Amenorrhea – absent menstruation symptoms, causes and treatment

Medically reviewed: 15, February 2024

Amenorrhea: What You Need to Know

Amenorrhea is a medical term that means the absence of menstrual periods in a woman who has reached reproductive age. Menstrual periods are the monthly bleeding that occurs from the uterus as a result of the hormonal changes that regulate the reproductive cycle. Amenorrhea can affect various aspects of a woman’s health, such as bone density, fertility, and psychological well-being. Therefore, it is important to understand the causes, symptoms, diagnosis, and treatment of amenorrhea.

Types of Amenorrhea

There are two main types of amenorrhea: primary and secondary.

Primary Amenorrhea

Primary amenorrhea is when a girl has not started her periods by the age of 15, or has not developed any signs of puberty, such as breast growth or pubic hair, by the age of 13. Primary amenorrhea is usually caused by a problem in the development or function of the reproductive organs, such as the ovaries, uterus, or vagina. Some of the common causes of primary amenorrhea are:

• Chromosomal abnormalities, such as Turner syndrome, which affect the number or structure of the sex chromosomes. This can lead to the absence or underdevelopment of the ovaries, uterus, or vagina, as well as other physical features, such as short stature, webbed neck, or heart defects.
• Hormonal disorders, such as hypogonadotropic hypogonadism, which affect the production or action of the hormones that stimulate the ovaries. This can result from a problem in the hypothalamus or the pituitary gland, which are the parts of the brain that control the reproductive hormones. Some of the factors that can cause hormonal disorders are genetic mutations, tumors, infections, radiation, or medications.
• Anatomical defects, such as Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome, which affect the formation or opening of the uterus or vagina. This can prevent the menstrual blood from flowing out of the body, or cause the absence of the uterus or vagina altogether.

Secondary Amenorrhea

Secondary amenorrhea is when a woman who has had regular periods in the past stops having them for at least three months, or for six months if she has had irregular periods. Secondary amenorrhea is more common than primary amenorrhea, and can have various causes, such as:

Pregnancy, which is the most common cause of secondary amenorrhea. Pregnancy stops the menstrual cycle by increasing the levels of the hormones progesterone and human chorionic gonadotropin (hCG), which prevent ovulation and maintain the lining of the uterus.

Breastfeeding, which can also suppress the menstrual cycle by increasing the levels of the hormone prolactin, which inhibits the release of the hormones that stimulate the ovaries. Breastfeeding can delay the return of the periods for several months or even years, depending on the frequency and duration of nursing.

Menopause, which is the natural end of the reproductive years, usually occurring between the ages of 45 and 55. Menopause occurs when the ovaries stop producing eggs and hormones, leading to the cessation of the menstrual cycle and the onset of symptoms such as hot flashes, night sweats, vaginal dryness, and mood changes.

Contraceptives, which are methods of preventing pregnancy by interfering with the reproductive cycle. Some contraceptives, such as the birth control pill, mini pills, the injection, the implant, or the intrauterine device (IUD), can cause amenorrhea by suppressing ovulation and thinning the lining of the uterus. This can be a desired effect for some women, as it can reduce menstrual cramps, bleeding, and the risk of anemia. However, some women may experience irregular bleeding, spotting, or breakthrough bleeding while using contraceptives.

Hormonal imbalances, such as polycystic ovary syndrome (PCOS), which affect the production or action of the hormones that regulate the reproductive cycle. PCOS is a common condition that causes the ovaries to produce excess androgens, which are male hormones, and to develop multiple small cysts, which are fluid-filled sacs. This can interfere with ovulation and cause irregular or absent periods, as well as other symptoms, such as acne, excess hair growth, weight gain, and infertility.

Lifestyle factors, such as stress, weight changes, exercise, or diet, which can affect the balance of the hormones that control the reproductive cycle. Stress can increase the levels of the hormone cortisol, which can suppress the release of the hormones that stimulate the ovaries. Weight changes can affect the levels of the hormone leptin, which can also influence the reproductive hormones. Exercise can increase the levels of the hormone endorphin, which can inhibit the release of the reproductive hormones. Diet can affect the intake and metabolism of the nutrients that are essential for the production and function of the reproductive hormones. These factors can cause amenorrhea by disrupting ovulation and altering the lining of the uterus.

Amenorrhea Symptoms and Complications

The main symptom of amenorrhea is the absence of menstrual periods, which can have various effects on the body and the mind. Some of the possible symptoms and complications of amenorrhea are:

• Infertility, which is the inability to conceive a child after one year of regular unprotected sex. Amenorrhea can cause infertility by preventing ovulation, which is the release of an egg from the ovary, or by affecting the quality or quantity of the cervical mucus, which is the fluid that helps the sperm reach the egg.
• Osteoporosis, which is the loss of bone density and strength, leading to an increased risk of fractures. Amenorrhea can cause osteoporosis by lowering the levels of the hormone estrogen, which is important for maintaining bone health. Estrogen helps to regulate the balance between bone formation and resorption, which is the process of breaking down and rebuilding bone tissue. Low estrogen levels can tip this balance in favor of resorption, resulting in bone loss and weakness.
• Heart disease, which is the leading cause of death in women. Amenorrhea can increase the risk of heart disease by affecting the levels and function of the lipids, which are the fats that circulate in the blood. Estrogen helps to lower the levels of the low-density lipoprotein (LDL), which is the bad cholesterol that can clog the arteries, and to raise the levels of the high-density lipoprotein (HDL), which is the good cholesterol that can protect the arteries. Low estrogen levels can have the opposite effect, resulting in higher LDL and lower HDL levels, which can increase the risk of atherosclerosis, which is the buildup of plaque in the arteries, and coronary artery disease, which is the narrowing or blockage of the arteries that supply blood to the heart.
• Depression, which is a common mood disorder that affects how a person feels, thinks, and behaves. Amenorrhea can contribute to depression by affecting the levels and function of the neurotransmitters, which are the chemicals that transmit signals between the nerve cells in the brain. Estrogen helps to modulate the activity of the neurotransmitters, such as serotonin, dopamine, and norepinephrine, which are involved in regulating mood, motivation, and pleasure. Low estrogen levels can reduce the availability and effectiveness of these neurotransmitters, resulting in low mood, loss of interest, fatigue, and hopelessness.

Amenorrhea Diagnosis

The diagnosis of amenorrhea is based on the medical history, physical examination, and laboratory tests of the woman. The medical history includes questions about the age of onset, duration, and frequency of the periods, as well as the presence of any symptoms, medical conditions, medications, or lifestyle factors that may affect the menstrual cycle. The physical examination includes checking the vital signs, weight, height, body mass index (BMI), and secondary sexual characteristics, such as breast development, pubic hair, and body shape.

The physical examination also includes a pelvic exam, which involves inspecting the external and internal genitalia, and a Pap smear, which involves collecting cells from the cervix to screen for cervical cancer. The laboratory tests include blood tests, urine tests, and imaging tests, which can measure the levels of various hormones, such as FSH, LH, estrogen, progesterone, prolactin, thyroid hormone, cortisol, and hCG, as well as the presence of pregnancy, infection, or inflammation.

Treatment Options for Amenorrhea

The treatment of amenorrhea depends on the underlying cause and the individual goals of the woman. The main objectives of the treatment are to restore the menstrual cycle, to prevent or treat the complications of amenorrhea, and to address the psychological and emotional aspects of amenorrhea. Some of the possible treatment options are:

1. Hormone therapy, which involves taking medications that contain estrogen, progesterone, or both, to regulate the menstrual cycle and to prevent bone loss and heart disease. Hormone therapy can be given in the form of pills, patches, injections, or vaginal rings. Hormone therapy can also induce ovulation and improve fertility in some cases of amenorrhea. However, hormone therapy can have some side effects, such as nausea, bloating, breast tenderness, headaches, and blood clots. Hormone therapy is not suitable for women who have a history of breast cancer, liver disease, or blood clotting disorders.
2. Surgery, which involves correcting any anatomical defects or removing any tumors or cysts that may cause amenorrhea. Surgery can restore the normal function and appearance of the reproductive organs, as well as improve fertility in some cases of amenorrhea. It may also require general anesthesia, which can have some complications, such as allergic reactions, breathing problems, or heart problems.
3. Lifestyle changes, which involve modifying the diet, exercise, stress, and weight of the woman, to improve the balance of the hormones that control the menstrual cycle. Lifestyle changes can help to restore the periods, as well as to prevent or treat the complications of amenorrhea, such as osteoporosis, heart disease, and depression. Lifestyle changes can also enhance the overall health and well-being of the woman.

Some of the recommended lifestyle changes are:

Balanced diet

Eating a balanced and nutritious diet, that provides enough calories, protein, carbohydrates, fats, vitamins, and minerals, to support the normal function of the reproductive system. The diet should also include foods that are rich in calcium and vitamin D, such as dairy products, green leafy vegetables, fish, and fortified cereals, to prevent bone loss and fractures. The diet should also avoid foods that are high in salt, sugar, caffeine, alcohol, or processed foods, as they can interfere with the hormonal balance and cause fluid retention, weight gain, or inflammation.

Sport and exercises

Exercising regularly, but moderately, to maintain a healthy weight, to strengthen the bones and muscles, to improve the blood circulation and oxygen delivery, to reduce the stress and anxiety, and to boost the mood and self-esteem. The exercise should be appropriate for the age, fitness level, and medical condition of the woman, and should not be excessive or strenuous, as it can cause amenorrhea by suppressing the reproductive hormones and depleting the body fat.

The exercise should also be varied and enjoyable, to prevent boredom and injury. The recommended amount of exercise is at least 150 minutes of moderate-intensity aerobic activity, or 75 minutes of vigorous-intensity aerobic activity, or a combination of both, per week, along with some muscle-strengthening activities, such as lifting weights, doing push-ups, or using resistance bands, at least twice a week.

Manage stress

Managing stress, by using various techniques, such as relaxation, meditation, breathing, yoga, tai chi, massage, aromatherapy, music, art, or hobbies, to cope with the daily challenges and pressures, to calm the mind and body, to reduce the cortisol levels, and to increase the endorphin levels. Stress can cause amenorrhea by disrupting the communication between the brain and the ovaries, and by affecting the appetite, sleep, and mood of the woman. Stress can also worsen the symptoms and complications of amenorrhea, such as infertility, osteoporosis, heart disease, and depression. Therefore, it is important to identify the sources of stress, to seek help and support from family, friends, or professionals, and to practice self-care and positive thinking.

Maintain your weight

Achieving and maintaining a healthy weight, by balancing the calorie intake and expenditure, to avoid being underweight or overweight, which can cause amenorrhea by affecting the production and action of the reproductive hormones. Underweight women may not have enough body fat to produce enough estrogen, which is necessary for ovulation and menstruation. Overweight women may have excess body fat that produces too much estrogen, which can interfere with ovulation and menstruation. The healthy weight range for women can be determined by using the body mass index (BMI), which is a measure of weight in relation to height. The normal BMI range for women is between 18.5 and 24.9. Women who have a BMI below 18.5 or above 30 may have a higher risk of amenorrhea and its complications.

Can I Still Get Pregnant If I Have Amenorrhea?

Many women who experience amenorrhea often wonder if they can still conceive and become pregnant. The ability to conceive in the presence of amenorrhea is influenced by various factors such as the specific type and underlying cause of the condition, as well as the fertility levels of both the woman and her partner.

Primary Amenorrhea and Pregnancy

Women with primary amenorrhea, which is the absence of the first menstruation by the age of 15 or 16, usually have a low chance of getting pregnant naturally, because they have a problem in the development or function of their reproductive organs, such as the ovaries, uterus, or vagina. Some of these problems may prevent ovulation, which is the release of an egg from the ovary, or implantation, which is the attachment of the fertilized egg to the lining of the uterus.

Overall, while primary amenorrhea may present challenges in achieving pregnancy naturally, advancements in ART have opened up new possibilities for women who dream of starting a family. With the assistance of these innovative techniques, individuals can overcome the barriers posed by primary amenorrhea and fulfill their desires of becoming parents, regardless of the specific complexities they may face.

On the other hand, there is hope for women experiencing primary amenorrhea to conceive through the assistance of advanced reproductive technologies, commonly known as ART. These cutting-edge procedures, such as in vitro fertilization (IVF) and intracytoplasmic sperm injection (ICSI), offer a glimmer of hope to those who have been unable to conceive naturally.

In the procedure known as in vitro fertilization (IVF), the process involves the fusion of an egg and sperm within the controlled environment of a laboratory. Following this successful fertilization, the resulting embryo is subsequently introduced into the uterus of the woman seeking to conceive.

Similarly, ICSI involves the precise injection of a single sperm into an egg, followed by the transfer of the resulting embryo to the uterus. It’s important to note that the success of these techniques may vary depending on the individual’s specific circumstances. For some women, the use of donor eggs or donor sperm may be necessary to overcome any underlying fertility issues. In other cases, a gestational carrier may be employed, allowing the embryo to develop in another woman’s uterus before being transferred to the intended mother. These options provide alternative pathways to parenthood, offering a glimmer of hope to those facing primary amenorrhea.

Secondary Amenorrhea and Pregnancy

Women with secondary amenorrhea, which is the absence of menstruation for at least three months in women who have had regular periods before, may have a higher chance of getting pregnant naturally, because they may have a reversible or treatable cause of their amenorrhea, such as pregnancy, breastfeeding, menopause, contraceptives, hormonal imbalances, or lifestyle factors.

The first step to determine the possibility of pregnancy in women with secondary amenorrhea is to rule out pregnancy itself, by taking a pregnancy test or consulting a doctor. If the pregnancy test is negative, the next step is to identify and treat the underlying cause of amenorrhea, by using hormone therapy, surgery, medication, or lifestyle changes, as explained in the previous section.

Once the cause of amenorrhea is resolved, the menstrual cycle may resume and ovulation may occur, which can allow the woman to conceive naturally or with the help of fertility treatments, such as ovulation induction, which involves taking medications that stimulate the ovaries to produce and release eggs, or intrauterine insemination (IUI), which involves placing sperm directly into the uterus at the time of ovulation.

On the other hand, it is worth noting that a subset of women experiencing secondary amenorrhea may encounter a lingering or irreparable underlying factor contributing to their amenorrhea. This could be attributed to conditions such as ovarian failure or premature menopause, wherein the functionality of their ovaries ceases, resulting in the cessation of both egg production and hormone secretion.

In these cases, natural pregnancy is not possible, and the only option to get pregnant is to use donor eggs or embryos, which can be fertilized with the partner’s sperm or donor sperm, and transferred to the uterus.

How to Prevent Amenorrhea?

The prevention of amenorrhea is based on the same principles as the treatment of amenorrhea, which are to maintain a healthy and balanced lifestyle, to monitor and manage the hormonal levels, and to seek medical attention when needed. Some of the specific tips to prevent amenorrhea are:

Regular check-ups at the gynecologist

Having regular check-ups with a gynecologist, who can perform a physical examination, a pelvic exam, a Pap smear, and a breast exam, to detect any abnormalities or problems in the reproductive system, such as infections, inflammations, polyps, fibroids, cysts, or cancers.

The gynecologist can also order some blood tests, urine tests, or imaging tests, to measure the levels of various hormones, such as FSH, LH, estrogen, progesterone, prolactin, thyroid hormone, cortisol, and hCG, as well as the presence of pregnancy, infection, or inflammation.

The gynecologist can also prescribe some medications, such as hormone therapy, contraceptives, or antibiotics, to regulate the menstrual cycle, to prevent pregnancy, or to treat any underlying conditions that may cause amenorrhea. The gynecologist can also refer the woman to other specialists, such as an endocrinologist, a geneticist, a surgeon, or a psychologist, if needed.

Menstrual calender

Keeping a menstrual calendar, which is a record of the dates, duration, and amount of bleeding, as well as any symptoms, such as cramps, mood swings, or headaches, that occur during the menstrual cycle. The menstrual calendar can help to track the regularity and pattern of the periods, to identify any changes or abnormalities, and to plan for pregnancy or contraception. The menstrual calendar can also provide valuable information to the gynecologist, who can use it to diagnose and treat amenorrhea. The menstrual calendar can be kept in a notebook, a calendar, a smartphone app, or a website.

Quit smoking

Avoiding smoking, which is a harmful habit that can cause amenorrhea by affecting the blood vessels, the lungs, the heart, and the hormones. Smoking can reduce the blood flow and oxygen delivery to the reproductive organs, which can impair their function and health. Smoking can also increase the levels of carbon monoxide and nicotine in the blood, which can interfere with the production and action of the reproductive hormones. Smoking can also damage the DNA and the chromosomes, which can affect the quality and quantity of the eggs and the sperm, and increase the risk of miscarriage, birth defects, or infertility.

Smoking can also accelerate the aging process and the onset of menopause, which can lead to the cessation of the menstrual cycle and the symptoms of menopause. Therefore, it is advisable to quit smoking or to avoid exposure to secondhand smoke, to prevent amenorrhea and its complications.

You can also educate oneself and others about amenorrhea, which is a common and treatable condition that affects many women at some point in their lives. Amenorrhea can have various causes, symptoms, and complications, which can affect the physical, mental, and emotional health of the woman. Therefore, it is important to learn about the normal and abnormal aspects of the menstrual cycle, to recognize the signs and risk factors of amenorrhea, to seek medical help and advice when needed, and to follow the prescribed treatment and lifestyle changes. It is also important to share the knowledge and experience of amenorrhea with other women, who may have similar concerns or questions, and to support and encourage each other in coping with amenorrhea.

Can Men Have Amenorrhea Too?

The answer to this question is no, men cannot have amenorrhea, because amenorrhea is a condition that is specific to women and their menstrual cycle. Men do not have a menstrual cycle, which is the monthly process of preparing the uterus for a possible pregnancy, by producing and releasing an egg from the ovary, and by shedding the lining of the uterus, if the egg is not fertilized. Men do not have a uterus, an ovary, or an egg, which are the essential components of the menstrual cycle. Therefore, men cannot have amenorrhea, which is the absence of menstrual periods.

However, men can have some conditions that are similar to amenorrhea, in terms of affecting their reproductive hormones and their fertility. For example, men can have hypogonadism, which is a condition that occurs when the testicles do not produce enough testosterone, which is the main male hormone that regulates the development and function of the male reproductive organs, such as the penis, the testicles, the prostate, and the sperm.

Hypogonadism can be caused by various factors, such as genetic disorders, infections, injuries, tumors, medications, or aging. Hypogonadism can cause various symptoms, such as low libido, erectile dysfunction, infertility, decreased muscle mass, increased body fat, gynecomastia and osteoporosis.

Can Stress Cause Amenorrhea?

Stress is one of the common causes of amenorrhea, especially secondary amenorrhea, which occurs when a woman who has had regular periods in the past stops having them for at least three months, or for six months if she has had irregular periods. Stress can affect the menstrual cycle by disrupting the communication and balance of the hormones that regulate the reproductive system

Stress can be defined as any physical, mental, or emotional factor that causes tension or strain in the body or the mind. Stress can be acute or chronic, depending on the duration and intensity of the stressor. Acute stress is a short-term response to a sudden or unexpected challenge or threat, such as an accident, an exam, or a conflict. Chronic stress is a long-term response to a persistent or recurring challenge or threat, such as a disease, a job, or a relationship

Stress has the potential to disrupt the menstrual cycle as it can impact the hypothalamus, a crucial part of the brain responsible for various bodily functions, including the reproductive system. Specifically, the hypothalamus plays a role in producing a hormone known as gonadotropin-releasing hormone (GnRH). This hormone, in turn, stimulates the pituitary gland, another region of the brain that produces two important hormones called follicle-stimulating hormone (FSH) and luteinizing hormone (LH). These hormones are responsible for stimulating the ovaries to produce estrogen and progesterone, which are the primary female hormones crucial for regulating the menstrual cycle.

When the body is under stress, it produces another hormone called cortisol, which is also known as the stress hormone. Cortisol helps the body to cope with stress by increasing the blood sugar, blood pressure, and heart rate, and by suppressing the immune system, digestion, and reproduction. Cortisol can interfere with the production and action of GnRH, FSH, LH, estrogen, and progesterone, by either reducing or increasing their levels, depending on the type and duration of stress

When the levels of these hormones are altered, the menstrual cycle can be affected in various ways, such as:

• Delaying or preventing ovulation, which is the release of an egg from the ovary, and which is necessary for menstruation and pregnancy.
• Altering the thickness and shedding of the endometrium, which is the lining of the uterus, and which is responsible for the bleeding during menstruation.
• Changing the quality and quantity of the cervical mucus, which is the fluid that helps the sperm to reach the egg, and which can indicate the fertile window of the cycle.
• Affecting the mood, appetite, sleep, and libido of the woman, which can also influence the menstrual cycle.

The effects of stress on the menstrual cycle can vary from woman to woman, depending on the type, intensity, duration, and frequency of stress, as well as the individual sensitivity and resilience of the woman. Some women may experience irregular, light, or heavy periods, while others may experience amenorrhea, which is the absence of periods.

The treatment of stress-induced amenorrhea depends on the underlying cause and the individual goals of the woman. The main objectives of the treatment are to reduce the stress, to restore the hormonal balance, and to resume the menstrual cycle. Some of the possible treatment options are:

• Psychotherapy, which involves talking to a professional therapist, counselor, or psychologist, who can help the woman to identify the sources of stress, to cope with the emotions and thoughts, to develop coping skills and strategies, and to improve the self-esteem and well-being of the woman. Psychotherapy can also help the woman to address any underlying psychological issues, such as anxiety, depression, or trauma, that may contribute to stress and amenorrhea.
• Medication, which involves taking drugs that can help to reduce the symptoms of stress and amenorrhea, such as antidepressants, anti-anxiety drugs, or birth control pills. Antidepressants and anti-anxiety drugs can help to regulate the mood, sleep, and appetite of the woman, as well as to lower the cortisol levels. Birth control pills can help to regulate the menstrual cycle by providing synthetic hormones that mimic the natural hormones. However, medication can have some side effects, such as nausea, weight gain, headache, or blood clots, and it may not address the root cause of stress and amenorrhea. Therefore, medication should be used with caution and under the supervision of a doctor.

In conclusion, amenorrhea is a condition that affects the menstrual cycle and the fertility of women. The possibility of getting pregnant with amenorrhea depends on the type and cause of amenorrhea, as well as the individual fertility of the woman and her partner. Some women with amenorrhea may be able to get pregnant naturally, while others may need the help of assisted reproductive technologies, such as IVF, ICSI, ovulation induction, IUI, or donor eggs or embryos. The diagnosis and treatment of amenorrhea are essential to restore the menstrual cycle, to prevent or treat the complications of amenorrhea, and to achieve the desired pregnancy.