Absence of periods or amenorrhea

Amenorrhea is the absence of menstruation and can be primary or secondary in nature.

  1. Primary amenorrhea refers to the absence of menstruation and characteristic secondary sexual characteristics (for example, the development of the breast and pubic hair in a girl of 14 years) or the absence of the menstrual cycle with normal development of the characteristic secondary sexual characteristics in a girl of 16 years.
  2. Secondary amenorrhea is when a woman who has had normal menstrual cycles in the past misses the period for more than three months, without causes such as pregnancy, lactation, taking the birth control pill or menopause.

Amenorrhea is not to be confused with the term dysmenorrhea, which refers to menstrual pain.


Causes of amenorrhea

Amenorrhea can occur for various reasons. Some forms are part of a normal course in a woman’s life, while others are side effects on medication or the sign of a serious medical condition.

Natural amenorrhea

In the course of normal life, a woman may have amenorrhea for natural reasons, such as:

  1. Pregnancy
  2. Breastfeeding
  3. Menopause


Some medications and therapies can cause the absence of menstruation, including several types of:

  1. Antipsychotics
  2. Chemotherapy for cancer
  3. Antidepressants
  4. Medication for high blood pressure
  5. Radiotherapy

Diet and bad habits

  1. Anorexia/bulimia
  2. Massive weight loss
  3. metabolic disorder such as obesity
  4. Malnutrition
  5. Drug abuse
  6. Use of psychotropic drugs (prescribed drugs to stabilize or improve mood, mental status or behavior)
  7. Stress
  8. Excessive physical activity


  1. Chronic diseases (e.g. tuberculosis)
  2. Depression or other mental disorders

Hormonal imbalance

Many diseases can cause hormonal imbalance, including:

Polycystic ovary syndrome
Polycystic ovary syndrome causes relatively high concentrations of hormones instead of the normal fluctuations in the menstrual cycle.

Dysfunction of the thyroid gland
Overactive (hyperthyroidism) or decreased activity (hypothyroidism) of the thyroid gland can lead to irregularities in menstruation, including amenorrhea.

The clinical signs of thyroid disease are usually observed before amenorrhea.
Mild hypothyroidism is often associated with hypermenorrhea (heavy menstrual periods) or dysmenorrhea (these are menstrual irregularities that last longer than 32 days), compared to amenorrhea.
Treatment of hypothyroidism should restore menstruation, but it may take a few months before you see a result.

A patient with an elevated prolactin level, galactorrhea (pathological milk flow), headache or visual disturbances should undergo apparatus examinations (MRI or CT) to rule out a pituitary tumor.
Adenomas are the most common causes of anterior pituitary gland dysfunction.

Hypergonadotropic or primary hypogonadism
This disorder is characterized by the low or total absence of production of sex hormones (androgen, estrogen and progesterone).
People suffering from hypergonadotropic hypogonadism have normal hypothalamic-pituitary activity, but gonadotropins (FSH, LH and hCG) are elevated due to the lack of feedback from sex hormones.
Possible causes of this disorder are:

  • hereditary or autoimmune diseases (such as Turner or Klinefelter syndrome),
  • Infections
  • liver or kidney problems,
  • radiation exposure,
  • Operations.

Hypogonadotropic hypogonadism
Hypogonadism is a disorder characterized by the low or total production of sex hormones.
In this case, the hormones GnRH, FSH and LH, which stimulate the ovaries, are missing.
Hypothalamic amenorrhea is caused by some abnormalities in the secretion of the hormone that causes the release of gonadotropins or GnRH and by disruption of the system of hypothalamic-pituitary-ovarie.
This disorder is often caused by excessive weight loss, physical exercise, or stress.
How stress or weight loss affects the secretion of gonadotropin is unknown.
Women with excessive weight loss should undergo therapy for eating disorders such as anorexia nervosa or bulimia.

Pituitary tumor
A noncancerous (benign) tumor of the pituitary gland can disrupt the hormonal regulation of the menstrual cycle.

Amenorrhea after taking the pill
In women who have stopped taking oral contraceptives, menstruation should resume within three months of stopping the pill.
Women who do not menstruate for three months after stopping the pill could suffer from secondary amenorrhea.

Premature menopause
In general, menopause occurs between the ages of 45 and 55.
With premature or premature menopause, ovulation and menstruation stop before the age of 40.


Mental stress can temporarily impair hypothalamic function.
The hypothalamus is an area of the brain that controls the hormones associated with the menstrual cycle.
Ovulation and menstrual cycle can be interrupted as a result.
Normally, a regular cycle re-occurs as stress decreases.

Low body weight
Excessively low body weight disrupts many hormonal functions of the body and can lead to the cessation of ovulation.
Often, in women who have an eating disorder such as anorexia or bulimia, the cycle is absent due to hormonal changes.

Excessive training
Women who train hard because they engage in sports such as ballet, running, or gymnastics may experience a termination of the menstrual cycle.
Various factors contribute to the absence of menstruation in female athletes, including the loss of body fat, stress and excessive energy expenditure.
Young female athletes can develop a combination of diseases called the Athletic Triad; These include:

  • Eating disorder
  • Amenorrhoea
  • Osteoporosis.

Menstrual periods may return as they eat more and prepare less intensively for exercise.

Structural problems

Disorders of the genital organs can cause amenorrhea. Some examples:

Uterine scars. Asherman syndrome, a condition in which adhesions and scarring of the uterine wall are present.
Sometimes this can occur after a cesarean section, scraping, or treatment of uterine fibroma.
Uterine scars prevent accumulation and discharge of menstrual blood.

Deficit of the reproductive organs
Sometimes problems arise with fetal development and a young woman may be born without an important part of the reproductive system, such as the uterus, cervix or vagina.
Since the reproductive system does not develop normally, the young woman will not have a menstrual cycle.

Structural abnormality of the vagina
A vagina occlusion can prevent visible menstrual bleeding.
A membrane or abnormal wall in the vagina can block blood flow from the uterus and cervix.

Symptoms of amenorrhea

Other symptoms besides menstrual failure include:

  • Changes in breast size
  • Increase or decrease in body weight
  • Discharge from the chest (galactorrhea)
  • Increased hair growth according to male pattern (hirsutism) and acne
  • Vaginal dryness
  • Change of voice

If amenorrhea is caused by a pituitary tumor, you may experience other symptoms associated with the tumor, such as loss of vision and headache.

Diagnosis of amenorrhea

Examinations and tests
The gynaecologist must perform a physical examination and pelvic examination to determine if the patient is pregnant.
A pregnancy test must be performed.
Blood tests are used to check hormone levels, including:

  • estradiol levels,
  • levels of follicle-stimulating hormone (FSH),
  • luteinizing hormone (LH level),
  • prolactin levels,
  • serum testosterone levels,
  • Thyroid stimulating hormone (TSH).

Other possible tests are:

  • CT or MRI of the brain to detect tumors,
  • biopsy of the uterine lining,
  • genetic tests,
  • Echography of the pelvis or sonohysterography.

What therapy helps with amenorrhea?

Treatment of primary and secondary amenorrhea depends on the exact cause.
Treatment goals include:

  • relief of symptoms of hormonal imbalance,
  • restoring menstruation,
  • avoiding complications of amenorrhea,
  • Achieving fertility.

In cases where an anatomical or genetic abnormality is the cause of amenorrhea (generally primary amenorrhea), surgical intervention may be recommended.

Hypothalamic amenorrhea is associated with:

  • Weight loss
  • excessive physical training,
  • of a disease
  • emotional stress.

As a rule, it can be treated by eliminating the underlying cause.
For example, gaining weight and reducing the intensity of exercise in young female athletes can restore menstruation if amenorrhea has no other causes.
In some cases, consultation with a dietitian or nutritionist may be advisable.

In early ovarian failure, hormone therapy may be recommended, both to eliminate the unpleasant symptoms of estrogen deficiency and to prevent the complications of osteoporosis.
Treatment of early ovarian failure can be done in women who do not want to become pregnant by birth control pill or alternatively by drugs with estrogen and progesterone.

Postmenopausal hormone therapy can lead to health risks in older women, but in adolescents with early ovarian failure, this therapy has benefits in preventing loss of bone density.

Women with polycystic ovary syndrome may improve under treatment that lowers male hormones or androgens.

Dopamine agonists such as bromocriptine (Pravidel) may lower elevated levels of prolactin responsible for amenorrhea.
The dose of medication must be determined by the doctor.

Artificial or assisted insemination and the administration of medications containing gonadotropin (a stimulant for follicle maturation) can help women who suffer from certain forms of amenorrhea but want to become pregnant.
One should always contact the doctor to evaluate any contraindications or side effects of the medication.

Many companies and individuals have promoted plant-based therapies to treat amenorrhea, but there is no scientific evidence of the effectiveness of these products.

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