Understanding and Managing Amenorrhea

Amenorrhea, the absence of menstruation, is a condition that can be both confusing and concerning for those who experience it. Whether you are someone experiencing amenorrhea or a caregiver wanting to understand more, this article aims to provide comprehensive information on the topic. From understanding the causes to exploring diagnosis and management options, we will cover all you need to know about amenorrhea.

What is Amenorrhea?

Amenorrhea is described as the complete absence or cessation of menstruation. There are two main types of amenorrhea: (Wellons, M. F. et al., 2017)

Primary amenorrhea:

The lack of menstrual bleeding before age 15 in the absence of hormonal treatment or the lack of menstrual bleeding before age 13 without the development of secondary sex characteristics. (Marsh, C. A., & Grimstad, F. W. 2014)

Secondary amenorrhea:

After menarche, the absence of menses for a length of time equivalent to at least 3 of the previous menstrual cycle intervals, or 6 months. (Elahi, A. et al., 2016)

Understanding the distinction between these types is crucial for proper diagnosis and management.

Causes of Amenorrhea

The causes of amenorrhea can vary widely and may include lifestyle factors, medical conditions, and natural changes in the body. Here are some of the most common causes:

1. Pregnancy: The most common cause of secondary amenorrhea. When pregnant, the body stops ovulating and menstruating.
2. Breastfeeding: Prolactin, the hormone responsible for milk production, also inhibits menstruation.
3. Menopause: A natural biological process where the ovaries stop producing eggs, leading to the cessation of menstruation.
4. Contraceptives: Hormonal contraceptives like birth control pills, injections, and implants can cause menstrual periods to become irregular or stop altogether.

Do you experience severe cramps, irregular periods, and other menstrual discomforts? We've got the solution for you!

Say goodbye to discomfort and hello to confidence with our personalized Menstrual Health program!

Medical Conditions:

• Polycystic Ovary Syndrome (PCOS): Polycystic Ovary Syndrome. PCOS is a multifactorial endocrine disorder characterized by ovulatory dysfunction, biochemical or clinical androgen access, and polycystic ovaries. A hormonal disorder causing enlarged ovaries with small cysts on the outer edges. (Liu, J. H., Patel, B., & Collins, G. 2015).
• Thyroid Disorders: Hypo- and hyperthyroidism may cause amenorrhea. Late-onset congenital adrenal hyperplasia is a common cause of hyperandrogenic amenorrhea; an elevated serum 17-hydroxyprogesterone level should be followed by confirmatory adrenocorticotropic hormone stimulation testing. (Klein, D. A., Paradise, S. L., & Reeder, R. M. 2019).
• Pituitary Tumors: Noncancerous tumors in the pituitary gland can disrupt the production of hormones that regulate menstruation. Primary amenorrhea may also result from mutations in genes encoding transcription factors involved in the cellular proliferation and differentiation of the pituitary gland. (Fourman, L. T., & Fazeli, P. K. 2015), (Marsh, C. A., & Grimstad, F. W. 2014), (Seppä, S. et al., 2021).
• Premature Ovarian Insufficiency (POI): Also known as early menopause, occurs when the ovaries stop functioning normally before the age of 40.

Diagnosing Amenorrhea

Diagnosing amenorrhea involves a thorough medical history, physical examination, and several tests to determine the underlying cause.

1. Medical History and Physical Exam: A detailed history should include menstrual patterns (if any), pregnancy and breastfeeding history, eating and exercise habits, psychosocial stressors, changes in body weight, fractures, medication or substance use, chronic illness, and timing of breast and pubic hair development^. Galactorrhea, headaches, or visual field defects can indicate hypothalamic or pituitary disease and acne or hirsutism can indicate hyperandrogenism. 

Vasomotor symptoms such as hot flashes or night sweats may indicate primary ovarian insufficiency.  A family history should include the age of relatives' menarche and any chronic disease history.

A physical exam may include a pelvic exam to check for any abnormalities. Clinicians should review trends in height, weight, and body mass index. (Klein, D. A., Paradise, S. L., & Reeder, R. M. 2019). (Pitts, S. et al., 2021)  

2. Pregnancy Test: Since pregnancy is the most common cause of secondary amenorrhea, this test is usually the first step. In all cases, pregnancy should be excluded with a pregnancy test. Serum patterns of follicle-stimulating hormone, luteinizing hormone, prolactin, and thyroid-stimulating hormone identify most endocrine causes of amenorrhea. (Klein, D. A., Paradise, S. L., & Reeder, R. M. 2019).
3. Imaging Tests:

• Ultrasound: To visualize the reproductive organs and detect structural problems.
• MRI (Magnetic Resonance Imaging) or CT scan (Computed Tomography): To identify tumors or abnormalities in the pituitary gland or hypothalamus. (Klein, D. A., Paradise, S. L., & Reeder, R. M. 2019).

4. Genetic Testing: In cases of primary amenorrhea, genetic testing may be performed to identify chromosomal abnormalities. (Klein, D. A., Paradise, S. L., & Reeder, R. M. 2019).

Managing and Treating Amenorrhea

The treatment for amenorrhea depends on its underlying cause. Here are some common management and treatment options:

1. Lifestyle Changes:
• Diet and Exercise: Maintaining a healthy weight through a balanced diet and moderate exercise can help regulate menstrual cycles. Avoid excessive exercise and consider consulting a dietitian.
• For many athletic women, explaining the need for adequate caloric intake to match energy expenditure sometimes results in increased caloric intake or reduced exercise, followed by resumption of menses. However, many women are reluctant to modify their behaviors.
• Nonathletic women who are underweight or who appear to have nutritional deficiencies should have nutritional counseling, and they can be referred to a multidisciplinary team specializing in the assessment and treatment of individuals with eating disorders. (Gibson, M. E. S. et al., 2020)
• Healthy eating habits and regular exercise should be recommended for all patients with PCOS. Weight loss may restore regular menses and improve metabolic comorbidities in patients with an elevated body mass index.
• Stress Management: Techniques such as mindfulness, meditation, yoga, and counseling can help reduce stress and its impact on the menstrual cycle.
2. Medical Treatments:
• Hormonal Therapy: Birth control pills or hormone replacement therapy (HRT) can help regulate menstrual cycles, especially in cases of hormonal imbalance.
• Medications for Underlying Conditions: Treating thyroid disorders, PCOS, or other medical conditions can restore normal menstruation.
• Medications for Ovulation Induction: For women with PCOS or other ovulatory disorders, medications like clomiphene citrate or letrozole can induce ovulation. For women with PCOS and infertility, letrozole (Femara) is a first-line therapeutic option, because it confers higher ovulation, pregnancy, and live birth rates than clomiphene.
3. Surgical Treatments:
• Correcting Structural Problems: Surgery may be needed to correct congenital anomalies, remove tumors, or address scarring in the reproductive organs. (Kriplani, A. et al., 2017)
4. Cognitive behavioral therapy:  Cognitive behavioral therapy (CBT) may be effective for restoring ovulatory cycles in some women. (Welt, C. K et al., 2020)

Schedule a discovery call to explore how our program can help you achieve optimal menstrual wellness. During this call, our experts will discuss your menstrual concerns, and goals, and how our personalized approach can support you on your journey toward better menstrual health. Schedule your free consultation today and take charge of your menstrual health with our specialized program.

When to See a Doctor

It’s essential to consult a healthcare provider if you experience any of the following:

• No menstruation by age 15 or within five years of breast development.
• Absence of menstruation for three or more consecutive months.
• Other symptoms such as excessive hair growth, acne, or weight changes.
• Symptoms of menopause before age 40.
• Symptoms of other medical conditions like thyroid disorders or chronic diseases.

Early diagnosis and treatment can prevent complications and improve outcomes.

Conclusion

Amenorrhea, the absence of menstruation, can be caused by various factors ranging from lifestyle changes to underlying medical conditions. Understanding the different types of amenorrhea, their causes, and the diagnostic process is crucial for effective management. With appropriate medical care, lifestyle adjustments, and support, most women can manage amenorrhea and maintain a healthy reproductive system.

If you suspect you have amenorrhea or are experiencing symptoms, don't hesitate to seek medical advice. Early intervention can make a significant difference in your overall health and well-being.

References

Elahi, A., Fereidooni, A., Shahabinezhad, F., Ajdari Tafti, M., & Zarshenas, M. M. (2016). An overview of amenorrhea and respective remedies in Traditional Persian Medicine. Trends in Pharmaceutical Sciences, 2(1), 3-10.

Wellons, M. F., Weeber, K. M., & Rebar, R. W. (2017). Amenorrhea. Clinical Reproductive Medicine and Surgery: A Practical Guide, 109-122.

Marsh, C. A., & Grimstad, F. W. (2014). Primary amenorrhea: diagnosis and management. Obstetrical & Gynecological Survey, 69(10), 603-612.

Fourman, L. T., & Fazeli, P. K. (2015). Neuroendocrine causes of amenorrhea—an update. The Journal of Clinical Endocrinology & Metabolism, 100(3), 812-824.

Klein, D. A., Paradise, S. L., & Reeder, R. M. (2019). Amenorrhea: a systematic approach to diagnosis and management. American family physician, 100(1), 39-48.

Liu, J. H., Patel, B., & Collins, G. (2015). Central causes of amenorrhea.

Marsh, C. A., & Grimstad, F. W. (2014). Primary amenorrhea: diagnosis and management. Obstetrical & Gynecological Survey, 69(10), 603-612.

Pitts, S., DiVasta, A. D., & Gordon, C. M. (2021). Evaluation and management of amenorrhea. JAMA, 326(19), 1962-1963.

Seppä, S., Kuiri-Hänninen, T., Holopainen, E., & Voutilainen, R. (2021). Management of endocrine disease: diagnosis and management of primary amenorrhea and female delayed puberty. European Journal of Endocrinology, 184(6), R225-R242.

Gibson, M. E. S., Fleming, N., Zuijdwijk, C., & Dumont, T. (2020). Where have the periods gone? The evaluation and management of functional hypothalamic amenorrhea. Journal of clinical research in pediatric endocrinology, 12(Suppl 1), 18.

Welt, C. K., Barbieri, R. L., & Geffner, M. E. (2020). Evaluation and management of secondary amenorrhea. Waltham, MA: UpToDate.

Kriplani, A., Goyal, M., Kachhawa, G., Mahey, R., & Kulshrestha, V. (2017). Etiology and management of primary amenorrhoea: A study of 102 cases at tertiary centre. Taiwanese Journal of Obstetrics and Gynecology, 56(6), 761-764.