Amenorrhea (or no periods) Symptoms & treatments

The amenorrhea is the absence of menstruation in a woman of reproductive age.

From 2% to 5% of women would be affected by amenorrhea. This is a symptom and it is important to know the cause. The absence of periods is quite natural when, for example, the woman is pregnant, breastfeeding or approaching menopause. But outside of these situations, it can be a telltale sign of chronic stress or a health problem such as anorexia or a disorder of the thyroid gland.

Types of missed periods

  • Primary amenorrhea: when at the age of 16, your period has not yet started. Secondary sexual characteristics (development of the chest, hair in the pubis and armpits and distribution of fatty tissue in the hips, buttocks and thighs) may nevertheless be present.
  • Secondary amenorrhea: When a woman has had a period and stops menstruating for one reason or another, for a period equivalent to at least 3 intervals of previous menstrual cycles or 6 months without menstruation.

When to consult when you don’t have a period?

Often times, not knowing why you have amenorrhea is worrying. The following people should see a doctor  :
– women with primary or secondary amenorrhea;
– in the event of post-contraceptive amenorrhea, a medical evaluation is necessary if the amenorrhea persists for more than 6 months in women who have been on the contraceptive pill, who have worn a Mirena® hormonal IUD, or more than 12 months after the last injection of Dépo-Provera®.

Important. Sexually active women who are not taking hormonal contraceptives should be tested for pregnancy if their period is more than 8 days late, even when they are “sure” that they are not pregnant. Note that bleeding that occurs with hormonal contraception (especially a false period generated by the birth control pill) is not proof of absence of pregnancy.

Diagnosis of amenorrhea

In most cases, physical examination , a pregnancy test, and sometimes an ultrasound of the sexual organs are sufficient to guide the diagnosis.

An x-ray of the wrist (to assess pubertal development), hormone assays or chromosomal sex testing are done in rare cases of primary amenorrhea.

Causes of missing periods

There are many causes of amenorrhea. Here are the most frequent in descending order.

  • The pregnancy. The most common cause of secondary amenorrhea, it must be the first suspected in a sexually active woman. Surprisingly, it often happens that this cause is ruled out without prior checking, which is not without risk. Certain treatments indicated to treat amenorrhea are contraindicated in pregnancy. And with commercially available tests, diagnosis is simple.
  • A minor delay in puberty. It is the most common cause of primary amenorrhea. The age of puberty is normally between 11 and 13 years old, but can vary a lot depending on ethnicity, geographic location, diet, and state of health.
     
    In developed countries, delayed puberty is common in young women who are very thin or athletic. It seems that these young women do not have enough body fat to allow the production of estrogen hormones. Estrogens allow the uterine wall to thicken, and later menstruation if the egg has not been fertilized by a sperm. In a way, the bodies of these young women naturally protect themselves and signal that their physical form is inadequate to support a pregnancy.
     
    If their secondary sexual characteristics are present (appearance of breasts, pubic hair and armpits), there is no need to worry before the age of 16 or 17 years. If signs of sexual maturation are still absent at the age of 14, a chromosomal problem (a single X sex chromosome instead of 2, a condition called Turner syndrome), a problem with development of the reproductive system or a hormonal problem.
  • Breastfeeding. Often, breastfeeding women do not have a period. However, it should be noted that they can still have ovulation during this period, and therefore a new pregnancy. Breastfeeding suspends ovulation and protects against pregnancy (99%) only if:
    – the baby is exclusively at the breast;
    – the baby is less than 6 months old.
  • The onset of menopause. Menopause is the natural cessation of menstrual cycles that occurs in women between the ages of 45 and 55. The production of estrogen gradually decreases, causing your periods to become irregular and then go away completely. You can ovulate sporadically for 2 years after you stop having your period.
  • Taking hormonal contraception. The “periods” which occur between two packets of pills are not periods linked to an ovulatory cycle, but “withdrawal” bleeding when the tablets are stopped. Some of these pills reduce bleeding, which sometimes after a few months or years of taking it, may no longer occur. Mirena® hormonal intrauterine device (IUD), injectable Depo-Provera®, continuous contraceptive pill, Norplant and Implanon implants can cause amenorrhea. It is not serious and demonstrates contraceptive efficacy: the user is often in a “hormonal state of pregnancy” and is not ovulating. It therefore has no cycle, no rules.
  • Stopping taking a contraceptive method(birth control pills, Depo-Provera®, Mirena® hormonal IUD) after several months or years of use. It may take a few months before the normal cycle of ovulation and menstruation is restored. It is called post-contraceptive amenorrhea. In fact, hormonal contraceptive methods reproduce the hormonal state of pregnancy, and can therefore suspend periods. These may therefore take some time to return after stopping the method, such as after pregnancy. This is particularly the case in women who had a very long (more than 35 days) and unpredictable cycle before taking the contraceptive method. Post-contraceptive amenorrhea is not problematic and does not compromise subsequent fertility.
  • The practice of a discipline or a demanding sport such as marathon, bodybuilding, gymnastics or professional ballet. The “sportswoman’s amenorrhea” is thought to be attributable to the insufficiency of fatty tissue as well as to the stress to which the body is subjected. There is a lack of estrogen in these women. It can also be for the body not to waste energy unnecessarily since it often undergoes a low calorie diet. Amenorrhea is 4 to 20 times more common in athletes than in the general population 1 .
  • Stress or psychological shock . So-called psychogenic amenorrhea results from psychological stress (death in the family, divorce, job loss) or any other type of significant stress (travel, major changes in lifestyle, etc.). These conditions can temporarily interfere with the functioning of the hypothalamus and cause menstruation to stop as long as the source of stress persists.
  • Rapid weight loss or pathological eating behavior . Too low a body weight can lead to a drop in estrogen production and a cessation of menstruation. In the majority of women who suffer from anorexia or bulimia, periods stop.
  • Excessive secretion of prolactin from the pituitary gland . Prolactin is a hormone that promotes mammary gland growth and lactation. Excess secretion of prolactin from the pituitary gland can be caused by a small tumor (which is always benign) or by certain medications (especially antidepressants). In the latter case, its treatment is simple: the rules reappear a few weeks after stopping the drug.
  • Obesity or excess weight.
  • Taking certain medications such as oral corticosteroids, antidepressants, antipsychotics or chemotherapy. Drug addiction can also cause amenorrhea.
  • Uterine scars . Following surgery to treat uterine fibroids, endometrial resection, or sometimes a cesarean section, there may be a significant decrease in menstruation, or even transient or lasting amenorrhea.
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The following causes are much less common.

  • An abnormality in the development of sexual organs of non-genetic origin. Androgen insensitivity syndrome is the presence, in an XY (genetically male) subject, of female-looking sex organs due to the absence of sensitivity of cells to male hormones. These “intersex” people with a feminine appearance consult at puberty for primary amenorrhea. The clinical and ultrasound examination allows the diagnosis: they do not have a uterus, and their sex glands (testes) are located in the abdomen.
  • Chronic or endocrine diseases . An ovarian tumor, polycystic ovary syndrome , hyperthyroidism, hypothyroidism, etc. Chronic diseases that are accompanied by significant weight loss (tuberculosis, cancer, rheumatoid arthritis or other systemic inflammatory disease, etc.).
  • Medical treatments. For example, surgical removal of the uterus or ovaries; cancer chemotherapy and radiotherapy.
  • An anatomical abnormality of the sexual organs. If the hymen is not perforated (imperforation), this can be accompanied by painful amenorrhea in the pubescent girl: the first periods remain trapped in the vaginal cavity.
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 Course and possible complications

The duration of amenorrhea depends on the underlying cause. In the majority of cases, amenorrhea is reversible and is easily treated (with the exception, of course, of amenorrhea related to genetic abnormalities, non-operable malformations, menopause or removal of the uterus and ovaries). However, when long-standing amenorrhea is left untreated, the cause may eventually reach the reproductive mechanisms .

In addition, amenorrhea associated with a lack of estrogen (amenorrhea caused by demanding sports or an eating disorder) makes it more at risk of long-term osteoporosis – therefore fractures , instability of the vertebrae. and lordosis  – since estrogen plays an essential role in preserving bone structure. It is now well known that female athletes who suffer from amenorrhea have lower bone density than normal, which is why they are more prone to fractures 1 . While moderate exercise helps prevent osteoporosis, too much exercise has the opposite effect if it is not balanced by a higher calorie intake.

No period: what other symptoms of amenorrhea?

Symptoms

In a woman who has never had a period

  • No menstruation at age 14 and no development of secondary sexual characteristics.
  • No menstruation at the age of 16 despite the presence of development of secondary sexual characteristics.

In a woman who has had a previous period

  • Absence of menstruation for a period equivalent to at least 3 intervals of previous menstrual cycles or 6 months without periods.


People at risk

All women are susceptible to amenorrhea at some point in their life. See the list of causes above.

Risk factors

Here are the most common.

  • Significant weight loss.
  • Prolonged stress.
  • The intensive practice of a sporting activity.
  • A deficient diet.

Prevention of amenorrhea

Basic preventive measures

Eat a balanced diet and a healthy weight . Make sure that the diet provides enough calories to maintain a healthy weight – but not too many, since obesity also contributes to amenorrhea. The goal is to maintain a sufficient percentage of body fat. A minimum of body fat is indeed necessary to store estrogen.

Learn to deal with stress . Constraints, emotional tensions, the desire for success require a great capacity for adaptation. They are frequent stresses for many women, whether in the spheres of private, professional or sporting life. If this stress is prolonged, the body cannot recover and this can lead to a physiological imbalance, in particular hormonal. Thus, prolonged stress can lead to amenorrhea and ovulation arrest.
Consult our Stress and Anxiety file to learn about different ways to better resist stress.

For athletes: surround yourself with a multidisciplinary team . The intensity of the efforts must be adapted to the athlete, according to his age and his physical capacities. In addition, the nutritional intake must be optimal. According to the author of a study 2 , the 3 most common health problems in female athletes – osteoporosis, amenorrhea and eating disorders – would be completely preventable if women were followed by a multidisciplinary team of therapists (trainer, nutritionist, sports psychologist, etc.), especially when they are in a period of growth.

Medical treatments for amenorrhea

In the majority of cases, no medical treatment is necessary. Before prescribing treatment, it is imperative to find the cause of amenorrhea, treat the underlying disease if necessary, and obtain psychological support if needed. It is sometimes suggested that you have sex hormones if your doctor suspects you have endocrine disease.

The application of the preventive measures mentioned above allows the return of menstruation in many women:

  • Healthy eating;
  • – maintenance of a healthy weight;
  • – stress management;
  • – moderation in the practice of physical exercises.

Medication

 Hormonal treatments

In the case of ovarian dysfunction in a young woman, hormonal treatment will be suggested to promote the development of sexual characteristics and fertility, and to prevent osteoporosis in the long term.

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For women who have undergone surgical removal of the uterus and ovaries very early (before the presumed age of menopause), hormone replacement therapy including estrogen AND progestins may be offered to prevent osteoporosis and others. consequences attributable to the lowering of circulating hormone levels. This treatment can be stopped around the age of 55.

Please note  : this treatment cannot be prescribed to women who have had their uterus or ovaries removed for hormone-dependent cancer. It also cannot be prescribed to women who have had ovarian castration by radiotherapy or chemotherapy for breast cancer.

Apart from these situations, no hormonal treatment is effective in causing the return of menstruation.

Furthermore, “ cycle regularization ” treatments   (for example, taking a synthetic progestogen in the second part of the cycle for women with irregular periods who would like a regular cycle to conceive) have no scientific basis. They can even contribute to accentuate menstrual cycle disorders by compromising the spontaneous onset of ovulations. It is not the regularity of the cycle that counts, but the respect of the cycle as it is in a given woman.

Non-hormonal treatment

When amenorrhea is due to high prolactin secretion linked to a benign pituitary gland tumor, bromocriptine (Parlodel®) is a very effective drug which lowers prolactin levels and allows menstruation to return. This is the same treatment that is given, just after childbirth, to women who do not want to breastfeed.

 Psychotherapy

If amenorrhea is accompanied by a psychological disorder , the doctor may suggest psychotherapy. The parallel use of hormonal treatments can be discussed, depending on the age of the woman, the duration of amenorrhea and the side effects of hormonal deficiency (if any). However, psychotropic drugs should be avoided, as they can lead to amenorrhea.

Amenorrhea associated with anorexia imperatively requires monitoring by a multidisciplinary team including nutritionist, psychotherapist, psychiatrist, etc. The anorexia often affects teenage girls and young women.

In the event of significant psychological trauma (rape, loss of a loved one, accident, etc.) or personal conflicts (divorce, financial difficulties, etc.), amenorrhea lasting several months, or even several years, may set in, in particular in a woman whose psychic balance was already fragile. The best treatment is then to consult a psychotherapist.

 Surgical treatment

If the amenorrhea is caused by a malformation of the reproductive system, surgery can sometimes be undertaken (in case of imperforation of the hymen for example). But if the malformation is too important (Turner’s syndrome or insensitivity to androgens), the surgery will only have a cosmetic and comfort function by modifying the appearance and the functionality of the undeveloped sexual organs, but will not “bring back” the rules.

Amenorrhea – Our doctor’s opinion

Amenorrhea is a common occurrence, but most often mild, especially in women who have had their period. The first thing to think about is pregnancy, but very often amenorrhea is just a few days’ delay, not serious. The wisest attitude after taking a pregnancy test is … patience. In the absence of worrying symptoms (loss of weight or appetite, fatigue), it is not necessary to consult before having waited a few weeks.

In young women, primary amenorrhea is most often linked to delayed puberty which, in the majority of cases, is not serious: it is only if the rules have not appeared at 16 that it is necessary to consult. Prescribing treatments to “bring back your period” without first discovering the cause of the amenorrhea is not recommended.


References

Ask DrWeil, Polaris Health (Ed). Q&A Library – Missing Menstruation ?,  DrWeil.com . [Accessed April 4, 2011]. www.drweil.com
Canadian Medical Association. Medical Encyclopedia of the Family, Reader’s Digest Selection, Canada, 1993.
Biron P (Dir). Family Medical Encyclopedia, Canadian Medical Association and Dorling Kindersley Limited, Canada, England, 1993.
Blumenthal M, Goldberg A, Brinckmann J (Ed). Expanded Commission E Monographs, American Botanical Council, published in conjunction with Integrative Medicine Communications, USA, 2000.
InteliHealth (Ed). Diseases and Conditions – Amenorrhea, Aetna Intelihealth. [Accessed April 4, 2011]. www.intelihealth.com
Mayo Foundation for Medical Education and Research (Ed). Diseases and conditions – Amenorrhea,  MayoClinic.com . [Accessed April 4, 2011]. www.mayoclinic.com
National Library of Medicine (Ed). PubMed, NCBI. [Accessed April 4, 2011]. www.ncbi.nlm.nih.gov