No Menstrual Bleed? It could be Amenorrhoea

Overview of Amenorrhoea

Amenorrhoea is a condition prevalent in women of reproductive age characterized by the absence of menses. It can also be described as a lack of 'periods'. When there’s an absence of periods, it’s the body's way of sending out a distress signal to indicate that the problems run far deeper.

Amenorrhoea can be further classified as either primary amenorrhea (periods not having started by the age of puberty (14-16 years) or secondary where a woman who has previously been menstruating for three or more months, stops menstruating.

Before we go into depth about what amenorrhoea is and how it affects women, let’s understand how a menstrual cycle functions.

Hormones and menstruation

In order for women to have regular periods, it’s vital that her pituitary gland, ovaries, uterus, and hypothalamus – a small region on the brain that controls the menstrual cycle –are functioning normally. The hypothalamus triggers the pituitary gland to release certain hormones which, in turn, cause the ovaries to produce oestrogen and progesterone hormones. Oestrogen and progesterone are the hormones which are in charge of the cyclical changes that take place in the endometrium (lining of the uterus), including menstruation. These hormones make the uterus lining thicker in order to prepare the body for pregnancy. It also needs to be mentioned that there should be no abnormalities present in a woman’s genital tract in order to facilitate the smooth passage of menstrual blood.

In case there’s no pregnancy, hormone levels (oestrogen and progesterone) decline and the lining of the uterus sheds away along with blood, exiting through the vagina. This cycle which keeps repeating itself until the menopause can be better described as a period or menstrual cycle. Essentially, a period is said to occur when the egg doesn’t get fertilized. This cycle typically lasts anywhere between 3-5 days while the average menstrual cycle observed in most women lasts for 28 days. However, this cycle can also range from 21-45 days depending on the woman’s age along with other factors.

Any disorders affecting the hypothalamus, pituitary gland or ovaries can also have an impact on the menstrual cycle thus resulting in amenorrhoea. Amenorrhea or a lack of periods is considered to be normal under the following circumstances:

Puberty – Before puberty as the body doesn’t ovulate yet
Pregnancy – During pregnancy, the body tends to produce the pregnancy hormone – human chorionic gonadotrophin (hCG) – causing the menstrual cycle to stop
Breastfeeding – While breastfeeding, the body produces Prolactin – a primary hormone responsible for breast milk production. Prolactin plays a role in preventing menstruation. Moreover, as long as the prolactin hormones are high, the longer a woman tends to produce milk which, in turn, results in the woman not experiencing a period.

Types of Amenorrhoea

Amenorrhoea can be classified into two further types

Primary amenorrhoea – In the case of primary amenorrhoea, there is an absence of menstrual bleeding or periods in a girl by age the age of 14-16 years – a time when girls hit puberty. In addition, there’s an absence of development of other secondary sexual characteristics (for instance, developing breasts and pubic hair) as well.

Secondary amenorrhoea – Secondary amenorrhoea is when periods or menstrual bleeding have stopped for about three months or more in a woman who had been previously menstruating. It can also be termed as a cessation of menstruation in the absence of pregnancy, lactation (production of breast milk), menopause, or even suppressing the cycle with the aid of birth control pills.

Secondary amenorrhea is regarded to be far more common phenomenon vis-à-vis primary amenorrhea. Studies have pegged the frequency of primary amenorrhoea in the population to be in the range of between 0.5–1.2 percent. In the same regard, the frequency of secondary amenorrhoea has been pegged at approximately 5 percent.

Causes of Amenorrhoea

The management of amenorrhoea is entirely dependent on the underlying cause which is why it's important to understand the precise cause of amenorrhoea. That said, both primary and secondary amenorrhea is caused by different reasons. It also needs to be mentioned that every factor that causes secondary amenorrhoea can also be present as primary amenorrhoea.

Primary amenorrhea

In the case of primary amenorrhea, the causes are relatively uncommon. However, the most common reasons are listed below:

A genetic disorder or an anatomical abnormality
Presence of a birth defect in the reproductive organs which results in the blockage of the flow of menstrual blood.

Genetic disorders that can cause primary amenorrhea include –

Turner’s syndrome – often regarded as the most common cause of primary amenorrhoea
Kallmann syndrome – a genetic disorder that results in the absence or delay in puberty along with an impaired sense of smell.
Congenital adrenal hyperplasia – a condition that affects a child's normal growth and development and results in an overproduction of male hormones by the adrenal glands
Pseudohermaphroditism or true hermaphroditism – a condition in which the external genitalia is ambiguous—neither male nor female—genitals
Swyer Syndrome – a disorder which results in a woman having a Y chromosome which only occurs in males

Other lesser common causes that can result in primary amenorrhoea include:

Müllerian agenesis– also known as or vaginal agenesis, a rare congenital abnormality where there is underdevelopment or absence of development of the vagina, sometimes with or without the uterus, and usually occurs when the baby is developing in the foetus.
Enzymes deficiencies
Hypothyroidism
Polycystic ovarian syndrome or PCOS – which can be described as a hormonal disorder which results in enlarged ovaries with small cysts forming on the outer edges.
Delay in hitting puberty – this is more common in boys than girls and can be associated with chronic or acute illness
High prolactin levels owing to the presence of a pituitary tumour
High levels of stress
Low energy availability (from decreased caloric intake, excessive energy expenditure, eating disorders, excessive exercise)
Imperforate hymen – described as a congenital disorder where the hymen doesn’t have an opening thus completely obstructing the vagina
Transverse vaginal septum – described as a birth defect in which there is a scar-like tissue (septum) running horizontally across the vagina, blocking all or part of it

Causes of secondary amenorrhoea

The most common causes of secondary amenorrhoea are as below:

Pregnancy
Breastfeeding also referred to as lactational amenorrhoea
Polycystic ovary syndrome (PCOS) – Women with PCOS are at a higher risk of amenorrhoea especially when they put on weight
Premature menopause or a loss of normal function of the ovaries before the age of 40. (primary ovarian insufficiency)
Use of certain drugs & medications, such as oral contraceptives or birth control pills, antidepressants, or antipsychotic drugs
Having a very low body mass index (BMI)
Malnutrition
Serious weight loss resulting from a physical illness

Several factors can affect the functioning of the hypothalamus works and thereon, cause amenorrhoea. These are as below:

Excessive stress
Excessive exercising (especially in case of competitive or elite athletes which requires women to maintain low body weight)
Poor nutrition (in case of women who suffer from an eating disorder (Anorexia Nervosa, Bulimia Nervosa) or in case of women who have lost a significant amount of weight
Mental disorders such as depression or obsessive-compulsive disorder (OCD)
Radiation therapy
A head injury or a serious illness
Certain types of medication used to treat mental health conditions

Pituitary problems that can cause secondary amenorrhoea include:

Malfunctioning of the pituitary gland owing to damage
An underactive thyroid (hypothyroidism) or an overactive thyroid (hyperthyroidism) leading to a hormone imbalance
High levels of prolactin resulting from a benign or cancerous tumour present in the pituitary gland. Additionally, the use of certain medications such as antidepressants, antipsychotic drugs, birth control pills can also cause prolactin levels to increase and, in turn, cause pituitary tumours along with other disorders.
Thalamic pituitary problems
Hyperprolactinaemia – a common hormonal abnormality causing the body to produce high levels prolactin.
Postpartum pituitary necrosis also referred to the death of pituitary cells after a woman delivers a baby
Sarcoidosis – a disease which may affect the pituitary glands

Other factors that can cause secondary amenorrhoea include:

Emotional stress or severe emotional upheaval
Nutritional deficiencies
A symptom of endometrial cancer
Galactosemia – described as an inherited disorder where galactose, a type of sugar, keeps on accumulating in the blood
Coeliac disease – an autoimmune disorder that affects individuals eating gluten leading to damage in the small intestine
Premature ovarian insufficiency – also known as an ovarian failure or early menopause resulting in low levels of oestrogen causing ovulation to stop
Presence of a hydatidiform mole described as an overgrowth of tissue from the placenta
Scarring of the uterus due to an infection or from dilation and curettage
Chronic disorders (particularly those affecting the lungs, blood, digestive tract, liver, or kidneys)
Endometrial or uterine polyps – abnormal growths that start in the inner lining of the uterus.
Fibroids
Recreational drug abuse
Cushing syndrome or hypercortisolism – where the body produces excessive hormone cortisol.
Anovulation – characterized by a lack of release of an egg
Hyperandrogenaemia – where the body produces high levels of male sex hormones resulting in ovulatory dysfunction. This can be caused by tumours affecting the ovary or adrenal gland, or due to certain congenital conditions
Medications for cancer chemotherapy
Autoimmune oophoritis – a condition where the cells present in the ovaries are destroyed by the body’s own immune system
Presence of benign ovarian cysts
Removal of the ovaries or uterus

It needs to be mentioned that in most of the causes of amenorrhoea are not due to genetic defects and are thereon, rarely inherited. In case of certain patients suffering from primary amenorrhoea, there might be some abnormalities in hypothalamic hormone production or defects in which affect the functioning of the ovary which may have been inherited. That said, in the case of secondary amenorrhoea, the likelihood that family genetic history may cause amenorrhoea is relatively higher.

Symptoms of Amenorrhoea

While the primary symptom of amenorrhoea is the absence of menstrual periods, there are a few other signs and symptoms of amenorrhoea which may manifest itself in certain patients:

Delayed puberty
Development of masculine characteristics – such as excessive facial & body hair (hirsutism), a deepened husky voice, and an increased in the size of muscles caused by polycystic ovary syndrome
Vision problems such as changes in vision or visual disturbances
Persistent headaches
An impaired sense of smell – a symptom which may arise due to Kallmann syndrome
A significant change in weight
Milky nipple discharge that occurs spontaneously caused by excessive levels of prolactin also known as galactorrhoea
Excessive tiredness and fatigue caused by diseases affecting the pituitary gland
Acne
Hair loss
Hot flushes or a sudden feeling of warmth usually felt over the face, neck and chest regions along with profuse sweating, vaginal dryness, disordered sleep or reduced libido commonly symptoms of premature menopause.
Short Stature
Lack of secondary sexual characteristics – for instance, breast development – caused by Turner syndrome.
Excessive anxiety – especially in women with psychiatric disorders or abnormalities.

Upon noticing any of the above-mentioned symptoms, it's crucial that one visits their nearest health care professional as soon as possible. It's imperative that an individual learns to recognize the warning signs as it could either be indicative of amenorrhea or any other underlying condition. To that end, if the periods suddenly become irregular, it’s vital that the affected individual brings it to the doctor’s attention and gets it checked out immediately to avoid further the onset of further complications.

Diagnosis & Tests for Amenorrhoea

A history of lack of periods or menstrual cycles is the first step in the diagnosis of amenorrhoea. Often the first step in arriving at an accurate diagnosis is in the form of a simple blood or urine tests that can rule out pregnancy as well as the onset of menopause. It needs to be reiterated that amenorrhea is not an illness but a symptom which is why the doctor will try to find out why there is a lack of menstruation.

The physician or doctor might also ask questions about the nature of the symptoms, nature of the uneasiness, any recent changes made to the diet, exercise routine, or weight, any emotional challenges faced recently, drugs/medications currently being used, questions related to risk factors while also asking you to furnish your entire family and medical history. It’s important to answer his/her questions honestly and comprehensively as it will help in arriving at a correct diagnosis:

Once the initial pregnancy has been ruled out, further tests will be ordered by the health care professional in order to determine the reasons why the individual is not ovulating. All of these tests can be carried out as an outpatient.

A progesterone withdrawal test where the patient will be administered an orally-active dose of the ovarian hormone, progesterone. If the patient gets her period, then it’s certain that the uterus is working, but she is not ovulating.
Initial blood tests may be ordered to determine the levels of hormones involved in the regulation of reproduction such as follicle stimulating hormone (FSH), thyroid stimulating hormone (TSH), luteinizing hormone (LH), prolactin, oestrogen, and androgen levels.
An ultrasound scan of the pelvic region (uterus and vagina) may be performed to assess the anatomy and check for any abnormalities or to look for polycystic ovaries.
A physical examination might be conducted to determine overall health and to analyse if other secondary sexual characteristics, such as breast growth and pubic hair, are developing normally.
Imaging scans such as a magnetic resonance imaging scan (MRI scan), computed tomography (CT), of the abdomen and brain may be performed
In some cases, a hysteroscopy may also be ordered where the doctor passes a thin tube with a lighted camera through the vagina and cervix to further examine the uterus from the inside. If tests still prove to be inconclusive, a Hysterosalpingogram (X-ray test) or saline infusion sonography (SIS) might also be ordered to examine the uterus

Complications of Amenorrhoea

Long-term implications of amenorrhoea include the following:

Women with amenorrhoea are at risk of suffering from decreased bone density and as a result thin bones (osteoporosis) which could lead to fractures. This makes it very important that they regularly monitor their bone density.
Women suffering from amenorrhea can't ovulate which mean they are unable to release eggs. If they plan on childbirth, then they won't be able to get pregnant and conceive.
Other symptoms similar to menopause may occur such as vagina dryness, hot flashes as well as an increased risk of heart and blood vessel disorders owing to low levels of oestrogen.
Decreased libido, persistent headaches, and problems with vision.
Women might suffer from virilization which may lead them to develop masculine characteristics including excess body hair (hirsutism), a deepened/husky voice, along with increased muscle size.

Treatment of Amenorrhoea

Treatment for amenorrhoea is entirely dependent on its nature and cause.

If amenorrhoea is due to excessive weight loss or nutritional deficiencies caused by dieting, then patients will be encouraged to eat a properly balanced diet and maintain healthier body weight. In some cases, where weight-loss is linked to psychological disorders or peer pressure, counselling sessions with a psychiatrist, a nutritionist and/or dietician may also be arranged.
Conversely, in some cases, being overweight or carrying excessive body weight can also be a cause of amenorrhea. Such patients will be encouraged to lose weight by managing their diet and cutting out excess fat from their diet. They will also be encouraged to join an exercise regime to maintain ideal body weight.
Sport professionals or elite athletes who exercise vigorously may also be at risk of amenorrhea. They will be encouraged to opt for a moderate exercise regime as it may help in stabilizing the monthly cycle.
In cases where amenorrhea is caused by emotional or mental stress, counselling sessions with a psychiatrist may help in dealing with stress and conflicts.
Women suffering from amenorrhea are encouraged to lead a healthy lifestyle by avoiding excessive alcohol consumption and quitting smoking.
Women suffering from polycystic ovary syndrome (PCOS) will be suggested appropriate treatment as the underlying cause can wary. If PCOS has led to excess weight, she may be told to lose weight by going on a weight-loss diet.
In the case of women with a Y chromosome, surgical removal of both ovaries will be suggested as having a Y chromosome increases the risk of contracting ovarian germ cell cancer. This particular variant of cancer begins in the cells that are responsible for producing eggs in the ovaries.
Hormone replacement therapy comprising of an oestrogen and a progestin can be used in case of women where oestrogen deficiency remains as the ovarian function cannot be restored.
To treat any thyroid gland issues, medications such as hormone replacements such as thyroxin, a thyroid hormone, and/or surgery may be recommended. To treat ovarian or uterine cancer, a combination of medications, radiation therapy, and chemotherapy may also be recommended.
Dopamine agonists such as bromocriptine (Parlodel) or pergolide (Permax) help in reducing prolactin levels in women suffering from tumours producing excess prolactin (hyperprolactinemia). These medications can help in restoring ovarian endocrine function as well as ovulation.
In some cases, a combined oral contraceptive pill may be suggested as it can help in triggering regular periods. However, this therapy will not treat any underlying cause.
Surgery may be recommended in the following cases:

If there is an abnormality resulting in the blockage of the flow of menstrual blood (Imperforate hymen or Transverse vaginal septum) surgery may be necessary.
Women with intrauterine adhesions may require surgery to get rid of the scar tissue.
Ovarian cysts
Any other genetic or physical problems that involve the reproductive organs causing uterine or vaginal abnormalities

In the case of women suffering from early menopause, osteoporosis is a real worry. Such women will be suggested to change their diet or given supplements that contain calcium and Vitamin D. Similarly, medications that prevent bone loss such as bisphosphonates will also be recommended.

The Bottom Line

Amenorrhea is not a life-threatening condition (in most cases) and can easily be prevented. By simply making a few lifestyle adjustments, such as maintaining a normal weight, eating a well-balanced diet, exercising regularly without going overboard, quitting vices, and by learning to manage stress effectively, amenorrhea can be corrected.

If at all menstruation stops, the key is not to panic as it doesn’t always necessarily mean that the person has amenorrhea. If there are any concerns related to menstruation or menstrual cycle, it’s recommended that you visit your nearest doctor. In many cases, treatment is easily available.

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