Amenorrhea is the inability of a woman to have menstrual periods during her reproductive years.  Amenorrhea comes in two forms: having primary amenorrhea means that a girl has not had her first period by the time she turns 15; when a woman who normally menstruates suddenly stops having periods for three months or longer, this is called secondary amenorrhea.

Amenorrhea happens to about one in every 25 women who are not pregnant, breastfeeding, or going through menopause.

In primary amenorrhea the common reasons include: problems with the brain (hypothalamus or pituitary gland); problems with how the uterus, vagina, or hymen grow and form; delay in puberty. While in secondary amenorrhea, common causes include: Low body weight (about 10 percent under normal weight); rapid weight loss; eating disorders (such as anorexia nervosa); and polycystic ovary syndrome (PCOS); and thyroid problems.

The lack of periods is the most important sign. Other symptoms are dependent on the underlying cause. Women may experience:

• Hot flashes;
• Nipples leaking milk;
• Vaginal dryness;
• Headaches;
• Vision problems;
• Acne;
• Having too much hair on your face and body.

Since pregnancy is the most frequent cause of amenorrhea, a beta hCG test is recommended to rule it out. Other lab tests to be requested are the following:

• Measurement of prolactin to rule out prolactinoma;
• Testosterone and DHEA to rule out hyperandrogenism;
• follicle-stimulating hormone and luteinizing hormone levels to check for hypothalamic amenorrhea; 
• Body mass index to look for malnutrition, anorexia nervosa, and excessive strenuous exercise
• Pelvic ultrasound and adrenal glands CT to detect androgen-secreting tumors and other anatomical anomalies like Mayer-Rokitansky-Küster-Hauser syndrome;
• Progesterone levels are checked because amenorrhea can have a variety of reasons, including anovulation, anatomic, or an estradiol insufficiency.

Treatment

The treatment of amenorrhea is very dependent on the underlying reason. When an absence of menstruation is due to a lack of the hormone estrogen, treatment is possible. If the cause of amenorrhea is dietary, then a healthy eating plan should be able to correct the problem. Cognitive-behavioral therapy and selective serotonin reuptake inhibitors can help with anorexia nervosa and stress-induced amenorrhea. Prolactinoma can be treated with dopamine agonist medications like cabergoline, and if large enough, surgery can remove the tumor completely. Anatomical causes of amenorrhea can be treated with the right surgery. Oral contraceptives and metformin taken together can treat polycystic ovary syndrome. SSRIs are effective in treating hypothalamic amenorrhea caused by stress.

Some cases of secondary amenorrhea may be avoided by adhering to a healthy lifestyle. Other ways to prevent amenorrhea are:

• Making good food choices and maintaining an ideal weight;
• Keeping track of your period (so you can tell if it is missing);
• Scheduling regular visits to a gynecologist and getting checked out with a pelvic exam and Pap smear;
• Sleeping well and regularly every night. 

References

Nawaz G, Rogol AD. Amenorrhea. [Updated 2022 Jun 21]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK482168/ 

American College of Obstetrics and Gynecologist (2022). Amenorrhea: Absence of Periods. Retrieved November 13, 2022, from https://www.acog.org/womens-health/faqs/amenorrhea-absence-of-periods

Cleveland Clinic (2022). Amenorrhea. Retrieved November 13, 2022, from https://my.clevelandclinic.org/health/diseases/3924-amenorrhea