Amenorrhea is a health condition characterized by missing of periods (menstrual bleeding) in women of reproductive age group. The underlying causes of amenorrhea can be classified under two headings; physiological and pathological. Pregnancy and breastfeeding of the baby (lactational amenorrhea) are the two most important physiological causes of amenorrhea. Pathological amenorrhea can be classified under headings; one is primary amenorrhea and secondary amenorrhea.
In primary amenorrhea, the affected woman had never started to menstruate usually due to developmental defects whereas in secondary amenorrhea, there is sudden cessation of normal menstrual bleeding. Medically at least 3 missed period in a previously normally menstruating woman is considered to be the secondary type of amenorrhea. The duration is increased to 9 months in women with a history of oligomenorrhea (scanty and infrequent menstrual bleeding).
The aim of treatment is to manage the underlying cause.
Symptoms
As the definition of amenorrhea suggests, stoppage of menstrual blood loss is the for at least three months or in 15 year old girl who has not yet started to menstruate. Other than the stoppage of periodic blood loss amenorrhea may be associated with white milk like discharge from the nipples, loss of hair, headache, visual abnormalities, excessive growth of facial hair, pain in the lower abdomen (pelvic area), flaring of acne, etc.
Chronic amenorrhea may lead to a number of complications; if lack of ovulation is the underlying cause of amenorrhea then there is a risk of infertility, whereas if low circulating estrogen is the cause of amenorrhea then there is chance of weakening of bones and easy fracture often without any identifiable cause.
Causes
There are number of causes of amenorrhea. The natural or the physiological types of amenorrhea are quite common and known to occur at some point of time in all of the women. Common causes include pregnancy, breastfeeding and menopause. Other natural causes of amenorrhea include prolonged intake of hormonal contraceptive drugs as oral pills, impregnated in intrauterine devices, injectable preparations or implants.
After stoppage intake of hormonal contraceptives or removal of hormonal implants usually it takes some time to start normal menstruation. Other drugs that are responsible for amenorrhea includes, regular intake of antipsychotic agents, anticancer drugs, antidepressant drugs, certain antihypertensive agents and anti allergic drugs.
There are some life style patterns which are associated with stoppage of menstruation; these are excessive loss of body weight (about 10% below the normal body weight) especially in women suffering from anorexia nervosa, bulimia or other eating disorders, rigorous exercise may also alter the normal hormonal balance of the body resulting in amenorrhea. Excessive stress may also suppress menstrual blood loss as stress has a negative effect on the normal functions of the hypothalamus.
There are some life style patterns which are associated with stoppage of menstruation; these are excessive loss of body weight (about 10% below the normal body weight) especially in women suffering from anorexia nervosa, bulimia or other eating disorders, rigorous exercise may also alter the normal hormonal balance of the body resulting into amenorrhea. Excessive stress may also suppress menstrual blood loss as stress has a negative effect on the normal functions of the hypothalamus.
Common pathological causes include altered circulating hormonal level as in polycystic ovarian syndrome (PCOS) characterized by persistent high level of circulating hormones in contrast to fluctuating levels of hormones as in normal menstrual cycle, over or under activity of the thyroid gland, tumor, usually benign in nature, of the pituitary may lead to altered regulation of hormone secretion, premature onset of menopause characterized by stoppage of ovulation before 40 years.
Sometimes structural abnormality of the female reproductive organs may also lead to amenorrhea; these are
1. excessive scar tissue formation in the uterus as in Asherman’s syndrome usually following dilation and curettage (D & C ) procedure, surgery like caesarean section or removal of fibroids
2. abnormal development of reproductive organs like complete absence or congenital malformation of the uterus since birth.
3. structural abnormality of the vagina like presence of membrane at the opening of the vagina preventing visible menstrual blood loss
Risk factors
Common risk factors for amenorrhea include family history of premature amenorrhea, excessive physical exercise, suffering from eating disorders, etc.
Treatment
Treatment depends upon the underlying cause; sometimes hormone therapy may start normal menstruation, in other women correction of hypo or hyperthyroidism, removal of pituitary tumors or surgical procedure to remove the obstructing membrane at the vaginal outlet may be required.