DEFINITION
Amenorrhea is the absence of menstruation in a woman of childbearing age. The word amenorrhea comes from the Greek a for deprivation, mén for month, and rhein for flow.
From 2% to 5% of women are affected by amenorrhea. This is a symptom for which it is important to know the cause. The absence of periods is quite natural when, for example, the woman is pregnant, breastfeeding or approaching menopause. But apart from these situations, it can be a telltale sign of chronic stress or even a health problem such as anorexia or a disorder of the thyroid gland.
KINDS
- Primary amenorrhea: when at the age of 16, menstruation has not yet started. Secondary sexual characteristics (development of the chest, pubic and armpit hair and distribution of fatty tissue in the hips, buttocks and thighs) may nevertheless be present.
- Secondary amenorrhea: when a woman has had a period before and stops menstruating for one reason or another, for a period equivalent to at least 3 previous menstrual cycle intervals or 6 months without menstruation.
When to consult?
Oftentimes, not knowing why you have amenorrhea is worrying. The following people should see a doctor:
- women with primary or secondary amenorrhea;
- in the event of post-contraceptive amenorrhea, 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 Mirena® hormonal IUD, or more than 12 months after the last injection of Depo-Provera®.
IMPORTANT. Sexually active women who are not taking hormonal contraceptives should take a pregnancy test if their period has been delayed for more than 8 days, even when they are certain that they are not pregnant. Note that bleeding that occurs while on a hormonal contraceptive (particularly false periods generated by the birth control pill) is not proof of the absence of pregnancy.
DIAGNOSTIC
In most cases, clinical examination, a pregnancy test and sometimes an ultrasound of the sexual organs are sufficient to guide the diagnosis.
A wrist X-ray (to assess pubertal development), hormonal assays or chromosomal sex testing are performed in rare cases of primary amenorrhea.
CAUSES
There are many causes of amenorrhea. Here are the most common in descending order.
The pregnancy. The most frequent cause of secondary amenorrhea, it must be the first suspected in a sexually active woman. Surprisingly, it often happens that this cause is dismissed without prior verification, which is not without risk. Some treatments indicated to treat amenorrhea are contraindicated in pregnancy. And with commercially available tests, diagnosis is simple.
A mild 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 greatly depending on ethnicity, geographic location, diet, and health status.
In developed countries, delayed puberty is common in young women who are very thin or athletic. It would seem that these young women do not have enough body fat to allow the production of estrogen hormones. Estrogen allows the thickening of the uterine wall, and later menstruation if the egg has not been fertilized by a sperm. In a way, the body of these young women naturally protects itself and signals 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 nothing to worry about before the age of 16 or 17. If signs of sexual maturation are still absent at age 14, suspect a chromosomal problem (only one X sex chromosome instead of 2, a condition called Turner syndrome), a development of the reproductive system or a hormonal problem.
Breastfeeding. Often women who are breastfeeding do not have periods. However, it should be noted that they can still have an ovulation during this period, and therefore a new pregnancy. Breastfeeding suspends ovulation and protects against pregnancy (99%) only if:
- The baby exclusively takes the breast;
- The baby is less than 6 months old.
The onset of menopause. Menopause is the natural cessation of menstrual cycles that occurs in women between the ages of 45 and 55. Estrogen production gradually decreases, causing menstruation to become irregular and then completely disappear. Ovulation may occur sporadically for 2 years after the cessation of menstruation.
Taking hormonal contraception. Periods that occur between 2 packs of pills are not periods related 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 a few years of taking it, may no longer occur. The hormonal intrauterine device (IUD) Mirena®, injectable Depo-Provera®, the 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 does not ovulate. It therefore has no cycle or rules.
Stopping taking a contraceptive (birth control pills, Depo-Provera®, hormonal IUD Mirena®) after several months or years of use. It may take a few months for the normal cycle of ovulation and menstruation to resume. It is called post-contraceptive amenorrhea. Indeed, hormonal contraceptive methods reproduce the hormonal state of pregnancy, and can therefore suspend the rules. 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 discover that they have fertility problems after contraception already had them before, but because of their contraception, they had not tested their fertility.
The practice of a demanding discipline or sport such as marathon, bodybuilding, gymnastics or professional ballet. The amenorrhea of the sportswoman would be attributable to the insufficiency of fatty tissues as well as to the stress to which the body is subjected. There is a lack of estrogen in these women. It can also be for the body not to waste energy unnecessarily since it often undergoes a low-calorie diet. Amenorrhea is 4 to 20 times more common among athletes than in the general population.
Stress or psychological shock. The so-called psychogenic amenorrhea results from psychological stress (death in the family, divorce, job loss) or any other type of major stress (travel, major lifestyle changes, etc.). These conditions can temporarily impair 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 a cessation of menstruation. In the majority of women who suffer from anorexia or bulimia, menstruation stops.
Excessive secretion of prolactin by the pituitary gland. Prolactin is a hormone that promotes mammary gland growth and lactation. Excess prolactin secretion by the pituitary can be caused by a small tumor (which is always benign) or by certain medications (antidepressants, in particular). In the latter case, its treatment is simple: the rules reappear a few weeks after stopping the drug.
Obesity or overweight.
Taking certain medications such as oral corticosteroids, antidepressants, antipsychotics, or chemotherapy. Drug addiction can also cause amenorrhea.
Uterine scars. Following an operation to treat uterine fibroids, endometrial resection or sometimes a caesarean section, there may be a significant reduction in menstruation, or even temporary or lasting amenorrhea.
The following causes are much less common.
An abnormality of development of the sexual organs of non-genetic origin. Androgen insensitivity syndrome is the presence, in an XY (genetically male) subject, of female-looking sexual organs due to a lack of sensitivity of the cells to male hormones. These intersex people with a feminine appearance consult at puberty for primary amenorrhea. Clinical and ultrasound examination allows the diagnosis: they have no uterus, and their sex glands (testicles) are located in the abdomen.
Chronic or endocrine diseases. 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 pubescent girls: the first periods remain trapped in the vaginal cavity.
EVOLUTION AND POSSIBLE COMPLICATIONS
The duration of amenorrhea depends on the underlying cause. In the majority of cases, amenorrhea is reversible and easily treated (with the exception, of course, of amenorrhea linked to genetic anomalies, non-operable malformations, menopause or removal of the uterus and ovaries). However, when long-standing amenorrhea is left untreated, the cause may eventually reach into reproductive mechanisms.
Furthermore, amenorrhea associated with a lack of estrogen (amenorrhea caused by strenuous sports or an eating disorder) puts you at greater risk of long-term osteoporosis – thus fractures, instability of the vertebrae and lordosis - since estrogen plays a roleessential to preserve bone structure. It is now well known that female athletes who suffer from amenorrhea have lower than normal bone density, which explains why they are more prone to fractures. If moderate exercise helps prevent osteoporosis, excessive exercise has the opposite effect if it is not balanced by a higher caloric intake.
AMENORRHEA SYMPTOMS, PEOPLE, AND RISK FACTORS
SYMPTOMS
In a woman who has never had a period
- No menstruation at age 14 and no development of secondary sex characteristics.
- No menstruation at age 16 despite development of secondary sex characteristics.
In a woman who has already had a period
Absence of menstruation for a period equivalent to at least 3 intervals of previous menstrual cycles or 6 months without menstruation.
People At Risk
All women are susceptible to amenorrhoea at some point in their lives. See list of causes above.
RISK FACTORS
Here are the most common.
- Significant weight loss.
- Prolonged stress.
- The intensive practice of a sports activity.
- A deficient diet.
- Prevention of amenorrhea
- Basic preventive measures
- Have a balanced diet and a healthy weight. Make sure 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 manage 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 sporting life. If this stress is prolonged, the body cannot recover and this can lead to physiological, particularly hormonal, imbalance. Thus, prolonged stress can lead to amenorrhea and a cessation of ovulation.
Consult our Stress and Anxiety file to learn about different ways to better resist stress.
For athletes: surround yourself with a multidisciplinary team. The intensity of the efforts must be adapted to the athlete, according to his age and physical abilities. In addition, the nutritional intake must be optimal. According to a study author, the 3 most common health problems in female athletes - namely osteoporosis, amenorrhea and eating disorders - could be completely preventable if women were monitored by a multidisciplinary team of therapists (coach,nutritionist, sports psychologist, etc.), especially when they are growing.
MEDICAL TREATMENTS FOR AMENORRHEA
In the majority of cases, no medical treatment is necessary. Before prescribing treatment, it is imperative to find the cause of amenorrhea, to treat the underlying disease if there is one and to obtain psychological support if necessary. Sex hormone testing is sometimes suggested if the doctor suspects endocrine disease.
The application of the previously mentioned preventive measures allows the return of menstruation in many women:
- Healthy eating;
- maintaining a healthy weight;
- stress management;
- moderation in the practice of physical exercises.
Good to know
Very often, the causes of amenorrhea are mild and curable. It is still important to diagnose them as soon as possible, in order to avoid possible consequences on fertility and bone health.
No treatment will bring menstruation back on its own. To stop amenorrhea, you must first discover the cause and then treat it.
MEDICATION
Hormone treatments
In the case of ovarian dysfunction in a young woman, hormonal treatment will be suggested in order to promote the development of sexual characteristics and fertility, and to prevent long-term osteoporosis.
For women who have had their uterus and ovaries surgically removed very early (before their presumed age of menopause), hormone replacement therapy including estrogen AND progestins may be offered to prevent osteoporosis and other consequences attributable tolowering of circulating hormone levels. This treatment can be discontinued 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 cannot be prescribed either to women who have undergone ovarian castration by radiotherapy or chemotherapy for breast cancer.
Apart from these situations, no hormone treatment is effective in causing the return of menstruation.
Furthermore, cycle regularization treatments (for example, taking a synthetic progestogen 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 the disorders of the menstrual cycle by compromising the spontaneous occurrence 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 tumor of the pituitary gland, bromocriptine (Parlodel®) is a very effective drug which reduces prolactin levels and allows menstruation to return. It is this same treatment that is given, just after childbirth, to women who do not wish to breastfeed.
Psychotherapy
If amenorrhea is accompanied by a psychological disorder, the doctor may offer 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 it exists). However, psychotropic drugs should be avoided, as they can cause amenorrhea.
Amenorrhea associated with anorexia absolutely requires follow-up by a multidisciplinary team including nutritionist, psychotherapist, psychiatrist, etc. Anorexia often affects teenage 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.), an amenorrhea lasting several months or even several years can set in, particularly in a woman whose psychic balance wasalready weak. The best treatment is to consult a psychotherapist.
Surgical treatment
If amenorrhea is caused by a malformation of the reproductive system, surgery can sometimes be undertaken (in case of imperforation of the hymen for example). But if the malformation is too large (Turner's syndrome or androgen insensitivity), the surgery will only have a cosmetic and comfort function by modifying the appearance and functionality of the undeveloped sexual organs, but will not cause menstruation to return.
COMPLEMENTARY APPROACHES TO AMENORRHEA
Caution. It is important to rule out the possibility of pregnancy. In the absence of pregnancy, a doctor should be consulted to find the cause of amenorrhea. Several interventions aimed at inducing the return of menstruation are not recommended in the event of pregnancy. Self-treatment is not recommended.
Herbs traditionally used by women are known to have a regulating effect on the menstrual cycle, after several weeks of treatment. However, very few clinical studies have evaluated their effectiveness.
Chasteberry (Vitex agnus castus). Commission E recognizes the use of chasteberry fruit to treat menstrual cycle irregularities. According to Commission E, in vitro and animal studies indicate that chasteberry compounds reduce the production of prolactin by the pituitary gland. However, an excess of prolactin can lead to amenorrhea. Only one preliminary clinical trial has been reported. In this 6-month trial, researchers gave 40 drops of chasteberry extract daily to 20 women with amenorrhea. At the end of the study, 10 of the 15 women who continued treatment were menstruating again.
Dosage
Consult the Chaste Tree sheet.
Contraindications
- Do not use during pregnancy.
- Do not use at the same time as oral contraception.
Chinese Angelica (Angelica sp). In Asia, Chinese angelica (Angelica sinensis) is considered the key remedy for ensuring the proper functioning of the female reproductive system. It is used to treat dysmenorrhea, amenorrhea and menorrhagia as well as the symptoms of menopause.
Dosage
Consult our Chinese Angelica sheet.
Contraindications
- Chinese angelica is not recommended for pregnant women during the 1st trimester and those who are breastfeeding.
Feverfew (Tanacetum parthenium). Feverfew leaves have traditionally been used to treat amenorrhea. This use has not been validated by clinical studies.
Dosage
Consult the Feverfew sheet.
Contraindication
Pregnant women should not consume it.