Amenorrhea: Absence or cessation of menstruation. Amenorrhea is conventionally divided into primary and secondary amenorrhea.

Primary amenorrhea -- menstruation never takes place. It fails to occur at puberty. Secondary amenorrhea -- menstruation starts but then stops.

The absence of menstruation during pregnancy is a form of physiologic secondary amenorrhea, physiologic in the sense that it is completely normal and is not caused by anything medically harmful (pathologic). Amenorrhea during lactation is another type of physiologic secondary amenorrhea.

The word "amenorrhea" is compounded from three Greek roots "a-", no + "men", month + "rhoia", flow = no monthly flow. Amenorrhea is less commonly called amenia.

Amenorrhea Causes

Amenorrhea can result because of an abnormality in the hypothalamic-pituitary-ovarian axis, anatomical abnormalities of the genital tract, or functional causes.

Hypothalamic 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

Pituitary causes

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 Sarcoidosis  

Ovarian causes

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 Galactosemia (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 

Functional causes

Anorexia/bulimia Chronic diseases (for example, tuberculosis) Excessive weight gain or weight loss Malnutrition 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

Secondary amenorrhea occurs when a woman who has been having normal menstrual cycles stops getting her periods for 6 or more months.

Amenorrhea is when a woman does not get her monthly menstrual cycle, or period.

See also:

Menstruation - Absent Primary amenorrhea

Causes

Women who are pregnant, breastfeeding, or in menopause are not considered to have secondary amenorrhea.

Women who are taking birth control pills or receive hormone shots such as Depo-Provera may not have any monthly bleeding. When they stop taking these hormones, their periods may not return for more than 6 months.

You are more likely to have amenorrhea if you:

Are obese Exercise excessively and for long periods of time Have less than 15% - 17% body fat Have severe anxiety or emotional distress Lose a lot of weight suddenly (for example, with a strict diet or after gastric bypass surgery)

Other causes include:

Brain (pituitary) tumors Polycystic ovarian syndrome Premature ovarian failure Thyroid dysfunction

The following drugs may also cause missed periods:

Busulfan Chemotherapy drugs for cancer Chlorambucil Cyclophosphamide Phenothiazines

Also, procedures such as a dilation and curettage (D and C) can lead to scar tissue formation that may cause a woman to stop menstruating. This is called Asherman syndrome. Scarring may also be caused by some severe pelvic infections.

Symptoms

No menstrual period for 6 months or longer Previously had one or more menstrual periods that started on their own

Other symptoms that can occur with secondary amenorrhea include:

Breast size changes Considerable weight gain or weight loss Discharge from the breast (galactorrhea) Headache Increased hair growth in a "male" pattern (hirsutism) and acne Vaginal dryness Voice changes

If amenorrhea is caused by a pituitary tumor, there may be other symptoms related to the tumor, such as vision loss.

Exams and Tests

A physical exam and pelvic exam must be done to rule out pregnancy. A pregnancy test will be done.

Blood tests may be done to check hormone levels, including:

Estradiol levels Follicle stimulating hormone (FSH level) Luteinizing hormone (LH level) Prolactin level Serum hormone levels such as testosterone levels Thyroid stimulating hormone (TSH)

Other tests that may be performed include:

CT scan of the head Endometrial biopsy Genetic testing MRI of the head Ultrasound of the pelvis or hysterosonogram

Treatment

Treatment depends on the cause of the amenorrhea. Normal monthly periods usually return after the condition is treated.

For example, if the primary disorder is hypothyroidism, amenorrhea will be cured when it is treated with thyroid supplements.

If the primary cause is obesity, vigorous exercise, or weight loss, treatment may include a change in exercise routine or weight control.

Outlook (Prognosis)

The outlook depends on the cause of amenorrhea. Most of the conditions that cause secondary amenorrhea will respond to treatment.

Possible Complications

Complications depend on the cause of the condition. Amenorrhea may be harmless, or it may be associated with overgrowth of the uterine lining (endometrial hyperplasia). This can sometimes lead to uterine cancer.

There may be other complications, depending on the cause of the amenorrhea.

When to Contact a Medical Professional

Call for an appointment with your primary health care provider or OB/GYN provider if you have missed more than one period so that you can get diagnosed and treated, if necessary.

Prevention

Prevention depends on the cause. For example, moderate exercise instead of extreme exercise, weight control, and other measures may be helpful.

Amenorrhea - primary

Amenorrhea is the absence of menstruation. Menstruation is a woman's monthly period.

Primary amenorrhea is when a girl has not yet started her monthly periods, and she:

Has gone through other normal changes that occur during puberty Is older than 15

See also:

Menstruation - absent Secondary amenorrhea

Causes

Most girls begin menstruating between ages 9 and 18, with an average around 12 years old. Primary amenorrhea typically occurs when a girl is older than 15, if she has undergone other normal changes that occur during puberty. Primary amenorrhea may occur with or without other signs of puberty.

Being born with poorly formed genital or pelvic organs (missing uterus or vagina, vaginal septum, cervical stenosis, or imperforate hymen) can lead to primary amenorrhea.

Hormones play a big role in a woman's menstrual cycle. Hormone problems can occur when:

Changes occur to the parts of the brain where hormones that help manage the menstrual cycle are produced

The ovaries are not working correctly

These problems may be due to:

Genetic defects Infections that occur in the womb or after birth Other birth defects Tumors

In many cases, the cause of primary amenorrhea is not known.

Conditions associated with primary amenorrhea include:

Adrenogenital syndrome Anorexia Chromosomal abnormalities such as Turner syndrome or Sawyer syndrome Congenital heart disease (cyanotic) Congenital adrenal hyperplasia Craniopharyngioma Chronic (long-term) illnesses Cushing's disease Cystic fibrosis Gonadal dysgenesis Hypothyroidism and hyperthyroidism Hypogonadotropic hypogonadism Hyperprolactinemia Obesity Prader-Willi syndrome Polycystic ovarian disease Testicular feminization True hermaphroditism Tumors of the pituitary or adrenal glands Tumors of the ovaries

Symptoms

A female with amenorrhea will have no menstrual flow with or without other signs of puberty.

Exams and Tests

The doctor will perform a physical exam and ask questions about your medical history. A pregnancy test will be done.

Blood tests may include:

Estradiol FSH LH Prolactin TSH T3 and T4

Other tests that may be done include:

17 hydroxyprogesterone Chromosome analysis Head CT Head MRI scan Laparoscopy Pelvic ultrasound Progesterone withdrawal Serum progresterone

Treatment

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.

Outlook (Prognosis)

Overall the outlook is good, depending on the cause of the amenorrhea. If the amenorrhea is caused by one of the following conditions, there is a good chance that it can be corrected with medication, lifestyle changes, or surgery:

Adrenogenital syndrome Chronic illness Congenital heart disease Drastic weight reduction Hypogonadotropic hypogonadism Imperforate hymen or vaginal septum Malnutrition Normal delay of onset (up to age 14 or 15) Obesity

Overactive thyroid

Periods are unlikely to start on their own if the amenorrhea was caused by one of the following conditions:

Congenital abnormalities of the upper genital system Craniopharyngioma Cystic fibrosis Gonadal dysgenesis Prader-Willi syndrome Testicular feminization syndrome True hermaphroditism Turner syndrome (XO)

If the amenorrhea cannot be corrected, it is sometimes possible to create a menstrual-like situation (pseudomenstruation) with medications. Medicines can help you feel more like your friends or family, and will also protect the bones from becoming too thin (osteoporosis).

Possible Complications

Emotional distress due to feeling different from friends or family, or worrying you might not be able to have children

Osteoporosis and increased risk of fractures