of LH and FSH, causing anovulation.

A common cause of amenorrhea is functional hypothalamic amenorrhea. 1 It is

characterized by abnormal hypothalamic GnRH secretion, decreased gonadotropin
pulsations, low or normal LH concentrations, absent LH surges, abnormal follicular
development, and low serum estradiol. Serum FSH concentrations are usually in the
normal range, with high FSH to LH ratio. 2 This can be caused by eating disorders,
exercise, or high levels of prolonged physical or mental stress. This can also include
major psychiatric disorders such as depression.
 Sign and symptoms

Primary amenorrhea

 Headaches
 Abnormal blood pressure
 Vision problems
 Acne
 Excessive hair growth

secondary amenorrhea:

 Nausea
 Swollen breasts
 Headaches
 Vision problems
 Being very thirsty
 Goiter (an enlarged thyroid gland)
 Darkening skin

Hot flashes, mood changes, depression, and vaginal dryness are common with
estrogen deficiency.
 Etiology

Amenorrhea is usually classified as anovulatory. Each type has many causes, but
overall, the most common causes of amenorrhea include

Primary amenorrhea

 Lack of reproductive organs (such as uterus, cervix, or vagina)

 Problems with the pituitary gland
 Anorexia
 Stress
 Too much exercise
 Abnormal chromosones

Secondary amenorrhea

 Pregnancy or breast-feeding
 Using some kinds of birth control
 Taking some types of medication (such as corticosteroids)
 Hormone imbalance
 Low body weight
 Too much exercise
 Thyroid problems
 Pituitary tumor
 Stress
 Premature menopause (menopause before age 40)
Contraceptives can cause the endometrium to thin, sometimes resulting in amenorrhea.
Antidepressants and antipsychotics can elevate prolactin.Some disorders can cause
ovulatory or anovulatory amenorrhea. Congenital anatomic abnormalities cause only
primary amenorrhea.Anovulatory amenorrhea: The most common causes involve a
disruption of the hypothalamic-pituitary-ovarian axis. Thus, causes include

 Hypothalamic dysfunction (particularly functional hypothalamic anovulation)

 Pituitary dysfunction
 Premature ovarian failure
 Endocrine disorders that cause androgen excess (particularly polycystic ovary
syndrome)

Anovulatory amenorrhea is usually secondary but may be primary if ovulation never

begins—eg, because of a genetic disorder. If ovulation never begins, puberty and
development of secondary sexual characteristics are abnormal.
 Management

Primary amenorrhea

Treatment depends on the cause of the missing period. Primary amenorrhea caused by
birth defects may require medications (hormones), surgery, or both.

If the amenorrhea is caused by a tumor in the brain (pituitary tumor):

 Medications may shrink certain types of tumors.

 Surgery to remove the tumor may also be necessary.
 Radiation therapy is usually only performed when other treatments have not
worked.

If the condition is caused by a body-wide (systemic) disease, treatment of the disease

may allow menstruation to begin.

If the amenorrhea is due to low weight because of anorexia or too much exercise,
periods will often begin when the weight returns to normal or the exercise level is
decreased.

Secondary amenorrhea

Treatment depends on the cause of the amenorrhea. Normal menstrual function usually
returns after the primary disorder is treated.

For example, if the primary disorder is hypothyroidism, then amenorrhea will be cured
when it is treated with thyroid supplements.If the primary cause is obesity, vigorous
athletics, weight loss, or similar factors, treatment recommendations may include a
change in one's exercise routine and weight control.
 Complication

 Infertility is a significant complication of amenorrhea for women who desire to

become pregnant.
 Osteopenia (a reduction in bone density) or osteoporosis is a complication of low
estrogen levels, which may occur with prolonged amenorrhea
 Emotional distress due to feeling different from friends or family, or worrying you
might not be able to have children

Conclusion

In most cases, amenorrhea is not a life-threatening condition. In most women,

medications, lifestyle change, or surgery can correct amenorrhea. It can be due to
various cases. Menstrual cycle is a natural process in woman. It usually occurs in the
age of 12-14 when they have achieved puberty stages.

Examination should be done if a girl has become 15 and there is still no menstrual
cycle. Early investigation would be helpful to determine the right causes and
management of amenorrhea.