Absence of Menstruation (Amenorrhea)

Normal menstruation requires a complex interaction between the hypothalamus, pituitary gland, ovaries, and uterus. Any disruption in this hormonal cascade or structural abnormalities can result in amenorrhea. The menstrual cycle serves as a vital sign of women's health, and its absence often signals underlying issues that need attention.

Primary amenorrhea occurs when menstruation hasn't started by age 15 (or within 3 years of breast development). This may indicate genetic conditions, structural abnormalities, or hormonal disorders. Secondary amenorrhea, the more common type, happens when previously regular periods stop for three or more months, or irregular periods stop for six months.

While pregnancy is the most common cause of secondary amenorrhea, numerous other factors can interrupt menstruation. These range from lifestyle factors like stress and weight changes to medical conditions affecting hormone production. Understanding the distinction helps healthcare providers determine appropriate testing and treatment strategies.

Natural Causes

• Pregnancy: Most common cause in reproductive years
• Breastfeeding: Prolactin suppresses ovulation
• Menopause: Natural cessation around age 51
• Perimenopause: Irregular periods before menopause

Hormonal Disorders

• PCOS: Most common hormonal cause
• Thyroid disorders: Both hyper and hypothyroidism
• Hyperprolactinemia: Elevated prolactin levels
• Hypothalamic amenorrhea: Stress, weight loss, exercise
• Premature ovarian failure: Early menopause
• Cushing's syndrome: Excess cortisol
• Congenital adrenal hyperplasia: Enzyme deficiency

Structural Problems

• Müllerian anomalies: Absent uterus/vagina
• Asherman's syndrome: Uterine scarring
• Imperforate hymen: Blocked menstrual flow
• Vaginal septum: Anatomical barrier
• Cervical stenosis: Narrowed cervical opening

Lifestyle and Other Factors

• Excessive exercise: Female athlete triad
• Low body weight: BMI under 18.5
• Eating disorders: Anorexia, bulimia
• Significant stress: Physical or emotional
• Medications: Birth control, antipsychotics, chemotherapy
• Chronic illness: Diabetes, celiac disease
• Rapid weight changes: Gain or loss

Amenorrhea often occurs with other symptoms that help identify the cause:

• Hot flashes: Suggests menopause or ovarian failure
• Galactorrhea: Breast milk discharge, indicates high prolactin
• Hirsutism: Excess hair growth, common with PCOS
• Acne: Hormonal imbalance, especially androgens
• Weight changes: Gain with PCOS, loss with hypothalamic
• Headaches: May indicate pituitary tumor
• Vision changes: Pituitary adenoma pressing optic nerve
• Fatigue: Thyroid disorders, anemia
• Pelvic pain: Structural abnormalities
• Vaginal dryness: Low estrogen states
• Mood changes: Hormonal fluctuations
• Bone pain: Osteoporosis from low estrogen

• Family history: PCOS, early menopause, thyroid disease
• Eating disorders: Current or past history
• Athletic training: Especially endurance sports, gymnastics
• Low body weight: BMI less than 18.5
• Obesity: Increases PCOS risk
• Chronic stress: Physical or psychological
• Autoimmune diseases: Thyroid, adrenal disorders
• Cancer treatment: Chemotherapy, radiation
• Certain medications: Antipsychotics, antidepressants
• Genetic conditions: Turner syndrome, Fragile X

Medical History

• Menstrual history details
• Sexual activity and contraception
• Pregnancy symptoms
• Weight changes
• Exercise patterns
• Stress levels
• Medications and supplements
• Family history
• Associated symptoms

Physical Examination

• Height, weight, BMI
• Vital signs
• Thyroid examination
• Breast examination
• Skin assessment (acne, hirsutism)
• Pelvic examination
• Signs of virilization

Laboratory Tests

• Pregnancy test: First test always
• TSH, Free T4: Thyroid function
• Prolactin: Pituitary function
• FSH, LH: Ovarian function
• Estradiol: Estrogen levels
• Testosterone: If signs of excess
• AMH: Ovarian reserve
• 17-hydroxyprogesterone: CAH screening

Imaging Studies

• Pelvic ultrasound: Ovarian and uterine structure
• MRI brain: If pituitary tumor suspected
• Bone density scan: If prolonged amenorrhea
• Hysteroscopy: Uterine cavity evaluation

Untreated amenorrhea can lead to:

• Infertility: Inability to conceive without ovulation
• Osteoporosis: Low estrogen affects bone density
• Cardiovascular disease: Loss of estrogen's protective effects
• Endometrial hyperplasia: With unopposed estrogen
• Endometrial cancer: Rare but increased risk
• Psychological effects: Anxiety, depression
• Sexual dysfunction: Vaginal dryness, low libido

• Maintain healthy weight: BMI 18.5-24.9
• Balanced nutrition: Adequate calories and nutrients
• Moderate exercise: Avoid excessive training
• Stress management: Regular relaxation practices
• Regular check-ups: Annual gynecological exams
• Bone health: Calcium, vitamin D, weight-bearing exercise
• Avoid smoking: Affects ovarian function
• Limit alcohol: Can disrupt hormones
• Track periods: Note any changes
• Early treatment: Address issues promptly

See a Doctor Immediately For:

• Severe pelvic pain with amenorrhea
• Vision changes or severe headaches
• Breast discharge (galactorrhea)
• Signs of pregnancy with complications
• Rapid onset of male characteristics

Schedule an Appointment For:

• No period by age 15
• Missing 3 consecutive periods
• Irregular periods stopped for 6 months
• Periods haven't returned 3 months postpartum (not breastfeeding)
• Other concerning symptoms
• Planning pregnancy with amenorrhea
• Unexplained weight changes