By Joy Jensen, RN, MN & Susan Rutherford, MD

Amenorrhea means the absence of menstruation.

The menstrual cycle comes about due to hormonal increases, decreases and interactions.  Follicle stimulating hormone (FSH) and luteinizing hormone (LH) are made by the brain and send signals to the ovaries, where estrogen and progesterone hormones are made. Sufficient hormone levels at certain times of the month are necessary to trigger specific cycle events, including cervical mucus production, uterine lining proliferation, ovulation, and menstruation.

Amenorrhea can be either primary or secondary.

Primary amenorrhea is the term used when a young woman has not had a period by age 15.  If a young woman has not begun breast development by age 13, she will likely have primary amenorrhea. This may occur due to chromosome disorders, hypothalamic failure, imperforate hymen or Mullerian agenesis (absent uterus or vagina).

Secondary amenorrhea is the term used when a young woman has started having periods, but these have ceased for longer than 6 months without any physiological reasons. This may occur due to endocrine disorders of the thyroid, adrenal gland, hypothalamus, and pituitary gland. Excess stress, intense exercise, use of certain medications, weight loss, malnutrition and eating disorders can lead to absent menstrual periods.  Secondary amenorrhea may also occur due to problems with the pelvic reproductive structures, including surgical removal. This term is not generally used for the following causes of amenorrhea: pregnancy, breast feeding, use of certain types of birth control and menopause.

Diagnosis of amenorrhea begins with a complete health history. A medical professional will review with you your menstrual history (onset of menses, patterns of bleeding), pregnancy history, medical history (acute and chronic conditions), family history, surgical history, medications and some lifestyle factors. You will be asked about current signs and symptoms. A physical exam will include evaluation of your breasts, thyroid, skin, vagina, cervix, and uterus. Labs may be ordered to evaluate hormones such as TSH (thyroid stimulating hormone), FSH (Follicle Stimulating Hormone), LH (Luteinizing Hormone), progesterone, estrogen, and prolactin, as well as other indicated tests. Finally, diagnostic imaging such as ultrasound may be used to assess anatomy. The American College of Obstetricians and Gynecologists (ACOG) reports a good history can reveal the etiologic diagnosis in up to 85% of cases of amenorrhea.

Knowing the underlying cause of amenorrhea allows effective treatment. Treatment may include medication, surgery, lifestyle changes in diet and activity, or stress reduction counseling. Referrals may be indicated to see a nutritionist, physical therapist, psychiatrist, geneticist, gynecologist, reproductive endocrinologist or other appropriate professional.

Amenorrhea is associated with infertility and long-term consequences of untreated abnormal amenorrhea can include endometrial cancer, osteoporosis, and cardiovascular disease.

Many women occasionally miss a period.  If you are concerned about missed periods and would like to discuss this with one of our medical professionals, please call the clinic at 206-588-0311 and we will be happy to see you for an initial history and evaluation so you can consider your options.

We can also provide detailed individual teaching about monitoring multiple symptoms and signs related to your menstrual cycle.  Many women are finding this helpful in assessing their overall health or management of fertility choices.

References:

1. FEMM (Fertility Education and Medical Management) Instructors Course

2. ACOG (American College of Obstetricians and Gynecologists) Fall Conference PowerPoint, 2016