General Health

Causes, Diagnosis and Treatment of Amenorrhoea

A condition of absence of menstruation i.e., if you don’t have your period for more than three cycles and you are not pregnant, is referred to as amenorrhea and may be classified as primary or secondary:

  • Primary amenorrhea. Menstruation never begins at puberty, i.e., no history of menstrual periods by 15 years of age. The most common primary amenorrhea causes are hormonal levels, although anatomical problems may also cause amenorrhea.
  • Secondary amenorrhea. This type is due to a physical cause and usually of later onset i.e., the menstrual periods that were normal initially became irregular and abnormal or absent eventually. When body mass index (BMI) falls below 19, the risk of developing secondary amenorrhea increases significantly.

Causes of Amenorrhoea

Potential causes of amenorrhea include:

  1. Natural amenorrhea: During the normal course of life, you may experience amenorrhea for natural reasons including pregnancy, breastfeeding and as menopause.
  2. Contraceptives: Some women who take birth control pills (oral contraceptives) may not have menstrual periods. Even after the stoppage of birth control pills, it may take some time before regular ovulation and menstruation return. Injected or implanted contraceptives that may also cause amenorrhea, as can intrauterine devices.
  3. Ovulation abnormalities. Ovulation abnormalities usually cause frequently missed or irregular periods.
  4. Eating disorders. If you have bulimia or anorexia nervosa, you may develop amenorrhea because your body weight can be too low to sustain a pregnancy and therefore, to protect the body, the reproductive system may shut down since it’s severely malnourished. About 10% under normal body weight can interrupt several hormonal functions in the human body, potentially halting ovulation.
  5. Overexercise or strenuous exercises. If you over-exercise, your periods may stop due to reduced body fat content. Females who participate in activities requiring rigorous physical training, such as ballet, may have interruptions in their menstrual cycles. Several factors combine to contribute to the loss of menstrual periods in athletes, including stress, high energy expenditure and low body fat.
  6. Hormonal imbalances. If your thyroid gland is either underactive (hypothyroidism) or overactive (hyperthyroidism) your menstrual periods may stop. Polycystic ovary syndrome (PCOS) causes persistently high levels of hormones, rather than the fluctuating levels seen in the normal menstrual cycle. A benign or noncancerous tumour in the pituitary gland can also interfere with the hormonal regulation of menstruation. Menopause usually commences at around 50 years of age. But, for some women, the ovarian supply of eggs reduces before the age of 40 and menstruation stops (premature menopause).
  7. Medications: Several medications can cause menstrual periods to stop, including some types of antipsychotics, cancer chemotherapy, antidepressants, anti-hypertensive drugs and allergy medications.
  8. Obesity. You may have amenorrhea due to excess fat cells interfering with ovulation if you are overweight.
  9. High levels of stress. Mental stress can transiently alter the functioning of the hypothalamus — an area of the brain that controls hormones regulating the menstrual cycle, as a result of which, menstruation and ovulation may stop. Regular menstrual periods usually resume after a decrease in mental stress levels.
  10. Genetic predisposition: Individuals with genetic disorders such as Turner syndrome, androgen insensitivity syndrome, which leads to high levels of testosterone, and Müllerian defects may be predisposed to amenorrhoea.
  11. History of certain gynecological procedures. If you’ve had a D&C, particularly related to pregnancy, or a procedure known as loop electrodiathermy excision procedure (LEEP), the risk of developing amenorrhea is higher.
  12. Structural problems. Problems with the sexual organs themselves also can cause amenorrhea. Examples include:
  • Uterine scarring. Asherman’s syndrome, a condition in which scar tissue builds up in the uterus lining, can sometimes occur after dilation and curettage (D&C), Cesarean (C) section or treatment for uterine fibroids. Uterine scarring prevents the normal build-up and shedding of the uterine lining.
  • Lack of reproductive organs. Sometimes problems arise during fetal development leading to missing parts of the reproductive system, such as the uterus, vagina or cervix and if the reproductive system does not develop fully, menstrual cycles are not possible later in life.
  • Structural abnormality of the vagina. Vaginal obstructions may prevent visible menstrual bleeding. A membrane or a wall may be present in the vagina that blocks the outflow of blood from the uterus and cervix.

Symptoms of Amenorrhoea

Depending on the cause of amenorrhea, a female might experience other clinical signs or symptoms with the absence of menstruation, such as:

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  1. Milky discharge from the nipples
  2. Loss of hair
  3. Headache
  4. Changes in vision
  5. Excessive facial hair
  6. Pain in the pelvic region
  7. Acne
  8. Lowering of the voice and weight gain

Diagnosis and treatment of Amenorrhoea

Diagnosis begins with a medical history and a complete physical examination, including a pelvic examination. Tests for primary amenorrhoea include Follicle stimulating hormone (FSH), Thyroid stimulating hormone (TSH) and Luteinizing hormone (LH) tests. Tests for secondary amenorrhoea include pregnancy tests, thyroid function test, ovary function test, androgen and other hormone tests. Imaging tests may include MRI, CT, ultrasound scan or hysteroscopy.

Treatment options for amenorrhea could include hormonal treatment (progesterone supplements), oral birth control pills (to prevent ovulation), changes in diet to include increased fat and caloric intake and calcium supplements may be taken to decrease the loss of bone.


Pooja Toshniwal Paharia

Dr. Pooja Toshniwal Paharia is a Consultant Oral and Maxillofacial Physician and Radiologist, M.DS (Oral Medicine and Radiology) from Mumbai. She strongly believes in evidence-based radiodiagnosis and therapeutic regimens for benign, potentially malignant, or malignant lesions and conditions either arising from the oral and maxillofacial structures or manifesting in the associated regions.

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