Amenorrhoea (No Period)

What is amenorrhea?

Amenorrhea is abnormal uterine bleeding characterised by the absence of menstrual periods in a female of reproductive age. It can be a transient, intermittent or permanent condition.

What is menarche?

Menarche is the 1st menstrual period occuring when women reach a reproductive age, with the median age being around 12.4 years, though this varies somewhat from person to person. Menarche usually occurs within 2-3 years of initial breast development, which occurs between the ages of 8 & 10 years, known as thelarche.

Primary amenorrhea:

Primary amenorrhea is failing to have menarche, and is usually the result of a genetic or anatomical abnormality. It is diagnosed when there is no menarche by 15 years old in the presence of normal growth and signs of puberty.

What causes primary amenorrhea?

• Genetic or chromosomal abnormalities such as turner syndrome

• Delays in growth and puberty

• Hypothalamus or pituitary gland disorders

• Reproductive tract anomalies or disorders with the development of the uterus, vagina, or hymen, such as vaginal agenesis or an imperforate hymen

Secondary amenorrhea:

Secondary amenorrhea is the absence of menses for ≥ (greater than or equal to) 3 months in girls or women who had regular menstrual cycles; or the absence of menses for ≥ 6 months in girls or women who had irregular menses with at least one previous spontaneous menstruation.

What causes secondary amenorrhea?

• Stress

• Rapid weight loss

• Low body weight or body-mass-index

• Eating disorders (such as anorexia nervosa)

• Pregnancy (the most common cause in women of reproductive age)

• Cushing syndrome

• Disorder of thyroid glands

• Polycystic ovary syndrome (PCOS)

• Hormonal medications (oral contraceptives, depot medroxyprogesterone)

• Primary ovarian insufficiency (POI), also known as premature ovarian failure

• Disorders of the hypothalamus or pituitary gland (e.g hyperprolactinemia due to pituitary adenoma, lactational amenorrhea during breastfeeding or use of antipsychotics)

• Acquired anatomic reproductive tract abnormalities that interfere with menstrual function or obstruct the menstrual flow (E.g Asherman syndrome or cervical stenosis)

When should I see my doctor about primary amenorrhoea? 

• At 13 years old, if no menses has begun, along with no signs of puberty (complete absence of secondary sexual characteristics such as breast development/pubic and axillary hair or growth spurt)

• At 15 years old, if no menses have occurred but there is presence of normal growth and secondary sexual characteristics

• If younger than 15 years old but are amenorrheic with cyclic pelvic pain, then you should be evaluated for possible outflow tract obstruction

• 3 years after thelarche (onset of breast development) but menarche has yet to occur

When should I be checked for secondary amenorrhea?

• If you have had regular menses previously but missed menstrual cycles for ≥ 3 months

• If you have had irregular menses previously but missed menstrual cycles for ≥6 months

• Less than 9 menses a year or cycle length greater than 38 days (oligomenorrhea)

• A new and persistent change in your menstrual pattern (frequency, volume, duration)

How can I prevent amenorrhea?

Maintaining good overall health can help prevent some causes of secondary amenorrhea. You can try to have a healthy lifestyle, follow a healthy diet, get adequate sleep, find ways to reduce your stress and get regular gynaecological appointments.

What are the risk factors of amenorrhoea?

• Stress

• Chronic illness

• Eating disorder

• Over-exercising

• Obesity or being underweight

• Poor diet or depletion of nutrients

• Genetic or chromosomal condition

• Family history of amenorrhea or early menopause

How is amenorrhea diagnosed and investigated?

Medical History

Your comprehensive menstrual history, medical conditions, family history, medications, diet history, exercise habits, stress, lifestyles, exposure to chemotherapy or radiation, may be requested by your healthcare provider.

Physical examination

Besides physical examinations, your doctor may examine your BMI, the presence or absence of secondary sexual characteristics and conduct pregnancy tests breast and pelvic exams.

Breast bud and sexual hair development

The development of breast buds helps to indicate the presence of oestrogen, presumably from functional ovaries, while the growth of sexual hair indicates the presence of androgens.

Ultrasonography and resonance imaging

A pelvic ultrasonography may help identify abnormalities of the uterus, cervix and vagina or absent organs, while magnetic resonance imaging can detect hypothalamic or pituitary lesions.

Karyotype analysis

A doctor may conduct a karyotype analysis to aid in the identification of genetic problems.

Serum hormone testing 

Serum hormone tests can measure the results of your follicle stimulating hormone (FSH), luteinizing hormone (LH), prolactin, thyroid function test (TFT), B-HCG, testosterone, estradiol, progesterone.

Hysterosalpingography and hysteroscopy 

Both hysterosalpingography and hysteroscopy are indicated in cases of possible Asherman syndrome.

What are the possible complications of amenorrhea?

Usually associated with specific underlying conditions, amenorrhea complications include:

• Infertility

• Psychological effects (anxiety, depression)

• Metabolic and cardiovascular disease

• Impending ovarian failure

• Galactorrhea

• Vasomotor symptoms

• Osteoporotic fractures

• Endometrial hyperplasia

• Hyperandrogenism effects (virilisation, hirsutism, and ache)

How can amenorrhea be treated?

Ideally, treatment should be directed at correcting the underlying root cause. Amenorrhea treatment may include lifestyle changes, hormone therapy, surgery, and mental health services.

Lifestyle and diet

Most people with amenorrhea can benefit from a healthy diet, exercise and stress management.

Cause for surgery

In the case of outflow tract abnormalities, surgery may be indicated. In other cases, correcting the underlying pathology should restore normal ovarian endocrine function and prevent the development of osteoporosis.

Dopamine agonists

Dopamine agonists are effective in treating hyperprolactinemia. In most cases, this treatment restores normal ovarian endocrine function and ovulation

Hormone therapy

Hormone replacement therapy is required to achieve peak bone density if you have an underlying pathology that cannot be reversed. In conditions leading to oestrogen deficiency, hormone replacement therapy may also be required to maintain bone density.

Underlying medical issues

Women with evidence of hyperandrogenism and disordered menses have many other medical issues that must be addressed (e.g PCOS with associated diabetes and hypertension), weight loss and hormone therapy are mainstay of treatment.

Other disorders

Other than pregnancy, most other disorders that cause amenorrhea may require referrals for treatment. For adolescents with delay and anovulation, the goal should be the restoration of ovulatory cycles. Otherwise, oestrogen-progestin therapy is indicated.

Will I need surgery for amenorrhea?

Surgery for amenorrhea is rare. Certain conditions might need surgery such as an imperforate hymen, pituitary tumour or uterine scar tissues. It is also important to consume enough calcium and vitamin D to help prevent osteoporosis.

Will my period return after amenorrhea?

Usually, your period will return once you treat the underlying causes. It may take some time to become regular again.