Amenorrhea – Causes, Symptoms and Treatment
Amenorrhea refers to the absence of menstruation. It can be primary or secondary and may result from hormonal, anatomical, or systemic causes.
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Amenorrhea refers to the absence of menstruation. It can be primary or secondary and may result from hormonal, anatomical, or systemic causes.
What Is Amenorrhea?
Amenorrhea (also spelled amenorrhoea) is the absence of menstrual periods. There are two main types: primary amenorrhea, in which menstruation has never begun by age 15, and secondary amenorrhea, in which previously regular periods stop for three or more consecutive months. Amenorrhea is not a disease in itself but rather a symptom pointing to an underlying cause that requires evaluation.
Causes
Primary Amenorrhea
- Chromosomal abnormalities (e.g., Turner syndrome)
- Congenital malformations of the reproductive tract (e.g., absent uterus or vagina)
- Delayed puberty
- Hypothalamic or pituitary dysfunction
Secondary Amenorrhea
- Pregnancy (most common cause)
- Hormonal disorders: thyroid disease, elevated prolactin levels (hyperprolactinemia), polycystic ovary syndrome (PCOS)
- Significant weight loss or low body weight (e.g., in anorexia nervosa)
- Intense athletic training (exercise-induced amenorrhea)
- Chronic stress
- Asherman syndrome (intrauterine adhesions)
- Premature ovarian insufficiency (early menopause)
- Certain medications (e.g., antipsychotics, some contraceptives)
Symptoms
The primary symptom is the absence of the menstrual period. Depending on the underlying cause, additional symptoms may include:
- Hot flashes and night sweats (due to hormone deficiency)
- Acne and excessive body hair (in cases of hyperandrogenism, e.g., PCOS)
- Milky nipple discharge without pregnancy (galactorrhea, due to elevated prolactin)
- Headaches or visual disturbances (in cases of pituitary tumor)
- Changes in body weight
- Mood swings, anxiety, or depression
Diagnosis
Evaluation of amenorrhea typically follows a stepwise approach:
- Medical history and physical examination: Assessment of health history, body weight, stress levels, and physical activity
- Pregnancy test: The first step in evaluating secondary amenorrhea
- Blood tests: Hormone levels including FSH, LH, estradiol, prolactin, TSH, and androgens
- Ultrasound: Evaluation of the uterus and ovaries
- MRI or CT scan: If a pituitary tumor or anatomical abnormality is suspected
- Chromosomal analysis: In primary amenorrhea to rule out genetic causes
Treatment
Treatment is directed at the underlying cause:
- Hormone therapy: Replacement of deficient hormones such as estrogen, progesterone, or thyroid hormones
- Weight restoration: Nutritional therapy is central when low body weight is the cause
- Stress reduction and exercise modification: Reducing excessive physical training loads
- Medications: For example, dopamine agonists (cabergoline, bromocriptine) for hyperprolactinemia
- Surgical intervention: For anatomical causes such as intrauterine adhesions (Asherman syndrome) or tumors
- Psychotherapy: As a complementary measure in eating-disorder-related amenorrhea
If left untreated, amenorrhea can lead to long-term complications including osteoporosis, infertility, and increased cardiovascular risk. Early medical evaluation is therefore strongly recommended.
References
- World Health Organization (WHO): Medical Eligibility Criteria for Contraceptive Use, 5th Edition, 2015.
- Klein DA, Poth MA: Amenorrhea: An Approach to Diagnosis and Management. American Family Physician, 87(11):781-788, 2013. PubMed PMID: 23939500.
- Gordon CM: Clinical practice. Functional hypothalamic amenorrhea. New England Journal of Medicine, 363(4):365-371, 2010. PubMed PMID: 20660404.
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