Amenorrhea means not having menstrual periods. Amenorrhea is either primary or secondary. Primary amenorrhea is not having menstrual periods by the age of 16. Secondary amenorrhea is the absence of three or more periods in a woman who has had regular menstrual periods.

How does it occur?

Menstruation requires that the uterus, cervix (opening to the uterus), vagina, and ovaries be normal and healthy. The pituitary gland and the hypothalamus, both located in the brain, must also be functioning properly. A problem with any of these parts of the body may keep you from having a period.

Primary amenorrhea

The main cause of primary amenorrhea is late puberty. In most cases this delay occurs for no known reason. Sometimes it results from a hormonal problem, such as hypothyroidism, or a genetic disorder, such as chromosome abnormalities. In some cases, menstruation fails to occur because of a birth defect. For example, a woman may not have a vagina or uterus. Or the vagina may not have an opening that allows menstrual blood to escape.

Secondary amenorrhea

The most common cause of secondary amenorrhea is pregnancy. Sometimes a breast-feeding mother may not have menstrual periods. Periods may also take 3 months or longer to resume after a woman stops taking birth control pills. Secondary amenorrhea may also result from:

emotional stress brain injury
tumor in the brain (pituitary gland), ovary, or adrenal gland, or a cyst in the ovary
depression
thyroid problems, such as on under active or overactive thyroid gland
malnutrition
vigorous exercise, such as daily or long-distance running
increased production of the hormone prolactin by the pituitary gland
drugs, such as tranquilizers and antidepressants
rapid weight gain or loss
chronic illness (for example, kidney failure, cystic fibrosis, and colitis)
Asherman's syndrome, which is scarring of the lining resulting from an infection or surgery such as a D&C (dilatation and curettage).

Long lapses between periods, lasting 6 months or longer, are common with ongoing physical stress. This is particularly the case if you have lost a lot of weight, as with anorexia. It may also happen if you have little or no body fat, as is true for some women athletes.

Permanent secondary amenorrhea occurs after menopause. Menopause may occur prematurely before age 40. Periods also stop after a hysterectomy (surgical removal of the uterus).

What are the symptoms?

Not having menstrual periods is a symptom, not a disease. Other symptoms depend on what is causing the amenorrhea. For example, if you have a hormone imbalance, you may have a lot of body and facial hair, acne, breast milk secretions, a change in voice or sex drive, or weight gain.

How is it diagnosed?

Though rarely due to a life-threatening cause, amenorrhea can be a fairly complicated problem, and there is often no quick answer. It takes time and working closely with your doctor to diagnose the cause and to treat it. You will have a thorough history and physical exam, including a pelvic exam. Your doctor may order blood tests, x-rays, ultrasound scans, or chromosome studies.

How is it treated?

The treatment depends on the cause. If you have no other symptoms or signs besides the absence of periods, you may not need treatment. If you are overweight, a diet and exercise program may restore your menstrual periods. Learning to manage stress at school or work and decreasing excessive physical exercise may also help. Often the cause of amenorrhea is that the ovaries do not release eggs (ovulate). Your ovaries may be releasing the hormone estrogen but not producing progesterone, a hormone necessary for periods to occur. In this case, the usual treatment is to take progesterone for 7 to 14 days every 1 or 2 months. Surgery may be necessary if you have tumors or cysts in your ovaries or uterus. You may also need surgery if your vagina is shaped abnormally or has no opening.

How long will the effects last?

Amenorrhea after a hysterectomy or menopause is permanent. Amenorrhea after you stop taking birth control pills usually lasts for 6 to 8 weeks, but it may last a year or longer. If unusual stress or an illness has temporarily interrupted the hormone cycle, your periods should start again naturally, although how long you will go without periods cannot be predicted.

How can I take care of myself?

If you miss more than one menstrual period, see your doctor. Tell your doctor about any drugs you are taking, both prescription and nonprescription.
If your periods are irregular, keep a record of the dates that they start, how long they last, the amount of menstrual flow, and any symptoms.
If you have no periods at all, try to remember and record when your last period occurred, how long it lasted, and the amount of menstrual flow.
Try to find out if there is any family history of a problem similar to yours.
Follow your doctor's recommendations closely.

What can be done to help prevent amenorrhea?

To prevent amenorrhea from recurring, it is important to maintain a healthy lifestyle:

Make changes in your diet or activities to maintain your ideal weight.
Avoid excessive use of alcohol and mood-altering stimulants or sedative drugs.
Avoid cigarette smoking.
Think about the areas of emotional stress and conflict in your life. If you feel that you cannot resolve these conflicts on your own, ask for help from family, friends, or health professionals.
Be moderate in all your activities. Try to balance your work, recreation, and rest.
Maintain a positive outlook. This problem can often be corrected.

Robert B. McWilliams, MD

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Robert B. McWilliams, MD Reproductive Endocrinology and Gynecology

Amenorrhea

Robert B. McWilliams, MD
Reproductive Endocrinology
and Gynecology