Amenorrhea

Overview

Key Facts

Usually seen in

• Individuals above 16 years of age

Gender affected

• Women

Body part(s) involved

• Reproductive organs

Prevalence

• Worldwide: 1.5–3% (2004)

Mimicking Conditions

• Abdominal distention
• Pseudocyesis

Necessary health tests/imaging

• Lab tests: Beta human chorionic gonadotropin (hCG), Ovary function test, Follicle stimulating hormone (FSH) & Luteinizing hormone (LH)
  
• Imaging test: Ultrasound & Magnetic resonance imagining (MRI)
  
• Hysteroscopy 
  
• Karyotyping

Treatment

• Estrogen 
• Dopamine agonist: Bromocriptine (Parlodel) & Cabergoline
• Birth control pills: Medroxyprogesterone
• Estrogen replacement therapy (ERT)

Specialists to consult

• Endocrinologist
• Gynecologist

Symptoms Of Amenorrhoea 

The main symptom of amenorrhoea is the lack of periods for at least three months. Depending upon the cause the other symptoms of amenorrhoea can be: 

• Hair loss 

• Headache 

• Visual disturbances

• Tiredness

• Lack of breast development 

• Discharge from breast 

• Excess facial hair 

• Sleep disturbance

• Vaginal dryness 

• Pelvic pain 

• Acne 

• Deepening of the voice 

Causes Of Amenorrhoea 

Amenorrhea is often a sign of another health problem rather than a disease itself, and it can happen for many reasons. This can occur as a natural part of life such as during pregnancy, breastfeeding, and menopause. However, the absence of menstruation can also indicate a problem within the ovaries, uterus, hypothalamus, and pituitary gland, or an abnormality of the genital tract. Amenorrhea has also been linked to infertility, some medications, and lifestyle factors. 

There can be two types of amenorrhoea namely primary and secondary. 

Primary amenorrhea (failure of menses by the age of 16)

It can be due to the following reasons:

1. Genetic abnormalities: Sometimes, it causes the ovaries to stop functioning. A genetic syndrome that is linked to the missing of an X chromosome, is called Turner’s syndrome. This syndrome is characterized by ovarian insufficiency due to defects in the development of genitals, hence it can delay or disrupt menstruation.

Another genetic cause of primary amenorrhoea is Mayer–Rokitansky–Küster–Hauser (MRKH) syndrome. In MRKH syndrome, the mullerian ducts (an embryonic structure that develops into the female reproductive tract) develop abnormally which results in the absence of a uterus and cervix. Even though patients with MRKH have functioning ovaries and secondary sexual characteristics, they may experience primary amenorrhea due to absence of any functioning uterus.

2. Problems with hypothalamus or pituitary gland: Hormonal issues because of problems with the hypothalamus or the pituitary gland can cause amenorrhoea or delay in onset of menstruation.

3. Imperforate hymen: This is a disorder in which a hymen has no opening and completely obstructs the vagina.

4. Transverse vaginal septum: This is a birth defect that results in a wall of tissue running horizontally across the vagina, blocking all or part of it.

5. Constitutional delay of puberty: Constitutional delay of puberty is a transient state associated with prolonged childhood phase and delayed pubertal growth spurt. It is not attributed to any disease but is considered just a modification of the timeline of puberty. Although it is more common in boys, girls with delayed puberty present with onset of secondary sexual characteristics after the age of 14, as well as menarche (beginning of menstrual periods) after the age of 16. This may be due to genetics or family history.  This diagnosis is made when other causes have been ruled out.

Secondary amenorrhea (not having periods for at least 6 months after menstruating normally) 

This can result from various causes like:

1. Natural causes: Pregnancy is the most common natural cause of secondary amenorrhea and other physiologic causes include breastfeeding and menopause.

Breastfeeding or lactational amenorrhea is due to the presence of elevated prolactin and low levels of luteinizing hormone (LH) in the blood. LH plays an important role in sexual development and functioning, which suppress ovarian hormone secretion. The duration of lactational amenorrhoea depends on how often a woman breastfeeds. 

2. Health conditions: Several health conditions can also lead to seconday amenorrhea such as:

• Pituitary tumors: The pituitary gland in the brain regulates the production of hormones that affect many body functions. The tumors of the pituitary gland are usually noncancerous but can interfere with the normal hormonal regulation of menstruation.
• Thyroid issues: The thyroid is a small butterfly-shaped gland at the base of the neck. The thyroid produces two hormones that control metabolism and plays a vital role in puberty and menstruation. Both upregulation and downregulation of the thyroid gland can cause menstrual irregularities, including amenorrhea.
• Polycystic ovary syndrome (PCOS): PCOS is a hormonal disorder common among women of reproductive age. PCOS may cause menstrual cycle changes, increased facial and body hair, cysts in the ovaries, and infertility. Most women with PCOS either have amenorrhea or experience irregular periods, called oligomenorrhea.
• Hypothalamic amenorrhoea: This condition occurs when the hypothalamus, a gland in the brain that regulates body processes, slows or stops releasing gonadotropin-releasing hormone (GnRH). GnRH is the primary hormone for the starting of the menstrual cycle. 
• Low body weight: Women who perform extraneous exercise regularly or lose a significant amount of weight are at risk of developing Functional Hypothalamic Amenorrhoea (FHA). In such cases, women do not consume enough calories to maintain their normal menstrual cycles.
• Hyperandrogenaemia: In this case, the body makes high levels of male sex hormones, which can affect the female reproductive system. This can be caused by tumors of the ovary or adrenal gland, or certain conditions present at birth.
• Premature menopause: Menopause usually begins around age of 50 years. But, for some women, the ovarian supply of eggs diminishes before the age of 40 leading to early cessation of menstruation.

3. Medications and therapies: These include:

• Birth control pills: Some birth control pills may cause missed periods or the complete absence of menstruation. A few injectable contraceptives and hormonal intrauterine devices (IUDs) can cause amenorrhea. After stopping the pills and injectables it takes a few months to restart a regular menstrual cycle.
• Recreational drugs: The use of opiates (such as heroin) on a regular basis has also been known to cause amenorrhoea in longer term users.
• Antipsychotic drugs: The drugs which are commonly used to treat schizophrenia, have been known to cause amenorrhoea as well. Research suggests that antipsychotic medications result in hormonal imbalance which can cause amenorrhea.
• Radiation and chemotherapy: Certain cancer treatments like bone marrow, blood, lymph nodes, and breast can destroy estrogen-producing cells and eggs in the ovaries, leading to amenorrhea. 

4. Poor nutrition: Nutritional deficiencies may affect the functioning of the hypothalamus and pituitary gland, which can lead to amenorrhea.

5. Stress: Stress can affect hormone levels in the body, and can lead to hypothalamic amenorrhoea. 

Risk Factors For Amenorrhoea 

There are various factors that can put one at the risk of developing amenorrhea. Some of the risk factors are:

1. Eating disorders

These disorders are psychological conditions that cause the development of unhealthy eating habits. They might start with an obsession with food, body weight, or body shape. Anorexia nervosa is likely the most well-known eating disorder. People with anorexia generally view themselves as overweight, even if they’re dangerously underweight.

Another eating disorder is bulimia nervosa, people with bulimia frequently eat unusually large amounts of food in a specific period. Both these disorders affect women more than men during adolescence and early adulthood. When an eating disorder is present, the most common cause of missing a period is hypothalamic amenorrhea (HA).

2. Excessive exercise 

Excessive exercise may cause the hormone to be released less frequently or it may cause the amount of the hormone released at each pulse to decrease. The prevalence of amenorrhoea is more likely when excessive exercise is combined with low-calorie intake or a low body fat percentage.

3. Family history 

If there is a family history of delayed menstruation or irregular menstruation, there can be a chance of genetic predisposition to amenorrhea.

4. Structural abnormalities

Girls who have congenital abnormalities such as poorly developed genital and pelvic organs can be at the risk of developing amenorrhea. 

5. Tumor and its treatments

Sometimes, after receiving chemotherapy and radiotherapy ovarian failure can occur which leads to the absence of menstruation. 

Diagnosis Of Amenorrhoea 

1. Physical examination and medical history 

During the history and physical examination, clinicians first ask about the age of the person and the start of the menses at puberty (menarche). This will help the physician in diagnosing whether it is primary or secondary amenorrhoea. If the patient was not menstruating at all, then it must be primary amenorrhea. All other cases will be secondary amenorrhea. 

The medical findings would include a history of night sweats, sleep disturbance, and hot flashes for premature ovarian failure, a history of chemotherapy, and radiation therapy for neoplasm should be obtained because these can also cause ovarian failure in young women.

The doctor would also check the presence of any chronic illness to determine the exact reason as these diseases affect the hypothalamic-pituitary axis, which plays a vital role in controlling the female menstrual cycle.

The physical examination should include the following parameters: 

• Checking body mass index (BMI) to rule out disorders of eating like anorexia nervosa and malnutrition.

• Measuring the height, weight, and fat index of the patient to look for the presence of any chronic illness.

• Examining the breasts, pubic hair, and the clitoral index is also an important part during the physical examination to rule out genetic syndrome. For example, a normal chest examination can rule out Turner's syndrome. 

2. Lab tests

A variety of blood tests may be necessary, including:

• Beta human chorionic gonadotropin (Beta-hCG): This test is an accurate test for checking the pregnancy. The hCG hormone is produced by the embryo and it is present in the blood after a first missed period. This test is done to confirm or rule out pregnancy which is the most common cause of amenorrhoea. 

• Ovary function test: It measures the amount of follicle-stimulating hormone (FSH) and luteinizing hormone (LH). The FSH blood test is used to help diagnose problems with sexual development, menstruation, and fertility. The LH blood test measures the amount of luteinizing hormone, which plays role in sexual development and regulation of the menstrual cycle. Measuring the amount of FSH in the blood can determine if the ovaries are working properly.

• Thyroid function tests: A thyroid profile test shows high levels of thyroid-stimulating hormone (TSH) but normal levels of the other hormones generally indicate that amenorrhea has been caused by hypothyroidism. The thyroid produces hormones that control metabolism and play a role in puberty and menstruation. 

• Prolactin test: The level of prolactin is increased in the case of amenorrhoea. This hormone plays a central role in a variety of reproductive functions. Pathological hyperprolactinemia most commonly presents as an ovulatory disorder and is often associated with secondary amenorrhea or oligomenorrhea.

• Progesterone challenge test: This test is also called the progestin challenge test, which is performed to differentiate between the anovulation, anatomic, and estradiol deficiency as causes of amenorrhea. If bleeding takes place after withdrawing progesterone within 2 to 7 days, the cause must be the anovulation, but if no bleeding takes place after progesterone withdrawal, the causes are other than anovulation or premature ovarian failure. 

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3. Imaging tests

Depending on the sign and symptoms, various tests can be recommended. 

• Ultrasound: This test, also called sonography, is an imaging method that uses high-frequency sound waves to produce images of structures within your body. If a person never had menstruation, the doctor may suggest an ultrasound test to check for any abnormalities in the reproductive organs.

Note: If a uterus is not present on ultrasound, karyotype analysis is obtained to assess for MRKH.

• Magnetic resonance imaging (MRI): MRI uses a strong magnetic field and radio waves to create detailed images of the organs and tissues within the body. A doctor may recommend an MRI to check for a pituitary tumor, a large non-functioning pituitary tumor that causes amenorrhea by compressing the normal pituitary gland. Therefore, the pituitary hormone directly affects the menstrual cycle.

4. Hysteroscopy 

If another test does not reveal a specific cause, hysteroscopy is performed. It is an exam of the inside of the cervix and uterus using a thin, lighted, flexible tube called a hysteroscope. This test is done to diagnose problems related to the uterus like abnormal vaginal bleeding, polyps, and fibroids. 

5. Karyotyping 

In a few cases, where there is a family history or a genetic syndrome is running in the family. A karyotype (chromosomal analysis) is not indicated as an initial test for amenorrhea as it is not a screening test. Chromosomal abnormalities like turner syndrome contribute as one of the etiological factors in patients with primary amenorrhea; girls who did not attain menarche by the age of 11-15 years. 

Prevention Of Amenorrhoea 

A woman can prevent amenorrhea by following programs:

• Maintaining a healthy weight

• Exercising regularly

• Eating a well-balanced diet

• Managing stress 

• Getting regular and adequate sleep.

• Being aware of your menstrual cycle (so you’ll know if you miss a period)

Complications Of Amenorrhea 

The causes of amenorrhea can cause other problems as well. These include:

• Infertility: One of the problems caused by amenorrhea is not getting pregnant. Primary amenorrhea or secondary amenorrhea for several months may be a sign of a disease or chronic condition that can lead to infertility. Amenorrhea caused by hormonal imbalance can also lead to miscarriage or other problems with pregnancy. 

• Psychological stress: Not having regular menstrual flow when your peers are having theirs can be stressful, especially for women who are trying to conceive and are planning a family. 

• Osteoporosis: Estrogen also plays a role in bone health. If amenorrhea is caused by low estrogen or problems with estrogen production, a woman may be at risk for loss of weak or brittle bones. 

• Pelvic pain: If any structural problem is causing amenorrhea, it may also cause pain in the pelvic area.

Treatment Of Amenorrhoea 

Treatment is mainly dependent on the cause of amenorrhea and the health status of a person: 

Medication

1. If amenorrhoea is due to estrogen deficiency, estrogen can be administered. 

2. Dopamine agonist: Bromocriptine and cabergoline are effective for treating hyperprolactinemia (increased levels of prolactin). It restores the normal endocrine function and ovulation

3. In women with the polycystic ovarian syndrome (PCOS), metformin can be given to induce ovulation

4. Birth control pills or other types of hormonal medication, including oral contraceptives may be prescribed to restore the menstrual cycle and to provide estrogen replacement to women with amenorrhea. Before administering oral contraceptives, withdrawal bleeding is induced with an injection of progesterone, or oral administration of 5-10 mg of medroxyprogesterone can be recommended for 10 days. 

5. Estrogen replacement therapy (ERT) helps in balancing hormonal levels and restarting the menstrual cycle in women with primary ovarian insufficiency (POI). Hormone replacement therapy works by replacing estrogen hormone that is no longer being made by the body. 

6. Treatment of hypo or hyperthyroidism: Replacement therapy with levothyroxine to correct hypothyroidism and antithyroid drugs like methimazole to correct the underlying hyperthyroidism.

Surgical treatment 

1. In the case of pituitary tumor, medications may be recommended to shrink the tumor. If medication does not work, surgery may be necessary to remove the tumor. Most of the time, pituitary tumors are removed through the nose and sinuses, but sometimes radiation therapy may be used to shrink the tumor. 

2. Women with intrauterine adhesions require dissolution of the scar tissue. Removal of the scar tissue during a procedure called a hysteroscopic resection can help restore the menstrual cycle.

Home-care For Amenorrhoea 

Home remedies 

Some of the herbs mimic estrogen-like effects and are sometimes used to treat amenorrhoea symptoms. Apart from these traditional treatments, there are several home remedies for amenorrhea that may bring some symptomatic relief such as:

1. Fenugreek (Methi): It is considered to be a solution for many problems related to the menstrual cycle and reproduction. Fenugreek intake has shown many positive results in milk production, amenorrhea, and relief from menstrual cramps.

2. Saffron (Kesar): It is an antioxidant that can act as a toxin-flushing and stress-reducing agent. The therapeutic effects of saffron are attributed to its relaxant effect on smooth muscles and stimulating menstruation.

3. Chamomile (Babunah ke phul): It is used as a relaxant and an antispasmodic that can be taken as a supplement or drunk as a tea. The absence of menstruation caused by stress and anxiety can be treated with chamomile.

4. Turmeric (Haldi): It has its ancient medicinal properties that help to heal internal injuries and is also used as a uterine stimulant that is used to regulate menstrual flow. 

5. Lemon (nimbu) balm: It is another herb that has been used in the treatment of amenorrhea and other menstrual problems. It promotes the menstrual cycle and eases menstrual cramps. 

6. Blue cohosh: Blue and black cohosh are phytoestrogenic herbs, which are commonly used to treat menopause symptoms in middle-aged women. A phytochemical called opsonin, which is present in this herb, provides stimulation for blood flow in the pelvic region to effectively treat amenorrhea and other gynecological diseases. 

Alternative Therapies For Amenorrhoea 

1. Yoga and exercise 

Doing yoga and exercises three times a week can help improve blood circulation and help the body to feel fresh and prevent from feeling fatigued all the time. Yoga and exercise are useful in reducing stress or pressure on the body and have also proven to relieve stress, manage anxiety, and pain management.

2. Acupuncture 

Acupuncture is a traditional chinese medicine technique that involves sticking finely pointed needles in areas of the body known as acupuncture points. Acupuncture may improve hormonal imbalances that go along with amenorrhea. It is also believed that the needles stimulate specific nerves and muscles, which in turn release natural pain-relieving hormones in the body.

3. Massage 

Massage helps in increasing circulation and relieving pain from pelvic congestion. But, massage is only used for treating physical symptoms like pain rather than treating the cause of the problem. 

4. Nutritional approach 

Eating a healthy diet and limiting processed foods, and eating foods with heart-healthy fats (unsaturated fats) rather than saturated fats. Eating a more wholesome diet containing grains, vegetables, and omega-3 fatty acids. A diet that is very low in fat can raise your risk of amenorrhea. 

• Supplemental calcium, Vitamin D3, magnesium, and Vitamin K should be taken as women having irregular periods are at an increased risk of weak and brittle bones (osteoporosis). These vitamins and minerals may help to keep bones strong.

• Vitamin B6 (pyridoxine) is important for normal brain development and for keeping the nervous system and immune system healthy. Vitamin B6 may reduce high prolactin levels. Prolactin is a hormone released by the pituitary gland, and women with amenorrhea often have increased levels of prolactin.

5. Chiropractic care 

Chiropractic is a healthcare profession that cares for a patient's neuromusculoskeletal system, the bones, nerves, muscles, tendons, and ligaments. This is a natural, safe, and effective way to relieve menstrual cycle symptoms as well as increase fertility. This form of alternative therapy aims to ease any pain you have and improve the way your body functions. 

6. Hot water bath 

It helps in relieving the pain due to the absence of the menstrual cycle, the hot water bath has muscle relaxant properties, the heat from the water can improve the blood circulation in the body and also ease tension from the muscles. 

Living With Amenorrhoea

Self management can help in taking care of yourself. 

Know about your condition: Sometimes, amenorrhoea can affect the mental health of a person and it can lead to anxiety and depression. Talking to your near and dear ones can eliminate cases of emotional drainage and thus an effective treatment plan. 

Exercising daily: It increases the blood circulation of the body and frees the mind from tension and stress. 

Take your medicine on time: Self helps give a sense of satisfaction to the person that he/she is aware of the condition. 

Talk with a doctor openly in case of any questions related to the issues faced: The person having amenorrhoea should ask as many questions that come to his mind. 

Lower the stress levels: Practicing meditation and yoga helps in eliminating stress and keeps the person happy. 

Take adequate sleep: Sleep activates and calms the body and mind. This makes the person feel less fatigued.