Amenorrhea is the absence of menstruation in a woman of childbearing age. Amenorrhea occurs normally during pregnancy but can also occur pathologically during the fertile period, most often a sign of an underlying disease.
The menstrual cycle is the set of physiological phenomena that prepare women (and other female mammals) for reproduction. It is regulated by hormones of the hypothalamic-pituitary axis (LH and FSH). During this time, the uterus undergoes changes. The endometrium, the lining of the uterus, grows during the cycle, so as to accommodate the embryo in the event of fertilization. It is a region heavily supplied with blood vessels. If there is no implantation of the embryo, and therefore no pregnancy, then the cycle ends before a new one begins. This transition is characterized by loss of the endometrium, which is accompanied by heavy bleeding, called periods.
From 2% to 5% of women are thought to be affected by a lack of periods (amenorrhea). While not having a period is quite natural when, for example, a woman is pregnant, breastfeeding or approaching menopause, amenorrhea is serious problem that should not be neglected. Outside of the aforementioned situations, it can be a telltale sign of chronic stress or a health problem like anorexia or a thyroid disorder.
Types of amenorrhea
Primary amenorrhea relates to the absence of menarche in a 16-year-old woman or older. Menarche is the first menstrual cycle or the first menstrual bleeding in a young woman, which varies by factors, such as ethnicity, geographic region, and other characteristics. Primary amenorrhea may present due to conditions like:
- Turner syndrome
- Müllerian syndrome
- Vaginal atresia
- Atresic hymen
- Swyer syndrome
- Prader-Willi syndrome
- Kallmann syndrome
Secondary amenorrhea involves the disappearance of menstruation in a woman who has previously had a regular menstrual cycle. Three months or more without a menstrual period in a woman is the definition of amenorrhea. This most often occurs in women who are pregnant, breastfeeding or approaching menopause (between 40 and 55 years old).
However, there are various other causes of secondary amenorrhea, including Asherman’s syndrome, strained physical activity, and lower body weight. These can affect a woman of any age and, for this reason, can lead to amenorrhea in a woman who has previously had a regular menstrual cycle.
These are the most frequent. The hypothalamus, whose role is among other things to control hormonal secretions, is the seat of affective processes and intellectual activity. An important event (bereavement, grief, fear, emotion, disappointment, emotional shock, or even simply a change in lifestyle or climate, etc.) can inhibit the hypothalamus which is unable to play its very punctual role of releasing of LH-RF, which stimulate the genital glands.
The intensive practice of sport can cause amenorrhea which heals with reduced training. The most intense form of amenorrhea is anorexia nervosa.
When to consult a doctor?
The following people should see a doctor:
- Women with primary or secondary amenorrhea;
- In the event of amenorrhea after a period of contraception, a medical evaluation is necessary if the amenorrhea persists for more than 6 months in women who have been on the contraceptive pill, who have worn a IUD, or more than 12 months after the last injection of medroxyprogesterone acetate.
Important. Sexually active women who are not taking hormonal contraceptives should be tested for pregnancy if their period is more than 8 days late, even when they are “sure” that they are not pregnant. Note that bleeding that occurs with hormonal contraception (especially a false period generated by the birth control pill) is not proof of absence of pregnancy.
Diagnosis of amenorrhea
In most cases, physical examination, a pregnancy test, and sometimes an ultrasound of the sexual organs are sufficient to guide the diagnosis.
An x-ray of the wrist (to assess pubertal development), hormone assays or chromosomal sex testing are done in rare cases of primary amenorrhea.
Causes of amenorrhea
There are many causes of amenorrhea. Here are the most frequent in descending order.
The most common cause of secondary amenorrhea, it must be the first suspected in a sexually active woman. Surprisingly, it often happens that this cause is ruled out without prior checking, which is not without risk. Some treatments indicated to treat amenorrhea are contraindicated in pregnancy. And with commercially available tests, diagnosis is simple.
- A minor delay in puberty
It is the most common cause of primary amenorrhea. The age of puberty is normally between 11 and 13 years old, but can vary widely depending on ethnicity, geographic location, diet, and state of health.
In developed countries, delayed puberty is common in young women who are very thin or athletic. It seems that these young women do not have enough body fat to allow the production of estrogen hormones. Estrogens allow the lining of the uterus to thicken, and later menstruation if the egg has not been fertilized by a sperm. In a way, the bodies of these young women naturally protect themselves and signal that their physical form is inadequate to support a pregnancy.
If their secondary sexual characteristics are present (appearance of breasts, pubic hair and armpits), there is no need to worry before the age of 16 or 17. If signs of sexual maturation are still absent at the age of 14, a chromosomal problem (a single X sex chromosome instead of 2, a condition called Turner syndrome), a problem with development of the reproductive system or a hormonal problem.
Often women who are breastfeeding do not have a period. However, it should be noted that they can still ovulate during this period, and therefore become pregnant again. Breastfeeding suspends ovulation and protects against pregnancy (99%) only if:
- the baby takes the breast exclusively;
- the baby is less than 6 months old.
- The onset of menopause
Menopause is the natural cessation of menstrual cycles that occurs in women aged 45 to 55 years old. The production of estrogen gradually decreases, causing your periods to become irregular and then go away completely. You can ovulate sporadically for 2 years after you stop having your period.
- Taking hormonal contraception
The “periods” that occur between two packets of pills are not periods linked to an ovulatory cycle, but “withdrawal” bleeding when the tablets are stopped. Some of these pills reduce bleeding, which sometimes after a few months or years of taking it may no longer occur. Mirena® hormonal intrauterine device (IUD), injectable Depo-Provera®, continuous contraceptive pill, Norplant and Implanon implants can cause amenorrhea. It is not serious and demonstrates contraceptive efficacy: the user is often in a “hormonal state of pregnancy” and is not ovulating. It therefore has no cycle, no rules.
- Stopping a contraceptive
Stopping a contraceptive method (birth control pills, Depo-Provera®, Mirena® hormonal IUD) after several months or years of use. It may take a few months before your normal ovulation and menstruation cycle is restored. It is called post-contraceptive amenorrhea. In fact, hormonal contraceptive methods reproduce the hormonal state of pregnancy, and can therefore suspend periods. These may therefore take some time to return after stopping the method, such as after pregnancy. This is particularly the case in women who had a very long (more than 35 days) and unpredictable cycle before taking the contraceptive method. Post-contraceptive amenorrhea is not problematic and does not compromise subsequent fertility. Women who find out they have fertility problems after contraception have had them before, but because of their contraception, they had not “tested” their fertility.
- The practice of a demanding sport
The practice of a demanding sport such as marathon, bodybuilding, gymnastics or professional ballet. “Sportswoman’s amenorrhea” is believed to be due to insufficient fatty tissue as well as the stress to which the body is subjected. There is a lack of estrogen in these women. It can also be a matter of the body not wasting energy unnecessarily since it is often on a low calorie diet. Amenorrhea is 4 to 20 times more common in athletes than in the general population.
- Stress or psychological shock
So-called psychogenic amenorrhea results from psychological stress (death in the family, divorce, loss of employment) or any other type of significant stress (travel, major changes in lifestyle, etc.). These conditions can temporarily interfere with the functioning of the hypothalamus and cause menstruation to stop as long as the source of stress persists.
- Rapid weight loss or pathological eating behavior
Too low a body weight can lead to a drop in estrogen production and to stopping menstruation. In the majority of women who have anorexia or bulimia, their periods stop.
- Excessive secretion of prolactin from the pituitary gland.
Prolactin is a hormone that promotes mammary gland growth and lactation. Excess secretion of prolactin from the pituitary gland can be caused by a small tumor (which is always benign) or by certain medications (especially antidepressants). In the latter case, its treatment is simple: the rules reappear a few weeks after stopping the drug.
- Taking certain medications
Taking certain medications such as oral corticosteroids, antidepressants, antipsychotics or chemotherapy. Drug addiction can also cause amenorrhea.
- Uterine scars
Following surgery to treat uterine fibroids, endometrial resection, or sometimes a cesarean section, there may be a severe decrease in menstruation, or even transient or lasting amenorrhea.
- Obesity or being overweight
The following causes are much less common:
- An abnormality in the development of sexual organs of non-genetic origin. Androgen insensitivity syndrome is the presence, in an XY (genetically male) subject, of female-looking sex organs due to the absence of sensitivity of cells to male hormones. These “intersex” people with a feminine appearance consult at puberty for primary amenorrhea. The clinical and ultrasound examination allows the diagnosis: they do not have a uterus, and their sex glands (testes) are located in the abdomen.
- Chronic or endocrine diseases. An ovarian tumor, polycystic ovary syndrome, hyperthyroidism, hypothyroidism, etc. Chronic diseases that are accompanied by significant weight loss (tuberculosis, cancer, rheumatoid arthritis or other systemic inflammatory disease, etc.).
- Medical treatments. For example, surgical removal of the uterus or ovaries; cancer chemotherapy and radiotherapy.
- An anatomical abnormality of the sexual organs. If the hymen is not perforated (imperforation), this can be accompanied by painful amenorrhea in a young girl who is pubescent: the first periods remain trapped in the vaginal cavity.
Course and possible complications
The duration of amenorrhea depends on the underlying cause. In the majority of cases, amenorrhea is reversible and is easily treated (with the exception, of course, of amenorrhea related to genetic abnormalities, non-operable malformations, menopause or removal of the uterus and ovaries). However, when long-standing amenorrhea goes untreated, the cause can eventually extend to reproductive mechanisms.
In addition, amenorrhea associated with a lack of estrogen (amenorrhea caused by demanding sports or an eating disorder) makes it more at risk of long-term osteoporosis – therefore of fractures, instability of the vertebrae. and lordosis – since estrogen plays an essential role in preserving bone structure. It is now well known that female athletes who suffer from amenorrhea have lower than normal bone density, which is why they are more prone to fractures. While moderate exercise helps prevent osteoporosis, too much exercise has the opposite effect if it is not balanced by a higher calorie intake.
Symptoms of amenorrhea
- In a woman who has never had a period
- No menstruation by age 14 and no development of secondary sexual characteristics.
- No menstruation by age 16 despite the presence of development of secondary sexual characteristics.
- In a woman who has had a previous period
- Absence of menstruation for a period equivalent to at least 3 intervals of previous menstrual cycles or 6 months without periods.
People at risk
All women are likely to have amenorrhea at some point in their life.
- Significant weight loss.
- Prolonged stress.
- Intensive practice of a sports activity.
- A deficient diet.
Prevention of amenorrhea
- Eat a balanced diet and a healthy weight. Make sure that the diet provides enough calories to maintain a healthy weight – but not too many, since obesity also contributes to amenorrhea. The goal is to maintain a sufficient percentage of body fat. A minimum of body fat is indeed necessary to store estrogen.
- Learn to deal with stress. Constraints, emotional tensions, the desire for success require a great capacity for adaptation. They are frequent stresses for many women, whether in the spheres of private, professional or sports life. If this stress is prolonged, the body cannot recover and this can lead to a physiological disturbance, in particular hormonal. Thus, prolonged stress can lead to amenorrhea and stop ovulation
- For athletes: surround yourself with a multidisciplinary team. The intensity of the effort should be appropriate for the athlete, depending on his age and physical abilities. In addition, nutritional intake must be optimal. According to the author of a study2, the 3 most common health problems in female athletes – osteoporosis, amenorrhea and eating disorders – would be completely preventable if women were followed by a multidisciplinary team of therapists (trainer, nutritionist, sports psychologist, etc.), especially when they are in a period of growth.
Treatment of amenorrhea
In the majority of cases, no medical treatment is necessary. Before prescribing treatment, it is imperative to find the cause of the amenorrhea, treat the underlying disease if necessary, and obtain psychological support if needed. Sometimes it is suggested that the sex hormone is tested if the doctor suspects endocrine disease.
The application of the preventive measures mentioned above allows the return of menstruation in many women:
- Healthy eating;
- maintaining a healthy weight;
- stress management;
- moderation in the practice of physical exercises.
Very often, the causes of amenorrhea are minor and curable. It is still important to diagnose them as early as possible to avoid possible consequences for fertility and bone health.
No single treatment can “brings your period back” on its own. To stop amenorrhea, you must first find out the cause and then treat it.
- Hormonal treatments
In the case of ovarian dysfunction in a young woman, hormonal treatment will be suggested to promote the development of sexual characteristics and fertility, and to prevent osteoporosis in the long term.
For women who have undergone surgical removal of the uterus and ovaries very early (before the presumed age of menopause), hormone replacement therapy including estrogen AND progestins may be offered to prevent osteoporosis and others. consequences attributable to the lowering of circulating hormone levels. This treatment can be stopped around the age of 55.
Please note: this treatment cannot be prescribed to women who have had their uterus or ovaries removed for hormone-dependent cancer. It also cannot be prescribed to women who have had ovarian castration by radiotherapy or chemotherapy for breast cancer.
Apart from these situations, no hormonal treatment is effective in bringing about a return of periods.
Also, “cycle regularization” treatments (for example, taking synthetic progestin in the second part of the cycle for women with irregular periods who would like a regular cycle to conceive) have no scientific basis. They can even contribute to accentuate menstrual cycle disorders by compromising the spontaneous onset of ovulations. It is not the regularity of the cycle that counts, but the respect of the cycle as it is in a given woman.
- Non-hormonal treatment
When amenorrhea is due to high prolactin secretion linked to a benign pituitary tumor, bromocriptine (Parlodel®) is a very effective drug that lowers prolactin levels and helps menstrual periods return. This is the same treatment that is given, just after childbirth, to women who do not want to breastfeed.
If amenorrhea is accompanied by a psychological disorder, the doctor may suggest psychotherapy. The parallel use of hormonal treatments can be discussed, depending on the age of the woman, the duration of amenorrhea and the adverse effects of hormonal deficiency (if any). However, psychotropic drugs should be avoided as they can lead to amenorrhea.
Amenorrhea associated with anorexia imperatively requires monitoring by a multidisciplinary team including nutritionist, psychotherapist, psychiatrist, etc. Anorexia often affects adolescent girls or young women.
In the event of significant psychological trauma (rape, loss of a loved one, accident, etc.) or personal conflicts (divorce, financial difficulties, etc.), amenorrhea lasting several months, or even several years, may set in, in particular in a woman whose psychic balance was already fragile. The best treatment is then to consult a psychotherapist.
- Surgical treatment
If amenorrhea is caused by a malformation of the reproductive system, surgery can sometimes be done (for example, if the hymen is imperforated). But if the malformation is too important (Turner’s syndrome or insensitivity to androgens), the surgery will only have a cosmetic and comfort function by modifying the appearance and the functionality of the undeveloped sexual organs, but will not “bring back” the rules.
Amenorrhea is a common occurrence, but most often mild, especially in women who have had their period. The first thing to think about is pregnancy, but very often amenorrhea is just a few days late, not serious. The wisest attitude after taking a pregnancy test is … patience. In the absence of worrying symptoms (loss of weight or appetite, fatigue), it is not necessary to consult before having waited a few weeks.
In young women, primary amenorrhea is most often linked to delayed puberty which, in the majority of cases, is not serious: it is only if the rules have not appeared at 16 that it is necessary to consult. Prescribing treatments to “bring back your period” without first finding out the cause of the amenorrhea is not recommended.