Amenorrhea : Causes, Symptoms, Treatment and Prevention

Defining Amenorrhea

Amenorrhea is a lack of menstrual periods in pre-menopausal women. Contrary to popular belief, a missed period is not necessary a cause for celebration as menstruation stops for a host of reasons other than a possible pregnancy.

Missed periods or amenorrhea can also be a natural occurrence, especially during pregnancy and breastfeeding. Following the onset of menopause, periods stop permanently.

Primary Amenorrhea

In this type of amenorrhea, menstruation does not commence at the time of puberty. In case a young teenager is developing normally but does not start her periods by 15 years of age, she is said to have primary amenorrhea.

It should also be noted that if signs of puberty are not visible at 13 years of age, medical advice needs to be sought. Primary amenorrhea is not so common.

Secondary Amenorrhea

In this kind of amenorrhea, (normal during lactation or pregnancy) a woman’s periods commence and then cease to occur. An absence of menstruation for at least half a year or three consecutive periods in women who had normal menstrual periods before this is termed secondary amenorrhea.

Many things can cause missed periods including problems with reproductive organs/glands regulating hormones, medication intake, and excessive weight loss/gain.

Causes

Apart from pregnancy, a host of factors can lead to amenorrhea. These include the following:

• Birth defects
• Genetic Conditions
• Uterine Infections
• Surgeries and tumours
• Hormones
• Extreme weight loss
• Breastfeeding
• Menopause
• Severe Stress
• Overexercising
• Hormonal disorders (thyroid/pituitary gland)
• Chronic health conditions
• Some medications
• Gynaecological disorders

Birth Defects

This includes blockage of the cervix. The cervix is the opening of the uterus or womb. Other rare anomalies include vaginal septum (where the vagina is divided into two) or a missing uterus. These two can be causes for primary amenorrhea.

Genetic Condition

Genetic factors can also come into play such as the XY gonadal dysgenesis which causes a woman’s ovaries to become abnormal during development- women with this genetic disorder have one X and one Y chromosome instead of the usual XX.

Acquired Conditions

While women may be born with the right organs, certain medical conditions like uterine infections, surgery and tumours can cause amenorrhea.

Hormonal Imbalances

Hormones control a woman’s cycle like a driver controls a car. When hormones are undergoing an imbalance, periods are disrupted.

Hormonal fluctuations can be the result of excessive weight loss, menopause, stress, overexercising and even issues with thyroid or pituitary glands. Hypothyroidism or a pituitary tumour can also cause amenorrhea.

Chronic Diseases

Chronic diseases like thyroid conditions, cystic fibrosis, polycystic ovarian syndrome, and cancer can also lead to missed periods.

Certain Medications

Medications that can disrupt the menstrual cycle include birth control pills, chemotherapy, antipsychotics, antidepressants, blood pressure, allergy medicines or corticosteroids.

Other factors

Menstruation can also cease on account of gynaecological disorders, critical illness, physical tension or underweight or malnourished body. Excessive exercise can also lead to secondary amenorrhea, common among long distance runners, gymnasts, and professional dancers.

Symptoms

The primary symptom is the absence of menstruation. Depending on the aetiology of the disorder, secondary symptoms may be present such as:

• Headaches
• Vision problems
• Pimples
• Hair in unwanted areas (for example facial hair)
• Nausea
• Enlarged thyroid
• Changes in Skin
• Swelling or discharge from the breasts
• Hair loss
• Pain in Pelvic region
• Breast milk secretions
• Weight gain
• Lowering of voice
• Altered sex drive
• Hormonal imbalance

While forming a diagnosis, the doctor may ask for the following data:

• Use of birth control methods (if any)
• Date of last menstruation
• Pregnancy history
• Eating habits
• Rapid weight gain/loss
• Typical monthly menstrual pattern
• Maternal onset of menstruation
• Medication
• Stress
• Exercise

A physical and pelvic exam will follow. The doctor may also wish to check for increased body hair, extreme sensitivity to cold, dry skin, constipation and hair loss.

Prevention

Prevention is always better than cure. Women can ward off amenorrhea by following a sensible exercise program and maintaining the normal weight. Anatomy induced amenorrhea cannot be avoided, however.

To ward off secondary amenorrhea, a balanced diet, moderate exercise, work-life balance and healthy outlets for stress as well as avoidance of alcohol overconsumption can be the quite effective. Balancing work and recreation, rest and activity can be the answer to ward off amenorrhea.

Treatment

Primary amenorrhea is the result of late puberty and does not need to be managed or treated. The condition leaves off on its own. But when it is caused by genetic abnormalities, primary amenorrhea is treated depending on the problem.

In the case of ovaries malfunctioning, supplemental ovarian hormones may be provided to allow onset of puberty and associated features like periods. If lack of menstruation is due to a structural problem, surgery may be needed. For example, if a vagina lacks an opening, surgical corrections are needed.

Secondary amenorrhea due to menopause or hysterectomy is treated through medications which prevent complications associated with low oestrogen levels. Other forms of secondary amenorrhea involve the following treatment:

• Stress-induced: stress management program
• Obesity- diet and exercise program
• Overexercise- a more moderate training program may be recommended
• Hormonal imbalance- supplemental hormones may be prescribed
• PCOS- multiple medical treatments can regulate menstruation including metformin, clomiphene, and cyclical female hormones.
• You may also need to adjust levels of activity and monitor the changes in menstrual cycle.
• If ovary function test shows low LH or FSH levels, menstruation could be delayed and common.
• Women with genetic conditions like 46 XY Gonadal Dysgenesis have to undergo laparoscopic surgery to remove poorly developed ovaries which can later cause cancer.

Common medical treatments for secondary amenorrhea include:

• Birth control pills
• PCOS medication
• Oestrogen replacement therapy : This may balance hormonal levels and restart the menstrual cycle in women with conditions like POI/ Primary Ovarian Insufficiency or Fragile Z Associated Primary Ovarian Insufficiency
• Surgery

Surgery for amenorrhea is rare but can be recommended. Uterine scarring after removal of uterine fibroids, C-section or abortion or dilation and cutterage following a miscarriage can necessitate surgery. A process called hysteroscopic resection can restore the menstrual cycle. Pituitary tumours can also be removed with surgery and radiation therapy.

Conclusion

While amenorrhea is not always a critical medical condition and can occur naturally under certain circumstances, it does require treatment and management in case it is caused by genetic factors, stress, lack of/excessive weight and other such factors. Missing your periods can be a tough experience and the healthcare professional can help you to make an easy transition back to normal life (and regular menstruation).