Absence of Menstrual Periods (Amenorrhea): Types, Causes & Treatment
What is Amenorrhea?
Amenorrhea refers to the absence of menstrual periods. It is considered normal in certain life stages and situations, such as:
- Before puberty
- During pregnancy
- While breastfeeding
- After menopause
However, outside of these circumstances, amenorrhea can be an early sign of an underlying health issue that may need attention.
Depending on the cause, amenorrhea may be accompanied by other symptoms. Some women may develop masculine features (a condition known as virilization), including excess body hair (hirsutism), a deeper voice, and increased muscle mass. Other possible symptoms include headaches, vision changes, reduced sex drive, and difficulty getting pregnant. In most cases of amenorrhea, the ovaries do not release an egg, which prevents pregnancy.
If amenorrhea persists over a long period, it can lead to complications similar to those experienced during menopause. These include hot flashes, vaginal dryness, decreased bone density (osteoporosis), and an increased risk of heart disease and other cardiovascular issues. This happens because low estrogen levels are common in women with amenorrhea.
Types of Amenorrhea
There are two main types of amenorrhea:
- Primary Amenorrhea: This occurs when menstruation has not begun by age 15. In these cases, girls typically do not go through puberty, and secondary sexual characteristics like breast development and pubic hair do not form normally.
- Secondary Amenorrhea: This occurs when a woman who previously had regular periods stops menstruating. Secondary amenorrhea is more common than primary and can result from a variety of factors, including hormonal imbalances, stress, or medical conditions.
Hormones and Menstruation
The menstrual cycle is regulated by a complex hormonal system. Every month, hormones are released in a specific sequence to prepare the body—particularly the uterus—for pregnancy. If pregnancy does not occur, this cycle ends with the shedding of the uterine lining, which is what causes menstruation.
Key players in the hormonal system that regulate menstruation include:
- The hypothalamus: A part of the brain that helps control the pituitary gland.
- The pituitary gland: Produces important reproductive hormones like luteinizing hormone (LH) and follicle-stimulating hormone (FSH).
- The ovaries: Produce estrogen and progesterone, the primary hormones involved in the menstrual cycle.
Other hormones, such as thyroid hormones and prolactin (produced by the pituitary gland), also play a role in regulating the menstrual cycle. Disruptions in any of these hormones can lead to irregular periods or the complete absence of menstruation (amenorrhea).
Causes of Amenorrhea
Amenorrhea can result from a variety of factors, including hormonal disorders, birth defects, genetic conditions, medications, or even illicit drug use.
The most common cause of amenorrhea in women who are not pregnant or breastfeeding is a malfunction in the hormonal system. This system includes the hypothalamus, pituitary gland, and ovaries, which regulate the menstrual cycle. When one part of this system fails to function properly, the ovaries may not release an egg, leading to what is known as ovulatory dysfunction.
Amenorrhea can also be caused by conditions affecting the uterus, cervix, or vagina. In rare cases, while the hormonal system functions normally, another issue may block menstruation. For example, the uterus may be scarred (a condition called Asherman syndrome), the cervix may be abnormally narrowed (cervical stenosis), or a birth defect might prevent menstrual blood from exiting the body.
The underlying causes of amenorrhea vary depending on whether it is classified as primary or secondary.
Primary Amenorrhea
Primary amenorrhea, where a girl has never had a menstrual period, is relatively rare. The most common causes include:
- Genetic Disorders: Conditions such as Turner syndrome or Kallmann syndrome can interfere with the normal development of reproductive organs or hormonal function.
- Birth Defects of the Reproductive Organs: Some girls are born with structural abnormalities, such as an imperforate hymen, which blocks menstrual blood flow.
- Hormonal Disorders: Overproduction of male hormones (androgens) by the adrenal glands, such as in congenital adrenal hyperplasia, can prevent normal menstrual function.
- Ambiguous Genitalia: Conditions like pseudohermaphroditism or true hermaphroditism, where the genitals are neither fully male nor female, can affect the onset of menstruation.
- Y Chromosome Abnormalities: In some cases, girls may have a Y chromosome, which typically occurs only in males, causing issues with reproductive development.
In some cases, puberty is simply delayed without any underlying disorder, and menstruation begins at a later age. Delayed puberty can run in families.
Secondary Amenorrhea
Secondary amenorrhea, where a woman who previously had regular periods stops menstruating, is far more common. The most frequent causes include:
- Pregnancy and Breastfeeding: Pregnancy is the most common reason for missed periods, while breastfeeding can also delay the return of menstruation.
- Hormonal Dysfunction: Malfunction of the hypothalamus, pituitary gland, or thyroid can disrupt the hormonal signals necessary for menstruation. Conditions like polycystic ovary syndrome (PCOS) or premature menopause (primary ovarian insufficiency) can also lead to secondary amenorrhea.
- Medications: Certain medications, including birth control pills, antidepressants, and antipsychotic drugs, can interfere with the menstrual cycle.
The hypothalamus, a part of the brain that regulates hormones, may stop functioning properly for several reasons:
- Stress or Excessive Exercise: High levels of stress or intense physical activity, especially in athletes who must maintain low body weight, can disrupt the menstrual cycle.
- Poor Nutrition: Eating disorders, significant weight loss, or malnutrition can impact hormonal balance.
- Mental Health Disorders: Conditions like depression or obsessive-compulsive disorder may also contribute to amenorrhea.
- Radiation or Brain Injury: Damage to the brain, whether from injury or treatments like radiation therapy, can affect the hypothalamus or pituitary gland.
The pituitary gland, which produces hormones like prolactin and luteinizing hormone (LH), may malfunction due to:
- Tumors or Head Injuries: These can damage the gland, impairing its function.
- Elevated Prolactin Levels: Certain medications, such as antidepressants or oral contraceptives, can increase prolactin levels, leading to amenorrhea. High prolactin can also result from pituitary tumors or other disorders.
Thyroid dysfunction can also lead to missed periods. An underactive thyroid (hypothyroidism) or an overactive thyroid (hyperthyroidism) can disrupt the menstrual cycle.
Other Causes of Secondary Amenorrhea
While less common, other conditions may lead to secondary amenorrhea, including:
- Chronic Illnesses: Diseases affecting the lungs, digestive system, blood, kidneys, or liver may interrupt menstruation.
- Autoimmune Disorders: Certain autoimmune conditions can affect the reproductive system.
- Cancer or HIV: These serious health conditions can disrupt the menstrual cycle.
- Scarring of the Uterus: Often caused by infections or surgery, scarring can prevent normal menstruation (Asherman syndrome).
- Uterine Polyps or Fibroids: These growths can interfere with normal menstrual bleeding.
- Cushing Syndrome: Caused by high levels of cortisol, this condition can lead to hormonal imbalances that disrupt menstruation.
- Adrenal Gland Malfunction: Disorders affecting the adrenal glands can influence hormone production and lead to amenorrhea.
Lastly, some genetic disorders, such as Fragile X syndrome, can cause menstrual periods to stop early, leading to premature menopause.
Evaluation of Amenorrhea
To evaluate amenorrhea, doctors first determine whether it is primary (periods never started) or secondary (periods started and then stopped). This distinction helps in identifying the potential causes.
Warning Signs
Certain symptoms in girls or women with amenorrhea are reasons for concern, including:
- Delayed puberty
- Development of masculine traits, such as excess body hair, a deepened voice, and increased muscle mass
- Vision issues
- Loss of smell, which could indicate a condition like Kallmann syndrome
- Unexplained milky discharge from the nipples
- Significant weight changes
When to See a Doctor
It’s important for girls and women to consult a doctor if:
- By age 13, there are no signs of puberty, such as breast development or a growth spurt.
- Menstruation hasn’t started within three years after breast development.
- By age 15, menstruation hasn’t started, even if other secondary sexual characteristics are present.
For women who have had regular periods but then stop, it’s crucial to see a doctor if:
- They miss three consecutive periods.
- They experience fewer than nine periods per year.
- There is a sudden change in their period patterns.
Doctors typically perform a pregnancy test when evaluating secondary amenorrhea, and women may choose to take a home pregnancy test before visiting their doctor.
Medical Evaluation
Doctors will begin by reviewing a woman’s medical history, including her menstrual history. A physical examination will follow, and both the history and exam results often provide clues to the cause of amenorrhea, guiding the need for additional tests.
In the menstrual history, doctors ask:
- When the periods started and when the last one occurred.
- How long periods lasted.
- How often they occurred.
- Whether they were regular or irregular in the last three to twelve months.
- The heaviness of the flow.
- Whether there were any associated symptoms, such as breast tenderness or mood swings.
For girls who have never had a period, doctors ask about the timing of other developmental milestones:
- When breast development began.
- When growth spurts occurred.
- The appearance of pubic and underarm hair.
- Whether family members have had any menstrual abnormalities.
This information can help rule out some causes of amenorrhea, such as genetic disorders or delayed puberty.
Physical Examination
The physical exam checks for the development of secondary sexual characteristics, such as breast development and pubic hair. A breast exam is also performed, and a pelvic exam may be conducted to ensure the reproductive organs are developing normally and to identify any abnormalities.
Doctors will also look for signs that could suggest a specific cause, such as:
- Milky discharge from the nipples, which could indicate a pituitary disorder or the effects of medications that raise prolactin levels.
- Headaches, hearing issues, or vision changes, which could point to tumors in the pituitary gland or hypothalamus.
- Masculine traits like excessive body hair or a deepened voice, which could indicate conditions such as polycystic ovary syndrome (PCOS), hormone-secreting tumors, or certain medications.
- Hot flashes, vaginal dryness, or night sweats, which suggest premature menopause or other ovarian issues.
- Tremors with weight loss or sluggishness with weight gain, which may indicate a thyroid disorder.
- Signs of eating disorders, such as tooth enamel erosion, enlarged cheek glands, or inflammation of the esophagus, which could suggest conditions like anorexia nervosa.
Testing for Amenorrhea
Depending on the patient’s age and symptoms, testing may include:
- Pregnancy Test: Always the first step for women of childbearing age.
- Blood Tests: Used to measure hormone levels, including thyroid hormones, prolactin, follicle-stimulating hormone (FSH), and androgens (male hormones).
- Imaging Tests: Ultrasounds or, in some cases, MRI or CT scans to examine the reproductive organs or brain for abnormalities.
- Hormonal Challenge Tests: Hormonal medications (like estrogen and progestin) may be given to see if they trigger a menstrual period, helping determine if the issue is related to hormone production or structural problems.
For primary amenorrhea (where periods have never started), if a girl has normal secondary sexual characteristics, doctors will start with hormonal blood tests, a physical examination, and an ultrasound to check for any structural abnormalities blocking menstrual flow. If necessary, more advanced imaging, like MRI, may be used.
If symptoms suggest a specific disorder, tests are prioritized accordingly. For example, if a woman has headaches or vision issues, an MRI may be done to check for a pituitary tumor.
Other tests might include:
- Chromosome Testing: To identify genetic disorders.
- Hysteroscopy or Hysterosalpingography: Procedures to check for blockages in the uterus or fallopian tubes.
If hormonal medications successfully trigger menstrual bleeding, this suggests that the cause is likely related to hormone production or premature menopause. If bleeding does not occur, the problem may involve the uterus or a structural abnormality preventing menstrual flow.
This thorough evaluation process allows doctors to pinpoint the cause of amenorrhea and determine the best course of treatment.
Treatment of Amenorrhea
The treatment for amenorrhea depends on its underlying cause. If the amenorrhea is due to a treatable condition, addressing that condition can often lead to the resumption of menstrual periods. For instance, if a woman has a hormonal imbalance, such as hypothyroidism (underactive thyroid), or if there is a physical obstruction preventing menstrual blood flow that can be corrected surgically, her periods may return after treatment.
For young girls whose periods have not started despite normal test results, regular check-ups with a healthcare provider every 3 to 6 months are recommended to monitor the progression of puberty. In some cases, medications like progestin or estrogen may be prescribed to initiate menstruation and encourage the development of secondary sexual characteristics, such as breast growth.
Other issues associated with amenorrhea may also require treatment:
- Infertility: If amenorrhea is preventing pregnancy, hormonal treatments may be necessary to stimulate ovulation (the release of an egg).
- Effects of Estrogen Deficiency: Long-term lack of estrogen can lead to problems like decreased bone density (osteoporosis), vaginal dryness, and a higher risk of cardiovascular disease. Hormone replacement therapy (HRT) may be used to alleviate these symptoms and mitigate the risk of further complications.
- Excess Hair Growth: If amenorrhea is caused by a hormonal disorder that leads to excess body hair (hirsutism), treating the underlying condition may reduce hair growth. In some cases, cosmetic procedures like hair removal may be considered.
To combat the effects of low estrogen, it’s important to support bone health by ensuring adequate intake of calcium and vitamin D, either through diet or supplements. Medications that help preserve bone density, such as bisphosphonates or denosumab, may also be recommended.
In rare cases, amenorrhea can result from genetic conditions that affect hormone production, such as Turner syndrome. While these conditions cannot be cured, treatment can help manage symptoms. Women with a Y chromosome may be advised to undergo preventive surgery to remove the ovaries due to the increased risk of ovarian germ cell cancer, a type of cancer that develops in the egg-producing cells of the ovaries.
Frequently Asked Questions (FAQs)
Can a UTI affect your period?
Yes, a UTI can potentially affect your menstrual cycle. The stress and inflammation caused by the infection may disrupt hormonal balance, which could lead to changes in your menstrual cycle. However, it’s important to note that while this is possible, it’s not a guaranteed effect for everyone with a UTI.
Can UTI delay menstruation?
A UTI might delay menstruation in some cases. The physical stress of fighting an infection can affect the body’s hormonal balance, potentially leading to a delayed period. However, if you experience a significant delay in your menstrual cycle along with UTI symptoms, it’s advisable to consult with a healthcare provider to rule out other potential causes.
Can a yeast infection prolong your period?
Yeast infections do not typically prolong menstruation. However, they can cause irritation and discomfort that may coincide with menstruation.
Can a UTI stop your period?
While a UTI is unlikely to completely stop your period, it may cause irregularities in your menstrual cycle. The stress on your body from fighting the infection could potentially lead to a lighter or shorter period, or in some cases, a delayed period. If you miss a period entirely while having a UTI, it’s advisable to consult with your healthcare provider.
How can I get my period back?
Restoring your period depends on the underlying cause. Addressing factors such as stress, diet, or hormonal imbalances through lifestyle adjustments or medical treatment can help resume regular menstrual cycles.
Conclusion
Amenorrhea, or the absence of menstrual periods, can have a wide range of causes, from lifestyle factors to medical conditions that require treatment. Early diagnosis and treatment are essential for preventing complications such as infertility, osteoporosis, or cardiovascular issues. If you experience missed periods, consult with a healthcare provider to determine the underlying cause and develop an appropriate treatment plan.
Maintaining a healthy lifestyle, managing stress, and seeking medical advice for hormonal or reproductive health issues are vital steps in managing amenorrhea and safeguarding overall well-being.
