Period Problems: Amenorrhea And Its Causes

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Causes Of Amenorrhea

Amenorrhea is not a disease but a symptom. Primary amenorrhea, marked by the absence of menarche, could either be due to anatomical abnormalities or ovarian insufficiency. Secondary amenorrhea could be caused by a host of diseases from PCOS to hormonal imbalances. Lifestyle factors could also cause the cessation of menstruation.

Amenorrhea may sound like a strange disease from another planet but it is, in fact, not a disease but a symptom. Strictly a female problem, amenorrhea means an absence of menstruation or period, and it affects about 10–15% of the total female population worldwide.1 It can be of two types: primary and secondary.

  • Primary amenorrhea: If you have reached 16 years of age or it’s been 2 years since you developed secondary sexual characters like breasts, it is primary amenorrhea.
  • Secondary amenorrhea: If you have a normal menstrual cycle and are not pregnant or close to menopause, missing your periods 3 times in a row indicates secondary amenorrhea.2

Primary Amenorrhea: Why Hasn’t Your Period Started?

How do you menstruate? The hypothalamus generates a hormone called gonadotropin-releasing hormone or GnRH that stimulates the pituitary glands to produce gonadotropins, also called follicle-stimulating hormone or FSH and luteinizing hormone or LH. The function of gonadotropins is to stimulate the ovaries to produce hormones like estrogen, androgens and progesterones. In a female body, estrogen stimulates the endometrium for it to proliferate. LH, during the menstrual cycle, facilitates oocyte release and the formation of corpus luteum, a temporary structure to facilitate pregnancy. Progesterone, on the other hand, prepares the endometrium for egg implantation. The entire system gets built up to facilitate pregnancy and when that doesn’t happen, the endometrium breaks down and is flushed out as menses. Any malfunction during any of these phases can result in amenorrhea.3

Since primary amenorrhea is the failure to reach menarche, it calls for a detailed evaluation of the patient’s physiology when she fails to menstruate by the age of 16. It could either be due to some anatomic abnormalities or ovarian insufficiency.4 Anatomic abnormalities include the absence of uterus in the body or conditions like gonadal dysgenesis or Müllerian agenesis.

1. Gonadal Dysgenesis: Dysfunction Of The Ovaries

The most common cause of primary amenorrhea, gonadal dysgenesis, is the premature ovarian failure – where ovaries fail to function normally – in otherwise normal women. This is due to the failure of the gonads to develop or due to the resistance of gonadotropin stimulation.5

In gonadal dysgenesis, pubertal development is absent. The girl doesn’t develop any sexual characteristics like breast development. Gonadal dysgenesis is often characterized by Turner’s syndrome.6 In this case, the absence of menarche at 16 years or above is considered primary amenorrhea.

2. Müllerian Agenesis: Underdeveloped Uterus And Vagina

Müllerian agenesis is another cause where the uterus and the upper two-thirds of the vagina are congenitally underdeveloped. In this case, since the ovaries develop normally, the patient will go through the normal pubertal development initially but fail to menstruate. They do develop breasts and exhibit other secondary sexual characteristics.7 In this case, the absence of menarche at 14 years of age or above is considered primary amenorrhea.

Secondary Amenorrhea: Why Has Your Period Stopped?

Health Factors

1. Polycystic Ovarian Syndrome

PCOS affects 4 to 12 percent women of reproductive age.8 PCOS can result in hormonal imbalance in the body resulting in ovarian cysts. These cysts can prevent menstruation.

2. Hypothalamic Amenorrhea Or Hypothalamic Hypogonadism

Hypothalamic amenorrhea, or hypothalamic hypogonadism is another cause. If the body fails to produce enough GnRH, it could leave the whole menstruation process in a tizzy resulting in very low production of FSH, LH and estrogen. Result? No periods!9

3. Hyperprolactinemia

Secondary amenorrhea could also be an indicator that you could be having hyperprolactinemia or an elevated level of prolactin in your blood. Prolactin is a pituitary hormone when produced in excess, could lead to cessation of menses.10 Do not ignore the possibility of a pituitary tumor in cases of amenorrhea.11

4. Hypothyroidism

Thyroid deficiency or hypothyroidism is also considered a reason why menstruation stops in women.12

5. Premature Ovarian Failure

Another cause of secondary amenorrhea is the premature ovarian failure where there are low levels of gonadal hormones and high levels of gonadotropins–FSH and LH.13 Premature ovarian failure could also be a cause of primary amenorrhea. Here are some other causes of primary amenorrhea.

Lifestyle Factors

Lifestyle choices do play a part in the normal functioning of hormones which, in turn, facilitate normal menstrual cycle. Here are some lifestyle factors that could affect menstruation.

6. Birth Control

Once pregnancy and any illnesses are ruled out, you could consider the possibility of amenorrhea from using birth control pills.14 Post-pill amenorrhea is the failure to resume menstruation within six months of discontinuing contraceptive pills.

7. Improper Weight

Are you overweight? If yes, you could experience amenorrhea from the fat cells interfering with ovulation.15 Not just overweight, even undernutrition is seen as a possible cause of amenorrhea. It is prevalent in people with eating disorders or those in professions where thinness is appreciated. In a study done to assess amenorrhea among female ballet dancers, it was found that restricting diet coupled with increased activity, contributed to their condition.16

8. Stress

Stress also contributes to it. Studies on college population have found that restricted diet, increased physical activity coupled with college stress accounted for cases of amenorrhea and oligomenorrhea (infrequent menstrual periods).17

9. Too Much Exercise

Exercising too much? That could also be a cause for infrequent menstruation or the periods stopping unexpectedly. This is evident from increased cases of amenorrhea among marathon runners.18

If you are going through amenorrhea and pregnancy is ruled out completely, you need to treat it as a symptom of an underlying disease or a wrong lifestyle decision you have taken. In any case, it calls for a thorough physical examination and an expert intervention.

References   [ + ]

1.Practice Committee of the American Society for Reproductive Medicine. “Current evaluation of amenorrhea.” Fertility and sterility 82 (2004): 33-39.
2.Amenorrhea. UMM.
3.Amenorrhea. MSD Manual.
4.Amenorrhea: An Approach To Diagnosis And Management. AAFP.
5.Kebaili, Sahbi, Kais Chaabane, Mouna Feki Mnif, Mahdi Kamoun, Faten Hadj Kacem, Nouha Guesmi, Hichem Gassara et al. “Gonadal dysgenesis and the Mayer-Rokitansky-Kuster-Hauser Syndrome in a girl with a 46, XX karyotype: a case report and review of literature.” Indian journal of endocrinology and metabolism 17, no. 3 (2013): 505.
6.Sexual Differentiation : Gonadal Dysgenesis. Utah.
7.Strauss, Jerome F., and Robert L. Barbieri. Yen & Jaffe’s Reproductive Endocrinology E-Book: Physiology, Pathophysiology, and Clinical Management. Elsevier Health Sciences, 2013.
8.Sheehan, Michael T. “Polycystic ovarian syndrome: diagnosis and management.” Clinical Medicine & Research 2, no. 1 (2004): 13-27.
9.Beltsos, Angeline N. “Hypothalamic Amenorrhea.” (2008).
10.Majumdar, Abha, and Nisha Sharma Mangal. “Hyperprolactinemia.” In Principles and Practice of Controlled Ovarian Stimulation in ART, pp. 319-328. Springer India, 2015.
11.What is amenorrhea?. MGH.
12.Kramer, Michael S., Arieh Kauschansky, and Myron Genel. “Adolescent secondary amenorrhea: association with hypothalamic hypothyroidism.” The Journal of pediatrics 94, no. 2 (1979): 300-303.
13.Beck-Peccoz, Paolo, and Luca Persani. “Premature ovarian failure.” Orphanet journal of rare diseases 1, no. 1 (2006): 9.
14.Rojas-Walsson, R., and R. Cardoso. “Diagnosis and management of post-pill amenorrhea.” The Journal of family practice 13, no. 2 (1981): 165-169.
15.Amenorrhea In Teens. URMC.
16.Frisch, Rose E., Grace Wyshak, and Larry Vincent. “Delayed menarche and amenorrhea in ballet dancers.” New England Journal of Medicine 303, no. 1 (1980): 17-19.
17.Bachmann, Gloria A., and Ekkehard Kemmann. “Prevalence of oligomenorrhea and amenorrhea in a college population.” American journal of obstetrics and gynecology 144, no. 1 (1982): 98-102.
18.Schwartz, Barbara, David C. Cumming, Eileen Riordan, Manuel Selye, Samuel SC Yen, and Robert W. Rebar. “Exercise-associated amenorrhea: a distinct entity?.” American journal of obstetrics and gynecology 141, no. 5 (1981): 662-670.

Disclaimer: The content is purely informative and educational in nature and should not be construed as medical advice. Please use the content only in consultation with an appropriate certified medical or healthcare professional.

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