Ask the Expert: Amenorrhea

Ask The Expert 

 

What is amenorrhea?

It means a woman who is capable of having children doesn't have a period.

 

A woman usually has a period every 21-45 days.  This is controlled by the hypothalamus, a gland in the brain that also controls temperature, appetite, and blood pressure.  It stimulates the pituitary gland (near the base of the brain) to release 2 hormones that regulate the female reproductive cycle, called LH (luteinizing hormone) and FSH (follicle stimulating hormone). LH and FSH also influence the production of estrogen and progesterone, which are responsible for cyclic changes in the lining of the uterus, including menstruation.  In order for a woman to have regular periods, her hypothalamus, pituitary gland, ovaries and uterus must be functioning properly.  Her cervix and vagina must also be normal enough for blood to pass through.

 

There are 2 types of amenorrhea:

Primary: when a woman doesn't have her first period by age 16.  This is most often due to late puberty, which is common in girls who are very thin or athletic.  These girls are usually underweight, and have little body fat that triggers the start of menstruation.  In other girls, the period may be delayed due to a genetic condition called Turner's Syndrome, which involves the sex chromosomes, or to abnormal reproductive organs.

 

Secondary: when a woman who has had a period in the past fails to have a period for 3 months. This may be caused by:

  • Pregnancy

  • Breastfeeding

  • Menopause

  • Menopause before age 40

  • Surgical removal of the uterus

  • Stopping birth control pills

  • Use of Depo-Provera

  • Tumors of the pituitary gland

  • Polycystic ovary disease

  • Endocrine problems, such as hyperthyroidism

  • Emotional or physical stress

  • Rapid weight loss

  • Obesity

  • Frequent strenuous exercise

  • Chronic and long-term illness, such as colitis, kidney failure, or cystic fibrosis

  • Chemotherapy for cancer

  • Cysts or tumors in the ovaries

 

Amenorrhea affects 2% to 5% of all women who can have children in the U.S. Female athletes may be more likely to have it.  While exercise or physical activity itself doesn't cause it, it is more likely to occur in those women who exercise very intensely or who increase the intensity of exercise rapidly.  Women who play sports such as ballet dancing or gymnastics, are more likely to develop it than women in other sports.

 

What are the symptoms?

Amenorrhea is a symptom in itself.  Any other symptoms associated with it will depend on the problem that is causing the missed periods.  For example, hormone imbalance may cause it together with excess body and facial hair, acne, a lowering of the voice, an altered sex drive, breast milk secretions, weight gain, or several or all these symptoms.

 

How is it diagnosed?

Your health care provider will ask you about the following:

  • Date of your last period

  • If you're sexually active

  • What is your birth control method

  • Your pregnancy history

  • Your eating habits, rapid weight changes, obesity or extreme underweight

  • Your typical monthly periods (regular or irregular cycles)

  • Age your mother became menopausal

  • Amount of stress in your life, and how you deal with it

  • Do you exercise, how often, how long, and what type of exercise do you do

  • Medications

 

If your health care provider is concerned about a particular cause for the amenorrhea, he or she may ask more specific questions, such as acne, increased body hair, extreme sensitivity to cold temperatures, dry skin, constipation, hair loss or unusual breast secretions.  If you're an athlete, you'll be asked to describe your training program.

 

You will have a physical exam along with a pelvic exam. If you are not pregnant, then you will need several tests done to try to find the cause of your absent periods:

  • Blood and urine tests.  Done to detect hormonal and endocrine imbalances

  • Pelvic ultrasound.  Done to look for problems in the structure of your uterus and ovaries

  • Progesterone challenge test.  You may be given progesterone (an oral medication) for a few days to see whether this causes you to have a period.  If bleeding occurs, then your not having periods is probably related to not ovulating.  If you don't bleed, the additional blood tests may be ordered to check your hormone levels

 

If these tests don't help find the cause, additional specialized testing may be necessary.

 

What is the expected duration of amenorrhea?

In many teenage girls puberty may be late, but there is no permanent problem.  For women with secondary amenorrhea, how long it lasts depends on the cause.  For example, pregnancy will stop the periods until the child is born, but for a woman who stops birth control pills, she may not have a period for 3 months to 1 full year.  Emotional stress can cause missed periods for as long as the stress is present.

 

How is it prevented?

Teenage girls need to follow a sensible exercise program and maintaining a normal weight for their height and age. If there are abnormalities of the reproductive system, it cannot be prevented. If the amenorrhea is related to diet, over-exercise or stress, you can take the following steps:

  • Eat a low-fat diet that meets your recommended daily nutritional needs

  • Exercise moderately, but not excessively, to maintain an ideal bodey weight and muscle tone.

  • Find healthy outlets for emotional stress and daily conflicts.

  • Avoid excessive alcohol consumption and cigarette smoking.

 

How is it treated?

Primary amenorrhea caused by late puberty usually doesn't need treatment because the condition goes away on its own.  If primary is caused by genetic abnormalities, treatment depends on the condition.  This woman may be given medications to prevent osteoporosis caused by low estrogen levels, and supplemental ovarian hormones to develop normal sex characteristics (breast development, pubic hair).  If there is a structural problem, then surgery may be necessary.

 

Secondary amenorrhea due to menopause or removal of the uterus, the woman will be given medications to prevent osteoporosis and other complications of low estrogen levels.  For other causes:

  • Stress:  enroll in a stress-management course or see a counselor

  • Obesity:  the health care provider may give you a specific diet and exercise plan, or refer you for nutritional and exercise counseling

  • Excessive athletic training:  try a moderate program. This will also decrease the risk for osteoporosis, heart disease, infertility and thinning of the tissues lining the vagina

  • Hormone imbalance:  try supplemental hormones

  • Tumors or cysts in the ovaries, uterus or pituitary gland:  treatment depends on their type and location.  Surgery is sometimes necessary. 

 

When should I call my health care provider?

If you have reached your 14th birthday and have not started to develop breasts or pubic hair, or if you have reached your 16th birthday and have not have your first period.

 

If you're sexually active, call your health care provider if you miss a period, since you will need to have a pregnancy test.  If your aren't sexually active, see your health care provider if you have missed 3 periods in a row, or if your periods are irregular.

 

What is the prognosis?

Rarely life-threatening.  In most instances, symptoms and conditions related to amenorrhea are reversible and treatable. 

 

Diana Jones, RNC, MSN, WHNP

Women's Health Nurse Practitioner

BSU Women's Center

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