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Amenorrhea

Amenorrhea

Definition

Amenorrhea is the medical term for the absence of menstruation . There are two types of amenorrhea, primary and secondary. Primary amenorrhea refers to delayed menarche (the first menstrual period) and is defined as any one of three conditions:

  • the absence of menarche by age 16 in a girl with otherwise normal pubertal development (development of breasts and/or pubic hair)
  • the absence of menarche by age 14 combined with delayed pubertal development
  • the absence of menarche two years after puberty is otherwise completed

Secondary amenorrhea is defined as the absence of menstruation after menarche has taken place. Although it is not uncommon for a girl's menstrual periods to be irregular during early adolescence , most girls' periods usually become regular within 18 months after the first one. After that time, it is considered abnormal for an adolescent to miss three consecutive periods.

Description

Normal menstrual periods are the result of proper functioning and synchronization of the hypothalamus, pituitary gland, and ovaries. The hypothalamus is the part of the brain that controls body temperature, cellular metabolism, and such basic functions as appetite for food, the sleep/wake cycle, and reproduction. The hypothalamus also secretes hormones that regulate the pituitary gland. The pituitary gland in turn produces hormones that stimulate the ovaries to secrete two hormones known as estradiol and progesterone. These ovarian hormones encourage the growth of the endometrium, which is the tissue that lines the uterus. If pregnancy does not occur, the endometrium breaks down and the uterus sheds the extra tissue during the next menstrual period.

Amenorrhea can result from an interruption at any of several points in the normal cycle:

  • The hypothalamus and pituitary may fail to produce enough hormone to stimulate the ovaries to produce their hormones.
  • The ovaries may fail to produce enough estradiol to stimulate the growth of the endometrium.
  • There may be structural abnormalities in the uterus, cervix, or vagina that prevent the shed tissue from leaving the body.

Demographics

Secondary amenorrhea is more common in females in North America than primary amenorrhea. One study estimates that about 5 percent of menstruating women have an episode of secondary amenorrhea each year.

The average age for the onset of the menses in girls in the United States and Canada is 12.77 years. There is no evidence as of the early 2000s that the incidence of either primary or secondary amenorrhea is related to race or ethnic background.

Causes and symptoms

Causes

There are a number of possible causes of amenorrhea:

  • Pregnancy: An adolescent with amenorrhea most likely does not have a serious underlying medical problem. All teenagers with amenorrhea should seek medical care, and an adolescent who has had sexual intercourse even once and then missed a period should assume she is pregnant until a reliable pregnancy test proves otherwise. It should be noted that spotting or even bleeding is not unusual during early pregnancy. In addition, it is possible for a girl to conceive before she has had even one period.
  • Disorders of the hypothalamus or the pituitary gland: These problems may be associated with brain tumors.
  • Ovarian disorders: These disorders may include premature ovarian failure or may be the side effects of chemotherapy or radiation therapy for cancer . Premature ovarian failure accounts for about 10 percent of cases of secondary amenorrhea.
  • Hyperandrogenism: The overproduction of male hormones (androgens) by the girl's body can interrupt menstruation. Male hormones are produced in small quantities by all women, but some individuals produce excessive amounts, leading to such conditions as polycystic ovarian syndrome (PCOS), hirsutism (excessive growth of body hair), or abnormalities of the external genitalia. PCOS in adolescents is often triggered by obesity .
  • Genetic disorders: Some genetic disorders that affect the X chromosome, such as Turner's syndrome, prevent normal sexual maturation in girls.
  • Psychiatric disorders: Depression, obsessive-compulsive disorder , eating disorders, and schizophrenia can all cause disturbances of the menstrual cycle.
  • Abuse of alcohol or other drugs: Excessive alcohol intake can lead to malnutrition , while cocaine and opioids (narcotics) can affect the menstrual cycle directly.
  • Immunodeficiency disorders or conditions.
  • Emotional stress: This disturbance can interfere with the brain's hormonal signals to the ovaries. It is not uncommon for a girl's period to be delayed when she is having problems with school, work, or relationships. A change in environment (the first year of college or taking a new job, for example) can also cause a young woman's period to be late.
  • Female athlete triad: Female athletes at the high school or college level are at increased risk for a triad of disorders: excessive dieting or disordered eating, amenorrhea, and loss of bone minerals leading to osteoporosis. The triad was first formally named in 1993 but had been known to doctors for decades before. Girls who are involved in sports that emphasize weight control or a slender body build (gymnastics, track and field, cheerleading) are at greater risk than those who play field hockey, basketball, softball, or other sports that emphasize strength.

Symptoms

Amenorrhea may be associated with the symptoms of other disorders; for example, girls with an eating disorder will often have eroded tooth enamel, tiny pinpoint hemorrhages around the eyes, an abnormal heart rhythm, low blood pressure, and other signs of frequent vomiting . Girls whose amenorrhea is part of the female athlete triad may have a record of bone fractures or other evidence of bone mineral loss. Hot flashes and night sweats may indicate premature ovarian failure. Headaches or visual disturbances may suggest a brain tumor.

When to call the doctor

Girls who have not had a menstrual period by age 16 or who have not shown any signs of breast development or other indications of puberty by age 14 should be examined for causes of primary dysmenorrhea . Girls who have begun to menstruate and have missed three periods should be evaluated for secondary amenorrhea. If they are sexually active, they should have a pregnancy test after missing even one period.

Diagnosis

History and physical examination

The first part of diagnosing amenorrhea is a careful history, including a record of medications and any surgical procedures involving the abdomen or genitals. The doctor will ask detailed questions about stress, dieting, sexual activity, and athletic participation, as well as questions about chronic diseases or disorders of the central nervous system. Family history should be taken into consideration in any adolescent with primary amenorrhea, as mothers who started to menstruate late will often have daughters who also menstruate late.

In the case of female athletes, the doctor may need to establish a relationship of trust with the patient before asking about such matters as diet, practice and workout schedules, and the use of such drugs as steroids or ephedrine. The presence of stress fractures in young women should be investigated. In some cases, the doctor may give the patient the Eating Disorder Inventory (EDI) or a similar screening questionnaire to help determine whether the patient is at risk for developing anorexia or bulimia.

The doctor will then perform a physical examination to evaluate the patient's weight in proportion to her height as well as her general nutritional status; to check for breast development, pubic hair, and other signs of normal female sexual development; to make sure the heart rhythm, blood pressure, and other vital signs are normal; and to palpate (feel) the thyroid gland for evidence of swelling. The physical examination may include a pelvic examination to check for abnormalities in the structure of the vagina or cervix.

Laboratory tests

To rule out specific causes of amenorrhea, the doctor may order a pregnancy test in sexually active young women as well as blood tests to check the level of thyroid hormone. Based on the initial test results, the doctor may want to perform additional tests to determine the level of other hormones that play a role in reproduction. A special type of blood test called a karyotype may be done to analyze the girl's chromosomes if the doctor suspects Turner's syndrome or another genetic disorder.

One way to determine whether a teenager's ovaries and uterus are functioning is a progesterone challenge test. In this test, an amenorrheic teenager is given a dose of progesterone either orally or as an injection. If her ovaries are producing estrogen and her uterus is responding normally, she should have a menstrual period within a few days of the progesterone dose. This challenge indicates that the ovaries and uterus are functioning normally, and the cause of the amenorrhea is probably in the brain.

Imaging studies

In some cases the doctor may order an ultrasound study of the pelvic region to check for anatomical abnormalities or x rays or a bone scan to check for bone fractures. In some cases the doctor may order an MRI to rule out tumors affecting the hypothalamus or pituitary gland.

Psychiatric interview

Teenagers whose amenorrhea may be related to depression, family stress, eating disorders, or other mental health issues may be referred to a psychiatrist for further evaluation.

Treatment

The most frequent risk associated with amenorrhea is osteoporosis (thinning of the bone) caused by low estrogen levels. Because osteoporosis can begin as early as adolescence, hormone replacement therapy is sometimes recommended for teenagers with chronic amenorrhea.

Amenorrhea associated with hormonal, genetic, psychiatric, or immunodeficiency disorders may require a variety of different medications and other treatments administered by specialists. Tumors of the hypothalamus and the pituitary gland or abnormalities of the reproductive organs usually require surgery.

Alternative treatment

As with conventional medical treatments, alternative treatments are based on the cause of the condition. If a hormonal imbalance is revealed by laboratory testing, hormone replacements that are more natural for the body (including tri-estrogen and natural progesterone) are recommended. Glandular therapy can assist in bringing about a balance in the glands involved in the reproductive cycle, including the hypothalmus, pituitary, thyroid, ovarian, and adrenal glands.

Since homeopathy and acupuncture work on deep energetic levels to rebalance the body, these two forms of therapy may be helpful in treating amenorrhea. Western and Chinese herbal medicines also can be very effective. Herbs used to treat amenorrhea include dong quai (Angelica sinensis ), black cohosh (Cimicifuga racemosa ), and chaste tree (Vitex agnus-castus ). Herbal preparations used to bring on the menstrual period are known as emmenagogues. For some adolescents, meditation, guided imagery, and visualization can play a key role in the treatment of amenorrhea by relieving emotional stress.

Nutritional concerns

Diet and adequate nutrition , including adequate protein, essential fatty acids, whole grains, and fresh fruits and vegetables are important for every female past puberty, especially if deficiencies are present or if she regularly exercises very strenuously. Girls who are abusing alcohol or other drugs should be evaluated for possible malnutrition as part of treatment for substance abuse.

Female athletes at the high school or college level should consult a nutritionist to make sure that they are eating a well-balanced diet that is adequate to maintain a healthy weight for their height. Girls participating in dance or in sports that emphasize weight control or a slender body type (gymnastics, track and field, swimming, and cheerleading) are at higher risk of developing eating disorders than those that are involved in such sports as softball, weight lifting, or basketball. In some cases the athlete may be given calcium or vitamin D supplements to lower the risk of osteoporosis.

Prognosis

The prognosis of either primary or secondary amenorrhea depends on the underlying cause.

Prevention

Amenorrhea related to pregnancy, the female athletic triad, drug or alcohol abuse, or eating disorders is preventable insofar as these are lifestyle choices. Primary or secondary amenorrhea associated with genetic mutations or other systemic diseases or disorders is not preventable.

Parental concerns

Amenorrhea is a fairly dramatic symptom of menstrual dysfunction that often causes parents to consult a doctor about a girl's health. Parental concerns about amenorrhea, however, should be directed to the underlying cause. Amenorrhea related to emotional stress, dieting, or excessive exercise usually goes away when the stress is relieved or when the girl makes appropriate lifestyle adjustments. On the other hand, amenorrhea associated with glandular disturbances, tumors, genetic or anatomical abnormalities, diabetes, or other systemic disorders is part of a larger and more worrisome picture. Parents should discuss their concerns about the long-term effects of amenorrhea on the girl's health, whether she will be able to have children in adult life, and how they can help her manage her condition with the doctors, nutritionists, and other healthcare professionals who are treating her.

KEY TERMS

Anorexia nervosa An eating disorder marked by an unrealistic fear of weight gain, self-starvation, and distortion of body image. It most commonly occurs in adolescent females.

Emmenagogue A type of medication that brings on or increases a woman's menstrual flow.

Endometrium The mucosal layer lining the inner cavity of the uterus. The endometrium's structure changes with age and with the menstrual cycle.

Female athlete triad A combination of disorders frequently found in female athletes that includes disordered eating, osteoporosis, and oligo- or amenorrhea. The triad was first officially named in 1993.

Hyperandrogenism The excessive secretion of androgens.

Menarche The first menstrual cycle in a girl's life.

Osteoporosis Literally meaning "porous bones," this condition occurs when bones lose an excessive amount of their protein and mineral content, particularly calcium. Over time, bone mass and strength are reduced leading to increased risk of fractures.

Turner syndrome A chromosome abnormality characterized by short stature and ovarian failure caused by an absent X chromosome. It occurs only in females.

See also Anorexia nervosa; Bulimia nervosa; Menstruation; Oligomenorrhea; Sports.

Resources

BOOKS

Diagnostic and Statistical Manual of Mental Disorders,4th edition, Text Revision. Washington, DC: American Psychiatric Association, 2000.

"Menstrual Abnormalities and Abnormal Uterine Bleeding." Section 18, Chapter 235 in The Merck Manual of Diagnosis and Therapy, edited by Mark H. Beers and Robert Berkow. Whitehouse Station, NJ: Merck Research Laboratories, 2002.

Pelletier, Kenneth R. "CAM Therapies for Specific Conditions: Menstrual Symptoms, Menopause, and PMS." In The Best Alternative Medicine, Part II. New York: Simon and Schuster, 2002.

PERIODICALS

Gordon, C. M., and L. M. Nelson. "Amenorrhea and Bone Health in Adolescents and Young Women." Current Opinion in Obstetrics and Gynecology 15 (October 2003): 37784.

Khalid, A. "Irregular or Absent Periods: What Can an Ultrasound Scan Tell You?" Best Practice and Research: Clinical Obstetrics and Gynaecology 18 (February 2004): 311.

Seidenfeld, Marjorie E. K., and Vaughn J. Rickert. "Impact of Anorexia, Bulimia and Obesity on the Gynecologic Health of Adolescents." American Family Physician 64 (August 1, 2001): 44550.

Warren, M. P., and L. R. Goodman. "Exercise-Induced Endocrine Pathologies." Journal of Endocrinological Investigation 26 (September 2003): 87378.

ORGANIZATIONS

American Academy of Child and Adolescent Psychiatry. 3615 Wisconsin Avenue, NW, Washington, DC 200163007. Web site: <www.aacap.org>.

American College of Obstetricians and Gynecologists (ACOG). 409 12th Street, SW, PO Box 96920, Washington, DC 200906920. Web site: <www.acog.org>.

American College of Sports Medicine (ACSM). 401 West Michigan Street, Indianapolis, IN 462023233. Web site: <www.acsm.org>.

WEB SITES

Barrow, Boone. "Female Athlete Triad." eMedicine, June 17, 2004. Available online at <www.emedicine.com/sports/topic163.htm> (accessed November 8, 2004).

Chandran, Latha. "Menstruation Disorders." eMedicine, August 9, 2004. Available online at <www.emedicine.com/ped/topic2781.htm> (accessed November 8, 2004).

Nelson, Lawrence M., et al. "Amenorrhea." eMedicine, August 9, 2004. Available online at <www.emedicine.com/med/topic117.htm> (accessed November 8, 2004).

Gail Slap, MD

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Amenorrhea

Amenorrhea

Definition

Amenorrhea is the absence of menstruation and is a symptom, not a diagnosis.

Primary amenorrhea refers to the absence of the onset of menstruation by age 16 whether or not normal growth and secondary sexual characteristics are present, or the absence of menses after age 14 when normal growth and signs of secondary sexual characteristics are present. Secondary amenorrhea is the absence of menses for three cycles or six months in women who have previously menstruated.

In terms of the relationship of amenorrhea to cancer, amenorrhea may be a symptom of a gynecologic tumor, or the pause or cessation in menstruation may develop as a side effect of cancer treatment.

Demographics

The prevalence of primary amenorrhea is 0.3% and secondary amenorrhea occurs in approximately 1%-3% of women. However, among college students and athletes the incidence can range from 3%-5% and 5%-60%, respectively.

For cancer-related amenorrhea, one clinician noted that nine out of ten women under his care reported secondary amenorrhea following bone marrow transplants. Chemotherapy and abdominal-pelvic radiation therapy likewise produce similar outcomes.

Causes

Normal menstrual bleeding occurs between menarche and menopause and has an average length of 28 days but varies from woman to woman. The normal menstrual cycle depends on cyclic changes in estrogen and progesterone levels, as well as the integrity of the clotting system and the ability of the spiral arterioles in the uterus to constrict. Abnormalities in any of these components may cause bleeding to stop or increase.

Primary amenorrhea

There are multiple causes for primary amenorrhea once pregnancy, lactation and missed abortion are ruled out. These include:

  • anorexia nervosa/bulimia/malnutrition
  • extreme obesity
  • hyperthyroidism/hypoglycemia
  • congenital heart disease
  • cystic fibrosis/Crohn's disease
  • genetic abnormalities
  • obstructions: imperforate hymen/vaginal or cervical absence
  • ovarian, pituitary (craniopharyngioma ) or adrenal tumors
  • polycystic ovarian disease
  • testicular feminization

It is rare for primary amenorrhea to be caused by tumors but it can be a cause and should always be a consideration if other factors are ruled out.

Gonadal failure (a nonfunctioning sex gland) is the most common cause of primary amenorrhea, accounting for almost half the patients with this syndrome. The second most common cause is uterovaginal agenesis (absence of a uterus and/or vagina) with an incidence of about 15% of individuals with this syndrome. One of the most important, and probably most common, causes of amenorrhea in adolescent girls is anorexia nervosa, which occurs in about 1 in 1, 000 white women. It is uncommon in women older than 25 and rare in women of both African and Asian descent. When women lose weight 15% below ideal body weight, amenorrhea can occur due to central nervous system-hypothalamic dys-function. When weight loss drops below 25% ideal body weight, pituitary gonadotrophin function (follicle stimulating hormone and luteinizing hormone) can also become abnormal.

Each year of athletic training before menarche (the beginning of menstrual function) delays menarche about four to five months. Amenorrhea associated with strenuous exercise is related to stress, not weight loss, and is most probably caused by an increase in central nervous system endorphins and other compounds which interfere with gonadotrophin-releasing hormone release.

Secondary amenorrhea

Once pregnancy, lactation and menopause are ruled out, the causes for secondary amenorrhea include:

  • extreme obesity
  • prolonged or extreme exercise
  • anxiety or emotional distress
  • non-oral contraceptives (Norplant/Depo-Provera)
  • D & C (dilatation and curettage ) (Asherman's syndrome)
  • early menopause
  • autoimmune dysfunction
  • pituitary tumors and central nervous system lesions

Cancer and secondary amenorrhea

As mentioned, not only does amenorrhea occur as a symptom of a tumor and/or lesion, but it often develops in women undergoing treatment for cancer.

RADIATION.

Radiation therapy is used in conjunction with chemotherapy in a number of clinical situations, including Hodgkin's disease and childhood leukemia and lymphomas. Ovarian damage occurs under these circumstances to varying degrees, depending upon the total dosage of radiation as well as the age of the patient at the time of exposure.

CHEMOTHERAPY.

Premenopausal women receiving single or multi-agent chemotherapy are at risk for short-term amenorrhea, as well as ovarian damage. Even young women who resume menstruation following chemotherapy are at risk for early menopause; therefore, those treated in childhood and adolescence should be counseled regarding the chance of early menopause in order to plan ahead for childbearing.

WEIGHT LOSS.

Side effects of cancer as well as treatments can cause a decrease in appetite and nausea and vomiting , which, in turn, can cause severe weight loss as associated with malnutrition. Thus, menstruation may cease for the same reasons as it does in young adolescents with anorexia nervosahypothalamic dysfunction.

STRESS.

Stress has always been noted to play a large role in the cause of amenorrhea, so the actual stress of having cancer and undergoing treatments may also cause amenorrhea to occur.

RETURN OF NORMAL OVARIAN FUNCTION FOLLOWING TREATMENT.

Research on the recovery of normal ovarian function with young girls and/or young women has not revealed any reliable data. There are individual success stories especially with new advances in assisted reproductive technologies (ARTs), but overall, the return of normal ovarian function seems to be age-dependent. One researcher recently reported on ovarian function in 65 women who underwent high-dose chemotherapy and bone marrow transplants for aplastic anemia. All women younger than 26 years at the time of chemotherapy recovered ovarian function, while 7 of the 18 women aged 26 to 38 years did not recover ovarian function. Thus, the risk of ovarian dysfunction appears to increase with advancing age when ovarian reserve decreases. Additionally, the risk of dysfunction increases with the dose of alkylating agents, notably cyclophosphamide .

Treatments for amenorrhea

Even with the possibility of ovarian compromise, women previously treated for cancer have successfully achieved pregnancy via ART's. Advances in the area of ART's include the use of donor eggs, the possibility of freezing embryos, and eventual oocyte (immature ovum) pretreatment offer more options to young women facing cancer chemotherapy.

Special concerns

The need for effective contraception during and after cancer treatment is imperative. Normal menstrual cycles do not imply normal fertility and likewise, irregular menses or even amenorrhea does not imply a lack of fertility. Women with dysfunctional bleeding or amenorrhea are still capable of spontaneous ovulation and conception.

The most reliable form of birth control for any population of women is injectable progestins, which suppress luteinizing hormone secretion. Depo-Provera, 150 mg injected intramuscularly, will effectively block ovulation for four months. Norplant (six rubber capsules placed under anesthesia in the upper arm) will effectively block ovulation for five years. If the treatment or the specific cancer diagnosis contraindicates the use of either of these contraceptives, other options should be considered, i.e., sterilization for the woman or her partner, an intrauterine device (IUD), or barrier methods (condoms, diaphragm or spermicides).

See Also Fertility and cancer

Resources

BOOKS

Jarvis, Carolyn. Physical Examination and Health Assessment. Philadelphia: W. B. Saunders Company, 2000.

Trimble, E. Cancer Obstetrics and Gynecology. Philadelphia:Lippincott William & Wilkins, 1999.

Youngkin, Ellis Quinn and Marcia Davis Szmania. Women's Health: A Primary Care Clinical Guide. Stamford, CT: Appleton & Lange, 1998.

Linda K. Bennington, C.N.S., M.S.N.

KEY TERMS

Alkylating agents

A group of synthetic compounds that act on the deoxyribonucleic acid (DNA) in the nucleus of the cell and are used in cancer chemotherapy.

Aplastic anemia

Any form of anemia caused by defective development of bone marrow.

Asherman's syndrome

The presence of adhesions within the uterus following a D & C.

Autoimmune dysfunction

A disease associated with the production of antibodies directed against one's own tissues.

Craniopharyngioma

Tumor arising from the cells in the pituitary.

Crohn's disease

Inflammation of the gastrointestinal tract.

Imperforate hymen

The lack of an opening in the membranous fold partly or completely closing the opening to the vagina.

Intermenstrual

Time period between one menstrual cycle to another.

Luteinizing hormone

A hormone which acts with follicle-stimulating hormone to cause ovulation of mature follicles and secretion of estrogen from the ovary.

Menopause

The stage of life during which a woman passes from the reproductive to the nonreproductive stage and she experiences the cessation of menstruation.

Menses/Menstruation

The periodic discharge from the vagina of blood and tissues from a non-pregnant uterus.

Polycystic ovary disease

Also called Stein-Leventhal syndrome, it is the presence of many cysts in the ovaries.

Postcoital

Following intercourse.

Progestins

A steroid sex hormone that maintains the lining of the uterus.

Testicular feminization

An individual with female external development, including secondary sex characteristics, but with the presence of testes and absence of uterus and tubes.

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Amenorrhea

Amenorrhea

Definition

The absence of menstrual periods is called amenorrhea. Primary amenorrhea is the failure to start having a period by the age of 16. Secondary amenorrhea is more common and refers to either the temporary or permanent ending of periods in a woman who has menstruated normally in the past. Many women miss a period occasionally. Amenorrhea occurs if a woman misses three or more periods in a row.

Description

The absence of menstrual periods is a symptom, not a disease. While the average age that menstruation begins is 12, the range varies. The incidence of primary amenorrhea in the United States is just 2.5%.

Some female athletes who participate in rowing, long distance running, and cycling, may notice a few missed periods. Women athletes at a particular risk for developing amenorrhea include ballerinas and gymnasts, who typically exercise strenuously and eat poorly.

Causes and symptoms

Amenorrhea can have many causes. Primary amenorrhea can be the result of hormonal imbalances, psychiatric disorders, eating disorders, malnutrition, excessive thinness or fatness, rapid weight loss, body fat content too low, and excessive physical conditioning. Intense physical training prior to puberty can delay menarche (the onset of menstruation). Every year of training can delay menarche for up to five months. Some medications such as anti-depressants, tranquilizers, steroids, and heroin can induce amenorrhea.

Primary amenorrhea

However, the main cause is a delay in the beginning of puberty either from natural reasons (such as heredity or poor nutrition ) or because of a problem in the endocrine system, such as a pituitary tumor or hypothyroidism. An obstructed flow tract or inflammation in the uterus may be the presenting indications of an underlying metabolic, endocrine, congenital or gynecological disorder.

Typical causes of primary amenorrhea include:

  • excessive physical activity
  • drastic weight loss (such as occurs in anorexia or bulimia)
  • extreme obesity
  • drugs (antidepressants or tranquilizers)
  • chronic illness
  • turner's syndrome. (A chromosomal problem in place at birth, relevant only in cases of primary amenorrhea)
  • the absence of a vagina or a uterus
  • imperforate hymen (lack of an opening to allow the menstrual blood through)

Secondary amenorrhea

Some of the causes of primary amenorrhea can also cause secondary amenorrheastrenuous physical activity, excessive weight loss, use of antidepressants or tranquilizers, in particular. In adolescents, pregnancy and stress are two major causes. Missed periods are usually caused in adolescents by stress and changes in environment. Adolescents are especially prone to irregular periods with fevers, weight loss, changes in environment, or increased physical or athletic activity. However, any cessation of periods for four months should be evaluated.

The most common cause of seconardy amenorrhea is pregnancy. Also, a woman's periods may halt temporarily after she stops taking birth control pills. This temporary halt usually lasts only for a month or two, though in some cases it can last for a year or more. Secondary amenorrhea may also be related to hormonal problems related to stress, depression, anorexia nervosa or drugs, or it may be caused by any condition affecting the ovaries, such as a tumor. The cessation of menstruation also occurs permanently after menopause or a hysterectomy.

Diagnosis

It may be difficult to find the cause of amenorrhea, but the exam should start with a pregnancy test; pregnancy needs to be ruled out whenever a woman's period is two to three weeks overdue. Androgen excess, estrogen deficiency, or other problems with the endocrine system need to be checked. Prolactin in the blood and the thyroid stimulating hormone (TSH) should also be checked.

The diagnosis usually includes a patient history and a physical exam (including a pelvic exam). If a woman has missed three or more periods in a row, a physician may recommend blood tests to measure hormone levels, a scan of the skull to rule out the possibility of a pituitary tumor, and ultrasound scans of the abdomen and pelvis to rule out a tumor of the adrenal gland or ovary.

Treatment

Treatment of amenorrhea depends on the cause. Primary amenorrhea often requires no treatment, but it's always important to discover the cause of the problem in any case. Not all conditions can be treated, but any underlying condition that is treatable should be treated.

If a hormonal imbalance is the problem, progesterone for one to two weeks every month or two may correct the problem. With polycystic ovary syndrome, birth control pills are often prescribed. A pituitary tumor is treated with bromocriptine, a drug that reduces certain hormone (prolactin) secretions. Weight loss may bring on a period in an obese woman. Easing up on excessive exercise and eating a proper diet may bring on periods in teen athletes. In very rare cases, surgery may be needed for women with ovarian or uterine cysts.

KEY TERMS

Hymen Membrane that stretches across the opening of the vagina.

Hypothyroidism Underactive thyroid gland.

Hysterectomy Surgical removal of the uterus.

Turner's syndrome A condition in which one female sex chromosome is missing.

Prognosis

Prolonged amenorrhea can lead to infertility and other medical problems such as osteoporosis (thinning of the bones). If the halt in the normal period is caused by stress or illness, periods should begin again when the stress passes or the illness is treated. Amenorrhea that occurs with discontinuing birth control pills usually go away within six to eight weeks, although it may take up to a year.

The prognosis for polycystic ovary disease depends on the severity of the symptoms and the treatment plan. Spironolactone, a drug that blocks the production of male hormones, can help in reducing body hair. If a woman wishes to become pregnant, treatment with clomiphene may be required or, on rare occasions, surgery on the ovaries.

Prevention

Primary amenorrhea caused by a congenital condition cannot be prevented. In general, however, women should maintain a healthy diet, with plenty of exercise, rest, and not too much stress, avoiding smoking and substance abuse. Female athletes should be sure to eat a balanced diet and rest and exercise normally. However, many cases of amenorrhea cannot be prevented.

Resources

PERIODICALS

Hogg, Anne Cahill. "Breaking the Cycle: Often Confused and Frustrated, Sufferers of Amenorrhea Now have Better Treatment Options." American Fitness 15, no. 4 (July-August 1997): 30-4.

ORGANIZATIONS

American College of Obstetricians and Gynecologists. 409 12th St., S.W., P.O. Box 96920, Washington, DC 20090-6920. http://www.acog.org.

Federation of Feminist Women's Health Centers.1469 Humboldt Rd, Suite 200, Chico, CA 96928. (530) 891-1911.

National Women's Health Network. 514 10th St. NW, Suite 400, Washington, DC 20004. (202) 628-7814. http://www.womenshealthnetwork.org.

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Turkington, Carol. "Amenorrhea." Gale Encyclopedia of Medicine, 3rd ed.. 2006. Retrieved July 29, 2016 from Encyclopedia.com: http://www.encyclopedia.com/doc/1G2-3451600073.html

amenorrhea

amenorrhea (āmĕn´ərē´a, əmĕn´–), cessation of menstruation. Primary amenorrhea is a delay in or a failure to start menstruation; secondary amenorrhea is an unexpected stop to the menstrual cycle. It is caused by dysfunctioning of the pituitary gland, ovaries, uterus, and hypothalamus, by surgical removal of the ovaries or uterus, by medication, or by emotional trauma. The result is an inadequate amount of body fat, calories, and protein to sustain menstruation. Female athletes have a higher than average rate of menstrual dysfunction, particularly amenorrhea, but the long-term effects of the exercise-related disorders are not known. It is also common among anorexics. The lack of estrogen, however, may contribute to the development of osteoporosis. Hormonal deficiencies over prolonged periods of time, particularly in combination with poor diets, may cause luteal phase deficiency and hypoestrogenic amenorrhea, which may last a long time. Methods of treatment include oral contraceptives or estrogen-progestin therapy.

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amenorrhoea

amenorrhoea (am-en-ŏ-ree-ă) n. the absence or stopping of the menstrual periods. primary a. the nonappearance of menstrual periods at puberty. This may be due to absence of the uterus or ovaries, a genetic disorder, or hormonal imbalance. secondary a. the stopping of menstrual periods after establishment at puberty, for reasons such as pituitary or thyroid hormone deficiency or anorexia nervosa.

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"amenorrhoea." A Dictionary of Nursing. 2008. Encyclopedia.com. 29 Jul. 2016 <http://www.encyclopedia.com>.

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amenorrhoea

amenorrhoea Cessation of menstruation, normally occurring between the ages of 40 and 55 (the menopause), but sometimes at an early age, especially as a result of severe under‐nutrition (as in anorexia nervosa) when body weight falls below about 45 kg.

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DAVID A. BENDER. "amenorrhoea." A Dictionary of Food and Nutrition. 2005. Encyclopedia.com. 29 Jul. 2016 <http://www.encyclopedia.com>.

DAVID A. BENDER. "amenorrhoea." A Dictionary of Food and Nutrition. 2005. Encyclopedia.com. (July 29, 2016). http://www.encyclopedia.com/doc/1O39-amenorrhoea.html

DAVID A. BENDER. "amenorrhoea." A Dictionary of Food and Nutrition. 2005. Retrieved July 29, 2016 from Encyclopedia.com: http://www.encyclopedia.com/doc/1O39-amenorrhoea.html

amenorrhea

a·men·or·rhe·a / āˌmenəˈrēə/ • n. an abnormal absence of menstruation.

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"amenorrhea." The Oxford Pocket Dictionary of Current English. 2009. Encyclopedia.com. 29 Jul. 2016 <http://www.encyclopedia.com>.

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"amenorrhea." The Oxford Pocket Dictionary of Current English. 2009. Retrieved July 29, 2016 from Encyclopedia.com: http://www.encyclopedia.com/doc/1O999-amenorrhea.html

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