amenorrhea journal

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What causes primary amenorrhea?There are three main causes of primary amenorrhea: Chromosomal or genetic abnormalities can cause the ovaries to stop

functioning normally. Turner syndrome, a condition caused by apartially or completely missing X chromosome, and androgen

insensitivity syndrome, often characterized by high levels oftestosterone, are two examples of genetic abnormalities that can delayor disrupt menstruation.1

Hypothalamic (pronounced hahy-poh-thuh-LAM-ik ) or pituitary(pronounced pi-TOO-i-ter-ee) problems in the brain and physicalproblems such as problems with reproductive organs can preventperiods from starting.

Excessive exercise, eating disorders, extreme physical or psychologicalstress, or a combination of these factors can delay the onset ofmenstruation.

What causes secondary amenorrhea?Secondary amenorrhea can result from various causes, such as: Natural causes. Pregnancy is the most common cause. Other natural causes include breastfeeding and menopause. Medications and therapies. Certain birth control pills, injectable contraceptives, and intrauterine

devices (IUDs) can cause amenorrhea. It can take a few monthsafter stopping birth control for the menstrual cycle to restart andbecome regular.

Some medications, including certain antidepressants and blood

pressure medications, can increase the levels of a hormone thatprevents ovulation and the menstrual cycle.2

Chemotherapy and radiation treatments for hematologic cancer(including blood, bone marrow, and lymph nodes) and breast orgynecologic cancer can destroy estrogen-producing cells andeggs in the ovaries, leading to amenorrhea. The resultingamenorrhea may be short-term, especially in younger women.3

Sometimes scar tissue can build up in the lining of the uterus,preventing the normal shedding of the uterine lining in themenstrual cycle. This scarring sometimes occurs after a dilationand curettage (D&C), a procedure in which tissue is removedfrom the uterus to diagnose or treat heavy bleeding or to clearthe uterine lining after a miscarriage,4 a cesarean section, ortreatment foruterine fibroids.

Hypothalamic amenorrhea.This condition occurs when the hypothalamus,a gland in the brain that regulates body processes, slows or stopsreleasing gonadotropin-releasing hormone (GnRH), the hormone thatstarts the menstrual cycle.5 Common characteristics of women withhypothalamic amenorrhea include:6

Low body weight Low percentage of body fat

Very low intake of calories or fat Emotional stress
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Strenuous exercise that burns more calories than are taken inthrough food

Deficiency of leptin, a protein hormone that regulates appetite andmetabolism

Some medical conditions or illnesses

Gynecological conditions. Unbalanced hormone levels are commonfeatures of certain conditions that have secondary amenorrhea as amain symptom. These can include:

Polycystic ovary syndrome (PCOS).PCOS occurs when a woman'sbody produces more androgens (a type of hormone) thannormal. High levels of androgens can cause fluid-filled sacs orcysts to grow in the ovaries, interfering with the release of eggs(ovulation). Most women with PCOS either have amenorrhea orexperience irregular periods, called oligomenorrhea(pronounced ol-i-goh-men-uh-REE-uh).

Fragile X-associated primary ovarian insufficiency (FXPOI).The term

FXPOI describes a condition in which a woman's ovaries stopfunctioning before normal menopause, sometimes around age40. FXPOI results from certain changes to a gene on the Xchromosome. As many as 10% of women who seek treatmentfor amenorrhea have FXPOI.7

Thyroid problems. The thyroid is a small butterfly-shaped gland at thebase of the neck, just below the Adam's apple. The thyroid produceshormones that control metabolism and play a role in puberty andmenstruation.8 A thyroid gland that is overactive (calledhyperthyroidism) or underactive (hypothyroidism) can cause menstrualirregularities, including amenorrhea.9

Pituitary tumor. Noncancerous tumors in the pituitary gland in the brain,which regulates the production of hormones that affect many body functions,including metabolism and the reproductive cycle, can interfere with the body'shormonal regulation of menstruation.10

How is Amenorrhea diagnosed?A health care provider will usually ask a series of questions to begindiagnosing amenorrhea, including:1 How old were you when you started your period? What are your menstrual cycles like? (What is the typical length of your

cycle? How heavy or light are your periods?)

Are you sexually active? Could you be pregnant? Have you gained or lost weight recently? How often and how much do you exercise?

Primary AmenorrheaIf you are older than 16 and have never had a period, your health careprovider will do a thorough medical history and physical exam, including apelvic exam, to see if you are experiencing other signs of puberty. Dependingon the findings and on your answers to the questions above, other tests maybe ordered to determine the cause of your amenorrhea.
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Secondary AmenorrheaIf you are sexually active, your health care provider will likely order apregnancy test. He or she will also perform a complete physical exam,including a pelvic exam.You should contact your health care provider as soon as possible after you

miss a period.Other tests you may need include:2 Thyroid function test. This test measures the amount of thyroid-

stimulating hormone (TSH) in your blood, which can help determine ifyour thyroid is working properly. A thyroid gland that is overactive(hyperthyroidism) or underactive (hypothyroidism) can cause menstrualirregularities, including amenorrhea.

Ovary function test.This test measures the amount of follicle-stimulatinghormone (FSH) or luteinizing hormone (LH)hormones made by thepituitary glandin your blood to determine if your ovaries are working

properly. Your health care provider may also evaluate the level of anti-Mullerian hormone (AMH), which is produced by the ovarian follicles.Higher levels of AMH may be associated with polycystic ovarysyndrome.3Low or undetectable amounts of AMH may be associatedwithmenopauseorprimary ovarian insufficiency.

Androgen test. Androgens are sometimes called "male hormones"because men need higher levels of these hormones than woman do foroverall health. However, both men and women need androgens to stayhealthy. Your health care provider may want to check the level of maleandrogens in your blood.

Hormone challenge test. With this test, you will take a hormonal

medication for seven to 10 days in an effort to trigger a menstrualcycle. Results from the test can tell your health care provider whetheryour periods have stopped because of a lack of estrogen.

Screening for a permutation of the FMR1 gene. Changes in this genecan cause the ovaries to stop functioning properly, leading toamenorrhea.4

Chromosome evaluation. This test, also known as a karyotype, involvescounting and evaluating the chromosomes from cells in the body toidentify any missing, extra, or rearranged cells. Results from thisevaluation can help determine the cause of the chromosomalabnormality causing primary or secondary amenorrhea.

Ultrasound. This painless test uses sound waves to produce images ofinternal organs. This test can help determine if your reproductiveorgans are all present and shaped normally.

Computed tomography (CT). CT scans combine many X-ray imagestaken from different directions to create cross-sectional views ofinternal structures. A CT scan can indicate whether your uterus,ovaries, and kidneys look normal.

Magnetic resonance imaging (MRI). MRI uses radio waves with a strongmagnetic field to produce detailed images of soft tissues within thebody. Your health care provider may order an MRI to check for apituitary tumor or to examine your reproductive organs.

Hysteroscopy. In this procedure a thin, lighted camera is passed throughyour vagina and cervix to allow your health care provider to look at the
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inside of your uterus.1Your health care provider might use several of these tests to attempt todiagnose the cause of amenorrhea. In some cases, no specific cause for theamenorrhea can be found. This situation is called idiopathic (pronounced id-ee-uh-PATH-ik) amenorrhea.5

What are the treatments for Amenorrhea?The treatment for amenorrhea depends on the underlying cause, as well asthe health status and goals of the individual.

If primary or secondary amenorrhea is caused by lifestyle factors, your healthcare provider may suggest changes in the areas below: Weight. Being overweight or severely underweight can affect your

menstrual cycle. Attaining and maintaining a healthy weight often helpsbalance hormone levels and restore your menstrual cycle.

Stress. Assess the areas of stress in your life and reduce the things thatare causing stress. If you can't decrease stress on your own, ask forhelp from family, friends, your health care provider, or a professionallistener such as a counselor.

Level of physical activity. You may need to change or adjust yourphysical activity level to help restart your menstrual cycle. Talk to yourhealth care provider and your coach or trainer about how to train in away that maintains your health and menstrual cycles.

Be aware of changes in your menstrual cycle and check with your health careprovider if you have concerns. Keep a record of when your periods occur.Note the date your period starts, how long it lasts, and any problems you

experience. The first day of bleeding is considered the first day of yourmenstrual cycle.For primary amenorrhea, depending on your age and the results of the ovaryfunction test, health care providers may recommend watchful waiting. If anovary function test shows low follicle-stimulating hormone (FSH) or luteinizinghormone (LH) levels, menstruation may just be delayed. In females with afamily history of delayed menstruation, this kind of delay is common.1Primary amenorrhea caused by chromosomal or genetic problems mayrequire surgery. Women with a genetic condition called 46, XY gonadaldysgenesis have one X and one Y chromosome, but their ovaries do notdevelop normally. This condition increases the risk for cancer developing in

the ovaries. The gonads (ovaries) are often removed through laparoscopicsurgery to prevent or reduce the risk of cancer.2Treatment for secondary amenorrhea, depending on the cause, may includemedical or surgical treatments or a combination of the two.

Medical Treatments for Secondary AmenorrheaCommon medical treatments for secondary amenorrhea include: Birth control pills or other types of hormonal medication. Certain oral

contraceptives may help restart the menstrual cycle. Medications to help relieve the symptoms of PCOS. Clomiphene citrate

(CC) therapy is often prescribed to help trigger ovulation.3

Estrogen replacement therapy (ERT). ERT may help balance hormonallevels and restart the menstrual cycle in women with primary ovarian
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insufficiency (POI) or fragile X-associated primary ovarian insufficiency(FXPOI).4 Women with FXPOI often experience symptoms ofmenopause, such as hot flashes and night sweats. ERT replaces theestrogen a woman's body should be making naturally for a normalmenstrual cycle. In addition, ERT may help women with FXPOI lower

their risk for the bone diseaseosteoporosis.5ERT can increase the riskfor uterine cancer, so your health care provider may also prescribeprogestin or progesterone to reduce this risk.

In general, medications are safe, but they can have side effects, some ofwhich may be serious. You should discuss side effects and risks with yourhealth care provider before deciding on any specific medical treatment.

Surgical Treatments for Secondary AmenorrheaSurgical treatment for amenorrhea is not common, but may be recommendedin certain conditions. These include: Uterine scarring. This scarring sometimes occurs after removal of uterine

fibroids, a cesarean section, or a dilation and curettage (D&C), aprocedure in which tissue is removed from the uterus to diagnose ortreat heavy bleeding or to clear the uterine lining after a miscarriage.6Removal of the scar tissue during a procedure called a hysteroscopicresection can help restore the menstrual cycle.7

Pituitary tumor.Medications may be recommended to shrink the tumor. Ifthis does not work, surgery may be necessary to remove the tumor.Pituitary tumors are not cancerous, but they can cause problems asthey grow. Pituitary tumors can put pressure on surrounding bloodvessels and nerves such as the optic nerve and may result in loss ofvision.

Most of the time, pituitary tumors are removed through the nose and sinuses.Radiation therapy may be used to shrink the tumor, either in combination withsurgery or, for those who cannot have surgery, by itself.
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