Amenorrhea: Absence or cessation of menstruation.

Amenorrhea is conventionally divided

into primary and secondary amenorrhea.

Primary amenorrhea -- menstruation never takes place. It fails to occur at puberty.

Secondary amenorrhea -- menstruation starts but then stops.

The absence of menstruation during pregnancy is a form of physiologic secondary

amenorrhea, physiologic in the sense that it is completely normal and is not caused by
anything medically harmful (pathologic). Amenorrhea during lactation is another type of
physiologic secondary amenorrhea.
The word "amenorrhea" is compounded from three Greek roots "a-", no + "men", month +
"rhoia", flow = no monthly flow. Amenorrhea is less commonly called amenia.

Amenorrhea Causes
Amenorrhea can result because of an abnormality in the hypothalamic-pituitary-ovarian axis,
anatomical abnormalities of the genital tract, or functional causes.
Hypothalamic causes

Craniopharyngioma (a brain tumor near the pituitary gland)

Teratoma (a tumor made up of a mixture of tissues)

Sarcoidosis (a chronic disease of unknown cause characterized by the formation of

nodules in different parts of the body)

Kallmann syndrome (deficiency of gonadotropins, which are hormones capable of

promoting growth and function of reproductive organs)

Nutritional deficiency

Low body weight

Pituitary causes

Prolactinemia (high blood levels of prolactin, a hormone that stimulates secretion of

milk from the breasts during breastfeeding) - Possibly caused by prolactinoma (a
tumor of the pituitary gland secreting the hormone prolactin)

Other pituitary tumors (for example, Cushing syndrome, acromegaly, or thyroidstimulating hormone)

Postpartum pituitary necrosis (death of pituitary cells after a woman delivers a baby)

Autoimmune hypophysitis (cells of the pituitary gland destroyed by the bodys own
defense system)

Pituitary radiation

Sarcoidosis

Ovarian causes

Anovulation (lack of the release of an egg)

Hyperandrogenemia (high blood levels of male hormones)

Polycystic ovary syndrome (hormonal disorder affecting women of reproductive age)

Premature ovarian failure

Turner syndrome (a genetic disorder characterized by underdeveloped ovaries,

absence of menstrual onset, and short stature)

Pure gonadal dysgenesis (defective development of the ovary)

Autoimmune oophoritis (cells of the ovaries destroyed by the bodys own defense
system)

Fragile X premutation

Radiation or chemotherapy

Galactosemia (an inherited disorder in which galactose, a type of sugar, accumulates

in the blood)

Anatomical abnormalities of the genital tract

Intrauterine adhesions (the opposing surfaces of the uterine cavity stick together)

Imperforate hymen (a hymen in which there is no opening, the membrane completely

closes off the vagina)

Transverse vaginal septum (a dividing wall or membrane in the vagina)

Aplasia (absence of an organ or tissue) of the vagina, the cervix, or the uterus

Functional causes

Anorexia/bulimia

Chronic diseases (for example, tuberculosis)

Excessive weight gain or weight loss

Malnutrition

Depression or other psychiatric disorders

Recreational drug abuse

Psychotropic drug use (drugs prescribed to stabilize or improve mood, mental status,
or behavior)

Excessive stress

Excessive exercise

Cycle suppression with systemic hormonal contraceptive (birth control) pills

Secondary amenorrhea occurs when a woman who has been having normal menstrual cycles
stops getting her periods for 6 or more months.
Amenorrhea is when a woman does not get her monthly menstrual cycle, or period.
See also:

Menstruation - Absent

Primary amenorrhea

Causes
Women who are pregnant, breastfeeding, or in menopause are not considered to have
secondary amenorrhea.
Women who are taking birth control pills or receive hormone shots such as Depo-Provera
may not have any monthly bleeding. When they stop taking these hormones, their periods
may not return for more than 6 months.
You are more likely to have amenorrhea if you:

Are obese

Exercise excessively and for long periods of time

Have less than 15% - 17% body fat

Have severe anxiety or emotional distress

Lose a lot of weight suddenly (for example, with a strict diet or after
gastric bypass surgery)

Other causes include:

Brain (pituitary) tumors

Polycystic ovarian syndrome

Premature ovarian failure

Thyroid dysfunction

The following drugs may also cause missed periods:

Busulfan

Chemotherapy drugs for cancer

Chlorambucil

Cyclophosphamide

Phenothiazines

Also, procedures such as a dilation and curettage (D and C) can lead to scar tissue formation
that may cause a woman to stop menstruating. This is called Asherman syndrome. Scarring
may also be caused by some severe pelvic infections.

Symptoms

No menstrual period for 6 months or longer

Previously had one or more menstrual periods that started on their own

Other symptoms that can occur with secondary amenorrhea include:

Breast size changes

Considerable weight gain or weight loss

Discharge from the breast (galactorrhea)

Headache

Increased hair growth in a "male" pattern (hirsutism) and acne

Vaginal dryness

Voice changes

If amenorrhea is caused by a pituitary tumor, there may be other symptoms related to the
tumor, such as vision loss.

Exams and Tests

A physical exam and pelvic exam must be done to rule out pregnancy. A pregnancy test will
be done.
Blood tests may be done to check hormone levels, including:

Estradiol levels

Follicle stimulating hormone (FSH level)

Luteinizing hormone (LH level)

Prolactin level

Serum hormone levels such as testosterone levels

Thyroid stimulating hormone (TSH)

Other tests that may be performed include:

CT scan of the head

Endometrial biopsy

Genetic testing

MRI of the head

Ultrasound of the pelvis or hysterosonogram

Treatment
Treatment depends on the cause of the amenorrhea. Normal monthly periods usually return
after the condition is treated.
For example, if the primary disorder is hypothyroidism, amenorrhea will be cured when it is
treated with thyroid supplements.
If the primary cause is obesity, vigorous exercise, or weight loss, treatment may include a
change in exercise routine or weight control.

Outlook (Prognosis)
The outlook depends on the cause of amenorrhea. Most of the conditions that cause
secondary amenorrhea will respond to treatment.

Possible Complications
Complications depend on the cause of the condition. Amenorrhea may be harmless, or it may
be associated with overgrowth of the uterine lining (endometrial hyperplasia). This can
sometimes lead to uterine cancer.
There may be other complications, depending on the cause of the amenorrhea.

When to Contact a Medical Professional

Call for an appointment with your primary health care provider or OB/GYN provider if you
have missed more than one period so that you can get diagnosed and treated, if necessary.

Prevention
Prevention depends on the cause. For example, moderate exercise instead of extreme
exercise, weight control, and other measures may be helpful.

Amenorrhea - primary
Amenorrhea is the absence of menstruation. Menstruation is a woman's monthly period.
Primary amenorrhea is when a girl has not yet started her monthly periods, and she:

Has gone through other normal changes that occur during puberty

Is older than 15

See also:

Menstruation - absent

Secondary amenorrhea

Causes
Most girls begin menstruating between ages 9 and 18, with an average around 12 years old.
Primary amenorrhea typically occurs when a girl is older than 15, if she has undergone other
normal changes that occur during puberty. Primary amenorrhea may occur with or without
other signs of puberty.
Being born with poorly formed genital or pelvic organs (missing uterus or vagina, vaginal
septum, cervical stenosis, or imperforate hymen) can lead to primary amenorrhea.
Hormones play a big role in a woman's menstrual cycle. Hormone problems can occur when:

Changes occur to the parts of the brain where hormones that help manage
the menstrual cycle are produced

The ovaries are not working correctly

These problems may be due to:

Genetic defects

Infections that occur in the womb or after birth

Other birth defects

Tumors

In many cases, the cause of primary amenorrhea is not known.

Conditions associated with primary amenorrhea include:

Adrenogenital syndrome

Anorexia

Chromosomal abnormalities such as Turner syndrome or Sawyer syndrome

Congenital heart disease (cyanotic)

Congenital adrenal hyperplasia

Craniopharyngioma

Chronic (long-term) illnesses

Cushing's disease

Cystic fibrosis

Gonadal dysgenesis

Hypothyroidism and hyperthyroidism

Hypogonadotropic hypogonadism

Hyperprolactinemia

Obesity

Prader-Willi syndrome

Polycystic ovarian disease

Testicular feminization

True hermaphroditism

Tumors of the pituitary or adrenal glands

Tumors of the ovaries

Symptoms
A female with amenorrhea will have no menstrual flow with or without other signs of
puberty.

Exams and Tests

The doctor will perform a physical exam and ask questions about your medical history. A
pregnancy test will be done.
Blood tests may include:

Estradiol

FSH

LH

Prolactin

TSH

T3 and T4

Other tests that may be done include:

17 hydroxyprogesterone

Chromosome analysis

Head CT

Head MRI scan

Laparoscopy

Pelvic ultrasound

Progesterone withdrawal

Serum progresterone

Treatment
Treatment depends on the cause of the missing period. Primary amenorrhea caused by birth
defects may require medications (hormones), surgery, or both.
If the amenorrhea is caused by a tumor in the brain (pituitary tumor):

Medications may shrink certain types of tumors.

Surgery to remove the tumor may also be necessary.

Radiation therapy is usually only performed when other treatments have

not worked.

If the condition is caused by a body-wide (systemic) disease, treatment of the disease may
allow menstruation to begin.
If the amenorrhea is due to low weight because of anorexia or too much exercise, periods will
often begin when the weight returns to normal or the exercise level is decreased.

Outlook (Prognosis)
Overall the outlook is good, depending on the cause of the amenorrhea. If the amenorrhea is
caused by one of the following conditions, there is a good chance that it can be corrected with
medication, lifestyle changes, or surgery:

Adrenogenital syndrome

Chronic illness

Congenital heart disease

Drastic weight reduction

Hypogonadotropic hypogonadism

Imperforate hymen or vaginal septum

Malnutrition

Normal delay of onset (up to age 14 or 15)

Obesity

Overactive thyroid

Periods are unlikely to start on their own if the amenorrhea was caused by one of the
following conditions:

Congenital abnormalities of the upper genital system

Craniopharyngioma

Cystic fibrosis

Gonadal dysgenesis

Prader-Willi syndrome

Testicular feminization syndrome

True hermaphroditism

Turner syndrome (XO)

If the amenorrhea cannot be corrected, it is sometimes possible to create a menstrual-like

situation (pseudomenstruation) with medications. Medicines can help you feel more like your
friends or family, and will also protect the bones from becoming too thin (osteoporosis).

Possible Complications

Emotional distress due to feeling different from friends or family, or

worrying you might not be able to have children

Osteoporosis and increased risk of fractures