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DESCRIPTION
Secondary amenorrhea is the cessation of menstruation for at least 3 months in a woman who has previously menstruated. In women who have had regular menstrual periods, it is an absence of menstruation for 6 months and for women who had irregular periods, it is a absence of menstruation for a period of 12 months. This problem is seen in about 1 percent of women of reproductive age. The incidence of secondary amenorrhea (due to some cause other than pregnancy) is about 4% in the general population.
Primary amenorrhea is when the woman has never had a period in her life. This condition is rare and causes are quite different from secondary amenorrhea.
FREQUENT SIGNS & SYMPTOMS
Absence of menstrual periods for 3 to 6 or more months in a woman who has menstruated at least once.
Note: Other symptoms associated with amenorrhea depend on the cause. They may include:
- Headache.
- Galactorrhea (breasts producing milk in a woman who is not pregnant or breastfeeding an infant).
- Marked weight gain or weight loss.
- Dry vagina.
- Increased hair growth in a "male pattern" (hirsutism).
- Voice changes.
- Breast size changes.
If amenorrhea is caused by a pituitary tumor, other symptoms related to the tumor such as visual loss, may be present.
CAUSES
NORMAL CAUSES:
Pregnancy (if a woman has had sexual intercourse). This is the most common cause of secondary amenorrhea in reproductive age women. This should always be excluded by a physical exam and laboratory testing for the pregnancy hormone HCG. Secondary amenorrhea, while pregnant, is a normal condition that needs no medical attention.
Breastfeeding an infant. Secondary amenorrhea, while breastfeeding your baby, is a normal condition and does not need any medical attention.
Menopause (if a woman is over 35 and not pregnant). Secondary amenorrhea occurs naturally in menopausal women and usually does not need any medical attention. Menopause is normal for women over age 45. Early appearance of menopause may account for some cases of amenorrhea.
ABNORMAL CAUSES:
Disorder of the endocrine system, including the pituitary, hypothalamus, thyroid, parathyroid, adrenal and ovarian glands. Both Cushing's disease (over activity of adrenal glands) and hypothyroidism (under-functioning thyroid gland) can cause amenorrhea.
If the patient has a history of severe postpartum hemorrhage (very heavy bleeding after a delivery), she may have pituitary insufficiency from infarction (Sheehan's syndrome).
When amenorrhea follows a D&C (dilation and curettage) one should suspect intrauterine adhesions (Asherman's syndrome), particularly if the procedure was pregnancy related. The procedure can cause a woman to develop amenorrhea if scar tissue develops within the uterine cavity.
Asherman's can also occasionally be seen following other types of uterine surgery such as metroplasty, myomectomy or cesarean section. The procedure can cause a woman to develop amenorrhea if scar tissue develops within the uterine cavity.
Amenorrhea following cervical conization can be due to procedure related cervical stenosis.
Discontinuing use of birth-control pills or other hormonal contraception or therapy. Following discontinuation of oral contraception some women will not have periods for up to several months. However, the reported incidence for amenorrhea lasting more than 6 months after the pill is stopped is 0.8% which is essentially the same as the incidence of amenorrhea in the general population. Therefore, amenorrhea of greater than 6 months duration after oral contraceptive use is not related to the pill use. Non-oral contraceptives such as Norplant and Depo-Provera, can all cause scanty or missed menstrual periods.
Emotional stress or psychological disorder. Anxiety over a possible pregnancy may cause a missed period, thereby increasing the anxiety even further. Emotional distress from other causes can also caused missed menstrual periods.
Surgical removal of the ovaries or uterus.
Drugs such as bufulfan, chlorambucil, cyclophosphamide, and phenothiazines can all cause scanty or missed menstrual periods.
Diabetes mellitus.
Tuberculosis.
Eating disorders, such as Obesity, anorexia nervosa or bulimia. A large amount of weight loss or gain can also lead to anovulation. Body fat content less than 15 to 17 percent in women will often result in menstruation cessation.
Strenuous program of physical exercise, such as long distance running. A large amount of extensive exercise and/or can also lead to anovulation. Many women athletes experience secondary amenorrhea during training, especially without adequate conditioning. Body fat content less than 15 to 17 percent in women will often result in menstruation cessation.
RISK INCREASES WITH
Stress.
Use of drugs, including oral contraceptives and hormones, phenothiazines, barbituates, narcotics, and reserpine.
Excessive exercise.
PREVENTIVE MEASURES
If your amenorrhea is cause by an underlying disease, such as tuberculosis, diabetes, or anorexia nervosa, obtain treatment for the primary disorder.
If the cause of your amenorrhea is unknown, there are no specific preventive measures.
Maintain proper nutrition & body weight. Moderate exercise instead of extreme exercise may be helpful.
EXPECTED OUTCOME
Amenorrhea is not, in itself, a threat to health. Whether it can be corrected varies with the underlying cause. Most of the conditions that cause secondary amenorrhea will respond to treatment:
- If from pregnancy or breast-feeding, menstruation will resume when these conditions cease.
- If from discontinuing use of oral contraceptives, other hormone contraceptives or therapies, periods should begin in 2 months to 2 years.
- If from menopause, periods will become less frequent or may never resume.
- Hysterectomy also ends menstruation permanently.
- If from endocrine disorders, hormone replacement usually causes periods to resume.
- If from eating disorders, successful treatment of that disorder is necessary for menstruation to resume.
- If from diabetes or tuberculosis, menstruation may never resume.
- If from strenuous exercise, periods usually resume when exercise decreases.
POSSIBLE COMPLICATIONS
None expected if no serious underlying cause can be discovered. Secondary amenorrhea, in itself, does not cause complications. However, the conditions that cause amenorrhea may have complications.
May experience estrogen deficiency symptoms, such as hot flashes, vaginal dryness.
May affect fertility.
TREATMENT
GENERAL MEASURES
Diagnosis and treatment depends on the cause of the amenorrhea. If it is caused by another systematic disorder, normal menstrual function usually returns after the primary disorder is treated.
DIAGNOSIS:
A good health history can reveal the etiologic diagnosis in up to 85 percent of cases. A detailed menstrual history should be taken.
To aid in diagnosis, laboratory studies, such as pregnancy test, blood studies of hormone levels (progestin, prolactin, testosterone, FSH-follicle stimulating hormone, LH-Luteinizing hormone, TSH-thyroid stimulating hormone and other thyroid function tests may be done. Karyotype to rule out the presence of Y chromosome abnormality. A Pap smear is usually necessary. Radiological tests may be done to aid in diagnosis. A CT scan of the head may be done if a pituitary tumor is suspected. Surgical diagnostic procedures, such as laparoscopy or hysteroscopy may be recommended.
During the physical exam your health care provider will be looking for certain things, such as:
- Signs of androgen excess such as hirsutism (excess hair growth) and clitoromegaly (enlargement of the clitoris).
- The breast exam may reveal galactorrhea.
- Estrogen deficiency may be suggested on pelvic exam by a smooth vagina that lacks the normal rugae (wrinkles) and a dry endocervix with no mucous.
TREATMENT:
Dilation and curettage, often referred to as a D & C (dilation of the cervix and a scraping out of the uterus with a curette) may be performed.
Secondary amenorrhea is a symptom that can be caused by many pathological states. Treatment of the underlying disorder if one is diagnosed. Some women will not demonstrate any obvious reasons for their amenorrhea on history and physical exam. These women can be worked up in a logical manner using a stepwise approach. Diagnostic approaches may vary, however, differences between them pertain mainly to the order in which tests are performed.The first tests usually used include after pregnancy is ruled out are a progesterone withdrawal test as well as a TSH (thyroid stimulating hormone) and prolactin level.
- Thyroid function - Both hypothyroidism and hyperprolactinemia can cause primary or secondary amenorrhea. If these entities are discovered, appropriate therapy should result in resumption of regular menstrual periods. If the amenorrhea is caused by hypothyroidism, as an example, then it will be cured when the thyroid disorder is treated with thyroid supplements.
- Progestational challenge (progesterone withdrawal test) - The progestational challenge test is performed by giving oral medroxyprogesterone acetate 10 mg daily for 7-10 days or progesterone in oil 100-200 mg intramuscularly. A positive response is any bleeding more than light spotting that occurs within 2 weeks after the progestin is given. This bleeding will usually occur 2-7 days after the progestin is finished. Withdrawal bleeding will usually be seen if the woman's estradiol level is 40 pg/ml or more. If the woman experiences bleeding after the progestin she has estrogen present but is not ovulating. If no withdrawal bleeding occurs, either she has very low estrogen levels or there is a problem with the outflow tract such as uterine synechiae (adhesions) or cervical stenosis (scarring).
- Women with withdrawal bleeding - Your health care provider may first consider the diagnostic evaluation of the woman with withdrawal bleeding and normal prolactin and TSH levels. The basic diagnosis at this point is anovulation for which there are many causes. If there is a history of recent stress, weight loss, medications or street drugs, these factors could be causing the amenorrhea. Some experts believe that an LH and FSH level may be helpful at this point. If the LH is high (above about 10 MIU/ml) and the LH/FSH ratio is above 2:1, this supports the clinical diagnosis of polycystic ovarian disease (PCO). However, many women with PCO do not demonstrate this high LH/FSH ratio. Testosterone and DHEAS levels may be useful in women with PCO, especially in the presence of hirsutism or other signs of hyperandrogenism (excess male hormones). Chronic anovulation should be managed by periodic0 progestin withdrawal, or oral contraceptive pills if the woman does not desire pregnancy at this time. If she desires pregnancy, induction of ovulation with clomiphene citrate or injectable gonadotropins can be discussed. If the anovulatory state has been longstanding, one should consider endometrial biopsy to rule out significant hyperplasia or carcinoma of the endometrium.
- Women without withdrawal bleeding - The health care provider will consider the evaluation of women who do not have withdrawal bleeding after the progestin challenge. These women have either a hypoestrogenic state or a compromised outflow tract. There are 2 ways to approach the next step.
1. One way is to use hormone therapy by giving estrogen to ensure endometrial proliferation, followed by a progestin to induce withdrawal. A course of 2.5 mg of Premarin for 21 days including 10 mg of Provera on days 17-21 will be adequate. If bleeding occurs, her amenorrhea is due to hypoestrogenism. If bleeding does not occur, then the woman most likely has outflow tract obstruction - either Asherman's syndrome or cervical stenosis.
2. The other approach is to perform an FSH level. If the level is high (above 30-40 MIU/ml), the woman has premature ovarian failure (see below) and does not need the estrogen and progestin challenge. If the FSH is normal, it is still a good idea to proceed with the course of estrogen and progestin as described above.
The next step in the women that do not bleed after the combined hormonal regimen is either hysterosalpingography or hysteroscopy. If adhesions are found, they should be hysteroscopically lysed if the patient is desirous of pregnancy or menses.
Intrauterine adhesions are rare in the absence of a history of pelvic infection or curettage. Therefore, if the pelvic exam is normal and the history is not consistent with development of adhesions, consideration can be given to skipping the estrogen-progestin step.
- FSH testing - If the woman did bleed after the combined hormonal regimen (or if that step was skipped) the next test to obtain is an FSH level. This should not be drawn for at least 2 weeks after the estrogen-progestin regimen is completed so that the level is not affected by the exogenous estrogen. If the FSH is greater than 30-40 MIU/ml, the woman almost certainly has ovarian failure. Mid-cycle FSH peak levels in ovulatory cycles should not be this high. FSH levels that are in the menopausal range should be checked at least once again in about 4 weeks. An estradiol level can be checked as well for further confirmation. With ovarian failure, the estrogen level will be low (usually less than 20-30 pg/ml).
- Ovarian failure (premature menopause) - Once ovarian failure is confirmed consideration should be given to 2 special etiologic situations. If the woman is under 30, a karyotype should be performed to rule out any mosaicism involving a Y chromosome. This is important because of the high risk (about 25 percent) for a gonadal malignancy developing if there is any testicular tissue present. If a Y chromosome is found the gonads should be surgically excised. These tumors apparently do not appear after age 30 so that karyotypic analysis is then no longer necessary. Other chromosomal anomalies will occasionally be found. These are usually either 45X (Turner's syndrome) or some variation of Turner's mosaic.
The other special category of premature ovarian failure is that associated with autoimmune disease. These women have autoimmune related dysfunction of other endocrine organs. The most common association is with thyroid disease, but the parathyroids and adrenals can also be affected. Therefore, it is prudent to screen for these conditions. Thyroid function tests and thyroid antibody levels should be obtained. A morning cortisol level or a corticotropin (ACTH) stimulation test assesses adrenal reserve. Serum calcium, phosphate and protein levels are ordered to evaluate possible hypoparathyroidism. A CBC with differential, sedimentation rate, anti-nuclear antibody and rheumatoid factor may be useful in further assessing any possible autoimmune dysfunction.
Laboratory evidence of autoimmune phenomenon is much more prevalent than clinically significant disease. Several studies have shown laboratory evidence of immune problems in about 15-40 percent of women with premature ovarian failure. Thyroid and Lupus-related antibodies are most commonly found. It is presently unknown as to what the incidence of clinically apparent autoimmune disease will be in these women when followed over time. Women with well documented premature ovarian failure should be placed on estrogen/progestin replacement therapy if there are no contraindications. This will provide some protection against osteoporosis and cardiovascular disease by eliminating the severely hypoestrogenic state associated with menopause. Regardless of the etiology, there currently is no effective treatment that will be likely to result in a pregnancy (with her own eggs) for premature ovarian failure. However, some women will spontaneously ovulate on occasion and pregnancy can occur although it is unusual. Those pregnancies that do occur are almost always in women on estrogen replacement therapy. These women should be educated about this possibility.
Egg donation with in vitro fertilization (IVF) can be a very effective therapy for women with premature ovarian failure that desire pregnancy.
In general, ovarian biopsy is not indicated in patients with premature ovarian failure since no clinically useful information will be obtained.
- Hypothalamic-pituitary failure - Women who do not bleed after the progestin challenge but do after estrogen/progestin and have normal or low FSH and LH levels make up the final group to be discussed. These women have hypothalamic-pituitary failure. Some medications (e.g. phenothiazines) as well as extremes of weight loss, stress or exercise can cause this type of secondary amenorrhea. A pituitary or hypothalamic tumor would be a rare finding in women who were all screened with prolactin levels at the beginning of the diagnostic evaluation. However, if there is no cause apparent from the history, it would be prudent to obtain a baseline CT (or MRI) evaluation of the sellar region to rule out a space occupying lesion.
Women with normal prolactin levels and normal imaging studies have hypothalamic amenorrhea of uncertain etiology. If the amenorrhea and lack of withdrawal bleeding persists, prolactin levels should be measured annually since a small microadenoma could be present that is escaping laboratory and radiographic detection.
women can be significantly hypoestrogenic (a low estrogen situation similar to menopause). If the state is persistent, hormone replacement therapy should be considered for protection against osteoporosis. One approach is to get an estradiol level and if it is less than 30 pg/ml, counsel the patient that hormonal replacement therapy is indicated.
Psychotherapy or counseling, if amenorrhea is related to stress. Weight loss as a result of anorexia nervosa is an important diagnosis to make because of the mortality rate of 5-15 percent. Psychiatric counseling is indicated in most, if not all cases.
If the primary cause is obesity, vigorous athletics, weight loss, or similar factors, treatment recommendations may include moderation in exercise and healthy weight control by using a healthy nutritional diet combined with appropriate lifestyle changes and psychological and/or emotional support.
A woman should keep a record of menstrual cycles to aid in early detection of recurrent amenorrhea.
MoonDragon's Pediatric Information: Anorexia Nervosa
MEDICATION
Therapeutic trial of hormone therapy using progesterone and/or estrogen. If bleeding occurs after progesterone is withdrawn, the reproductive system is functional.
Other drugs to treat underlying disorder may be prescribed.
Some drugs prescribed to women may cause secondary amenorrhea.
ACTIVITY
No restrictions.
DIET
Usually no special diet unless a woman is undernourished or obese. Follow a healthy diet plan.
If you are overweight or underweight, get medical advice about diets. Don't try to lose weight by crash-dieting.
Amenorrhea Supplements
Information and supplements for help with amenorrhea, the absence of menstrual periods.
Blue Cohosh (Caulophyllum thalictroides) Tincture, 100% Organic - 2 fl. oz.
Blue Cohosh is used to regulate the menstrual flow and for treating suppressed menstruation.Female Estrogen with Progestrone Tincture, 100% Organic - 2 fl. oz.
Female Estrogen With Progestrone formula is used mainly to promote hormonal balance. It does not contain hormones, however.Vitex Fruit (Chaste tree), 400mg - 100 Caps
Vitex is a woman's dietary supplement, traditionally used for menstrual difficulties. Vitex has been heavily researched in Europe. It is widely used to promote overall health and balance in a woman's life.Chaste Tree Berry / Vitex Tincture, Fertility and Herbal PMS Remedy - 2 fl. oz.
Chaste Tree Berry is an Herbal PMS remedy and a natural fertility herb. Trials have shown genuine effectiveness of Chaste Tree Berries for women suffering from infertility and irregular periods.Relora, NOW Foods 300mg - 60 Caps
Relora is used to normalize hormone levels associated with stress-induced obesity and poor eating and drinking behaviors. Preliminary findings suggest that Relora can decrease the cravings for high fat and high sugar foods in stressed individuals.PROGESTA, Natural Progesterone Cream - 2 oz.
Progesta is a unique natural progesterone supplement that provides incredible feminine support for overall mental health, normal feminine cycles and more.Motherwort Tincture, 100% Organic - 2 fl. oz.
Research has shown that Motherwort is able to calm palpitations and irregular heartbeat.Yarrow Flowers, 325mg - 100 Caps
Yarrow (achillea millefolium) may be helpful for Nosebleeds, fevers, colds, sore throat, indigestion, heartburn, inflammation, menstruation, dysmenorrhoea, high blood pressure, muscle spasms, urinary tract infections, and minor injuries.False Unicorn Tincture, 100% Organic - 2 fl. oz.
Many herbalists recommend False Unicorn for reducing menopausal symptoms, and treating ovarian cysts. It has also been used to normalize hormone levels following oral contraceptive use.DIM-Plus Estrogen Metabolism / Diindolylmethant Protectamins Cruciferous Nature's Way - 120 Caps
DIM-Plus Estrogen Metabolism Formula promotes healthy estrogen metabolism, Relieves PMS symptoms, Promotes fat loss, supports breast, cervical, uterine and prostate health. Scientific research shows diindolylmethane increases the level of "good" estrogens (2-hydroxyestrogen) while reducing the level of "bad" estrogens (16-hydroxyestrogen).Super Lignan - Herbal Estrogen Supplement - Nature's Way, 60 Vcaps
EFAGold (TM) Super Lignan is an ideal herbal estrogen supplement for supporting breast health during the menopausal phases of life helping alleviate breast tenderness and pain associated with the menstrual cycle.Calcium Complex Bone Formula Nature's Way - 100 Caps
Calcium, Magnesium, and other minerals help maintain normal structure and development of bones. Studies have shown that calcium supplementation may help to maintain normal bone density among women as they age.Appetite Stimulant Formula Tincture, 100% Organic - 2 fl. oz.
This herbal appetite stimulant has been designed by a Master Herbalist to stimulate the appetite. It combines herbs well known, and recommended by the German Commission E, for improving the appetite and eliminating symptoms of appetite loss.Tansy Herb Tincture, 100% Organic - 2 fl. oz.
Tansy Herb Tincture is used to expel worms, especially round and thread worms.Womans Raspberry Leaf, Female Support - 16 Tea Bags
Our Organic Woman's Raspberry Leaf is a gentle and organic way to support the special needs of a woman's reproductive system.Natural Progesterone Cream: A Safe Alternative to Conventional Hormone Replacement Therapy, By C. Norman Shealy, M.D., Ph.D.
In this Keat's Good Health Guide, Dr. Norman Shealy answers all your questions about natural progesterone cream, a viable and safe alternative to synthetic hormone replacement therapy.
PRODUCTS FOR CYCLE CHARTING, OVULATION MONITORING, PREGNANCY TESTS
NOTIFY YOUR MIDWIFE OR HEALTH CARE PROVIDER IF
You or a family member has symptoms of amenorrhea. If you are a woman and have missed more than one period so that the cause, and appropriate treatment, can be determined.
Periods don't begin in 6 months after treatment.
New, unexplained symptoms develop. Hormones used in treatment may produce side effects.
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Mountain Rose Aromatherapy Oils
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