Amenorrhea is a condition when a woman does not menstruate on her usual schedule. A person can be said to have amenorrhea if they have not menstruated until the age of 15 or have not menstruated for three or more cycles in a row.
Not having a period is a normal condition for women during pregnancy, breastfeeding, entering menopause, or before puberty. In some cases, menstruation also does not occur in women who are using contraceptives, such as birth control pills or birth control injections.
Amenorrhea occurs when a woman does not menstruate outside of these conditions and periods. Amenorrhea can be a sign of a disease, ranging from the common PCOS
(polycystic ovarian syndrome), to a pituitary gland tumor. Therefore, this condition needs to be checked by a doctor.
Causes of Amenorrhea
There are various conditions that can cause amenorrhea, as explained below:
Hormonal disorders
The most common cause of amenorrhea is hormonal disorders. Hormones are needed to produce eggs (ovulation) which then trigger menstruation. Therefore, hormonal imbalances can disrupt the menstrual cycle, including amenorrhea.
Conditions that cause an imbalance in hormone levels in the body include:
- Polycystic ovary syndrome (PCOS)
- Primary ovarian insufficiency (POI), which is a condition where the ovaries do not work before the age of 40 years.
- Thyroid disease, such as hyperthyroidism or hypothyroidism
- Pituitary gland tumor
- Excess prolactin hormone (hyperprolactinemia)
- Ovarian tumor or cancer
- Use of certain medications, such as antipsychotics, antidepressants, or hypertension medications
Abnormalities in the reproductive organs
Although rare, amenorrhea can also occur due to abnormalities in the shape of the reproductive organs. Some abnormalities in the reproductive organs that can cause amenorrhea are:
- Formation of scar tissue on the uterine wall, for example in Asherman’s syndrome due to curettage or caesarean section.
- Abnormalities in the shape of the uterus or cervix, for example not forming at all or forming imperfectly
- Closure of the vaginal opening (imperforate hymen)
- Total or partial removal of the uterus (hysterectomy)
Risk factors for amenorrhea
The risk of amenorrhea is higher in people who:
- Suffering from overweight or obesity
- Being underweight, including due to suffering from certain eating disorders, such as bulimia or anorexia
- Experiencing ongoing stress
- Excessive exercise or physical activity
- Experiencing malnutrition or lack of nutrition
- Having a family member who has also suffered from amenorrhea
Symptoms of Amenorrhea
The main symptom of amenorrhea is the absence of menstruation. Under normal conditions, menstruation begins when a woman enters puberty, which is between 11-14 years old, and will stop when she enters menopause.
Menstruation itself occurs in cycles or repeats, ideally every 21–35 days. Typically, one menstrual cycle lasts for 2–7 days.
Amenorrhea is divided into two types, namely:
- Primary amenorrhea, which is when the first menstruation (menarche) has not occurred in girls who are already 15 years old or have experienced other signs of puberty.
- Secondary amenorrhea, which is when menstruation does not occur for ≥3 consecutive cycles in women who have menstruated before and are not pregnant.
In addition to not having menstruation, amenorrhea can also be accompanied by other symptoms depending on the cause. These other symptoms include:
- Hair loss
- Excessive acne
- Excessive hair growth on the face or body (hirsutism)
- Back pain
- Headache
- Breast milk comes out even though you are not breastfeeding
- Vagina feels dry
- Hot sensation in the body (hot flashes)
When to see a doctor
See a doctor if you do not have your first period by the age of 15 or over or do not have your period for three consecutive cycles. A medical examination is also necessary if you experience other symptoms of amenorrhea mentioned above.
If you are diagnosed with amenorrhea, have regular check-ups with your doctor. This is so that your doctor can monitor the effectiveness of your treatment and prevent complications.
Diagnosis of Amenorrhea
To diagnose amenorrhea, the doctor will ask questions about the patient’s symptoms, medical history, and menstrual cycle. After that, the doctor will perform a physical examination, including the pelvis, to detect abnormalities in the reproductive organs.
In patients who have never experienced their first period, the doctor will also perform a physical examination of the breast and genital areas to determine whether the patient is experiencing normal puberty.
To confirm the diagnosis, the doctor will also carry out supporting examinations, such as:
- Pregnancy test, to ensure that amenorrhea is not due to pregnancy.
- Blood tests, to measure hormone levels in the body, such as prolactin, thyroid, estrogen, FSH (follicle-stimulating hormone), or testosterone.
- USG, to see the reproductive organs, can be from the stomach, vagina, or anus.
- MRI of the head, if the cause of amenorrhea is suspected to be from the pituitary gland in the brain.
- Hysteroscopy , to see the inside of the uterus by inserting a special instrument equipped with a camera through the vaginal opening.
Amenorrhea Treatment
Treatment for amenorrhea depends on the underlying condition. Some medical procedures that a doctor can perform are:
Medication and hormonal therapy
To treat amenorrhea caused by hormonal disorders, doctors will prescribe medication and hormonal therapy, such as:
- Progesterone, to trigger the first menstruation
- Birth control pills, to restore normal menstrual cycles
- Bromocriptine medication , to treat amenorrhea due to excess prolactin hormone
- Metformin, to treat amenorrhea caused by PCOS
Lifestyle improvements
In addition to providing medication, lifestyle changes also play a major role in treating amenorrhea, especially those caused by hormonal disorders. Efforts that patients can make include:
- Lose weight if overweight or obese
- Maintain ideal body weight
- Exercise regularly
- Consume complete and balanced nutritious food
- Managing stress well
- Avoid consuming alcoholic beverages
- Do not smoke
Operation
In amenorrhea caused by abnormalities of the reproductive organs or tumors, doctors can perform surgery to correct the abnormality
Complications of Amenorrhea
Depending on the underlying condition, amenorrhea can cause complications, such as:
- Infertility , due to the absence of ovulation
- Osteoporosis or heart and blood vessel disease, due to a lack of the hormone estrogen
- Pelvic pain, due to abnormalities in the reproductive organs
- Stres
Prevention of Amenorrhea
Amenorrhea caused by abnormalities in the reproductive organs is difficult to prevent. However, a healthy lifestyle can prevent amenorrhea due to hormonal disorders or cancer in the reproductive organs. Some things that can be done to reduce the risk of amenorrhea are:
- Exercise regularly, but not excessively
- Consume complete and balanced nutritious food
- Maintain ideal body weight
- Get enough rest
- Always record your menstrual cycle
- Have regular pelvic exams or pap smears
- Managing stress well
References :
Kim, H., et al. (2022). Etiology and Secular Trends in Primary Amenorrhea in 856 Patients: A 17-Year Retrospective Multicenter Study in Korea. Journal of Korean Medical Science, 37(29), pp. 1–10.
Peña, A., Codner, E., & Witchel, S. (2022). Criteria for Diagnosis of Polycystic Ovary Syndrome during Adolescence: Literature Review. Diagnostics (Basel, Switzerland), 12(8), pp. 1931.
National Institutes of Health (2022). National Library of Medicine. Amenorrhea.
American College of Obstetricians and Gynecologists (2022). FAQs. Amenorrhea: Absence of Periods.
American Academy of Family Physicians (2020). Diseases and Conditions. Amenorrhea.
Cleveland Clinic (2023). Diseases & Conditions. Amenorrhea.
Cleveland Clinic (2022). Diseases & Conditions. Menarche.
Mayo Clinic (2023). Diseases & Conditions. Amenorrhea.
EmedicineHealth (2022). Amenorrhea (Absence of Menstrual Bleeding).
Healthline (2020). Everything You Need to Know About Amenorrhea.
Medscape (2019). Amenorrhea.
WebMD (2022). Amenorrhea.