What is amenorrhea?

The most common causes of amenorrhea include pregnancy, breastfeeding, contraception, menopause, sudden weight loss, hormonal imbalance, and structural concerns.
The most common causes of amenorrhea include pregnancy, breastfeeding, contraception, menopause, sudden weight loss, hormonal imbalance, and structural concerns.

After puberty and before menopause, menstruation should be a regular occurrence for women without any underlying health conditions. The hypothalamus and pituitary gland in the brain, which send and produce hormones, regulate this process along with the uterus and ovaries. Irregular menstrual cycles can be a marker of both physical and mental health.

A lack of regular menstrual cycles is known as amenorrhea. The condition can be difficult to diagnose and address because it has so many causes.

Experts estimate that, when not linked to breastfeeding or menopause, amenorrhea is present in between 3% and 4% of adult women. Sometimes the condition is not cause for concern. Often, however, it accompanies major health problems that should be promptly addressed.

Signs and symptoms of amenorrhea

The loss of menstruation can be considered a symptom in and of itself. But sometimes, symptoms may begin even before women with amenorrhea are aware that their menstrual cycle has changed. These symptoms include:

Breast milk secretions

While lactation can prompt amenorrhea, some women who are not breastfeeding still experience milk discharge. Also known as galactorrhea, this symptom often accompanies amenorrhea but can be a sign of several other medical conditions.

Facial Hair

The hormone imbalances associated with amenorrhea may lead to the development of facial hair, a condition known as hirsutism. Some women may also experience excess body hair.

Acne

As with facial hair, increased acne may occur in response to the hormonal changes that take place while experiencing amenorrhea.

Types of amenorrhea

Primary amenorrhea

Primary amenorrhea is when young women have not experienced their first period by the age of 16. In such situations, amenorrhea may also be referred to as delayed menarche, or delayed puberty.

Secondary amenorrhea

In secondary amenorrhea, women who have already established a regular menstrual cycle miss menstruation three times in a row or more. This sometimes involves a dysfunction of the hypothalamus. If the production of hormones required to trigger ovulation ends, the menstrual cycle becomes unnecessary and may stop altogether. Some medical professionals refer to this version of the condition as hypothalamic amenorrhea

Causes of amenorrhea

While pregnancy is often responsible for amenorrhea, the condition can occur for a wide variety of other reasons. Some of these are of little concern, but others may point to urgent issues with mental or physical health. A few of the most common causes of amenorrhea include:

Breastfeeding

Timing for the return of menstruation can differ dramatically based on whether women breastfeed, and to what extent. Exclusive breastfeeding may delay menstrual cycles by several months or even a year or more.

Known as lactational amenorrhea, this phenomenon sometimes involves family planning. Research suggests that the effectiveness of the lactational amenorrhea method (LAM) is limited, though that may be because of how difficult it can be to implement correctly.

Contraception

Certain types of contraception limit menstruation or cause it to stop altogether. This response is most common for oral forms hormonal contraception, although some women with hormonal IUDs may also experience irregular periods or the full loss of menstruation.

Menopause

Ovulation and menstruation become more irregular with the beginning of menopause, eventually giving way to the loss of menstrual periods altogether. This transition can vary significantly between women. Some experience amenorrhea sooner than expected due to premature menopause.

Sudden weight loss

In some cases, the loss of menstruation may be accompanied by sudden and significant weight loss. Some extreme athletes, for example, experience amenorrhea during times of intense training. Additionally, the loss of menstrual cycles is associated with eating disorders such as anorexia nervosa. Weight loss due to health concerns, such as cancer or type 1 diabetes, may also affect menstruation.

Hormonal imbalance

Many women with amenorrhea have underlying hormonal concerns. Menstrual disruptions often accompany conditions such as polycystic ovary syndrome (PCOS) and noncancerous pituitary tumors.

Structural concerns

Some structural issues related to the reproductive system can contribute to amenorrhea. With Asherman's syndrome, for example, the buildup of scar tissue limits the buildup of the uterine lining required for menstruation.

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Diagnosing amenorrhea

Doctors often diagnose amenorrhea by inquiring about women's menstrual cycles. If these have not arrived by the age of 16—or if they have disappeared for three months or more—the condition may be diagnosed. Doctors also consider the influence of breastfeeding, contraception, or menopause, and they always rule out pregnancy first. A pelvic exam may follow after questions about these and other factors.

Treatments for amenorrhea

Preferred treatment for amenorrhea depends on the cause. The condition doesn’t always spark concern. Even when it does, treatments may focus on underlying factors rather than addressing the menstrual cycle itself. Some cases, however, may need swift treatment to avoid the long-term consequences of estrogen deficiency — low levels of the female hormone — that often accompanies amenorrhea.

When amenorrhea occurs due to genetic abnormalities, it can be treated with supplemental hormones. Cases involving structural issues of the reproductive system may require surgery.

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Medically Reviewed on 1/13/2021
References
American Family Physician: "Amenorrhea: An Approach to Diagnosis and Management."

American Family Physician: "Diagnosis and Management of Galactorrhea."

Cochrane Database of Systematic Reviews: "Lactational amenorrhea method for family planning."

Diabetes Care: "Menstrual Cycle Differences Between Women with Type 1 Diabetes and Women Without Diabetes."

Einstein (São Paulo): "Menstruation disorders in adolescents with eating disorders — target body mass index percentiles for their resolution."

Eunice Kennedy Shriver National Institute of Child Health and Human Development: "What causes amenorrhea?"

Fertility and Sterility: "Comprehensive Management of Severe Asherman Syndrome and Amenorrhea."

Harvard Health Publishing: "Amenorrhea."

The North American Menopause Society: "Chapter 1: Menopause."

The Practice Committee of the American Society for Reproductive Medicine: "Current Evaluation of Amenorrhea."

StatPearls: "Primary Amenorrhea."