Amenorrhoea

What is amenorrhoea?

Amenorrhoea (Greek: a no; + men month; + rhoia flow) is the absence of periods. This is a normal (physiological) occurrence in girls before puberty (menarche to be absolutely precise), during pregnancy and breast feeding (lactation) and following the menopause.

The physiology (normal body functioning) that results in menstrual cycles is discussed in menstrual cycles.

What is oligomenorrhoea?

Oligomenorrhoea (Greek = oligo a few) means infrequent periods. As periods should normally occur at between 21 and 35 day intervals, oligomenorrhoea indicates that they are occurring less than every 35 days. Periods tend to occur infrequently early in an adolescents life and before the menopause.

What are true and false amenorrhoea?

Amenorrhoea is usually true, which means that the endometrium (lining of the uterus) is not being shed. Occasionally, there may be false amenorrhoea the endometrium is being shed but there is a blockage preventing the blood from coming out.

What are primary and secondary amenorrhoea?

Amenorrhoea can be primary, indicating that periods have never occurred, or secondary if periods have occurred and then stopped.

The commonest cause of false primary amenorrhoea is an imperforate hymen. The teenager will have monthly pelvic symptoms but no bleeding. When she is examined, blood can be seen behind the hymen. Under a general anaesthetic, the hymen is opened and the problem is solved. The commonest (but not common) cause of secondary false amenorrhoea is cervical stenosis. Typically the periods stop some time after an operation such as a cone biopsy of the cervix.   The resulting scar tissue tightens (stenoses) the canal within the cervix. Monthly symptoms occur but periods cease. I have not seen this happen for more than twenty years. This problem is usually resolved by dilating the cervix under anaesthetic.

Primary amenorrhoea: When to seek advice?

Investigation is to be recommended if periods have not begun by the age of 16 or if secondary sexual development, and in particular breast development is not in evidence by the age of 14 (Q5. 5) Delayed puberty is often constitutional (e.g. Familial). Congenital abnormality (abnormality in structural development present at birth) can affect the ovaries, Fallopian tubes, uterus, vagina or external genitalia. In addition, primary amenorrhoea may be due to any of the causes of secondary amenorrhoea (Table 6.1).

Secondary Amenorrhoea: When to seek advice?

During reproductive years the commonest cause for amenorrhoea is pregnancy and this should be considered as soon as a period is late. Once pregnancy has been excluded, we generally consider six months without a period as indication for investigation although there have been suggestions that four months may be appropriate. As secondary amenorrhoea indicates that there have previously been periods, congenital abnormalities associated with absence of periods are automatically excluded.

What may cause of amenorrhoea?

The following video explains how the reproductive hormones control the normal menstrual cycle:

A full medical history, clinical examination and appropriate investigations are organised with particular reference to the possible causes of amenorrhoea (Table 6.1). A family history of premature menopause or autoimmune disease (Q12.17) may focus attention on these areas. Your doctor will wish to know whether there is an associated infertility problem or need for contraception as this will influence management.

Table 6. 1 Some of the more frequent causes of amenorrhoea:

System or organ Pathology
Physiological (natural) (Pre-puberty, pregnancy, lactation and menopause
Generalised ill health Stress
Weight loss e.g. anorexia
Diabetes
Thyroid disease
T.B.
Pituitary / Hypothalamus Hyperprolactinaemia
Gonads (usually ovaries) Polycystic Ovary Syndrome
Hormone secreting tumours
Turner’s Syndrome
Testicular Feminisation
Resistant Ovary Syndrome
BSO (Removal of both ovaries)
Uterus Congenital Absence
Hysterectomy
Asherman’s Syndrome
Vagina Imperforate Hymen
Congenital Absence

 

Amenorrhoea and ill health

.

Periods can stop if you have poor health. Usually it is the general ill health that is the presenting problem rather than the amenorrhoea.

Malnutrition

  • involuntary starvation because of famine or
  • psychological problems such as anorexia nervosa will result in suppression of the menstrual cycle.

Underweight women frequently have amenorrhoea. Weight and height measurements are used to determine accurately if there is a weight problem. From these measurements you can calculate your body mass index (BMI). Ideally this should be between 20 and 25. Body fat plays an important part in the chemistry of the sex hormones.

Hyperthyroidism

(an overactive thyroid gland) can suppress the menstrual cycle; there are other more typical symptoms including weight loss.

Cushing’s Syndrome

-Excessive glucocorticoid steroid production by the adrenal gland may lead to amenorrhoea although this is rare; patient’s with Cushing’s syndrome tend to have a round, moon-shaped face.

Psychological stress

may result in temporary amenorrhoea although this is unlikely to last for more than a couple of months unless there is weight loss.

Ultrasound examination of the ovaries may show small cysts but the central part of the ovaries is not dense; this is a picture of multicystic ovaries rather than polycystic ovaries which have a dense central stroma.

Sport and amenorrhoea.

Sportswomen are prone to amenorrhoea particularly if they undertake a lot or running. Reduced body fat is probably the cause. Although exercise is known to reduce the chance of osteoporosis, exercise related amenorrhoea still places young athletes at risk in later life as they may not achieve peak bone density.

What is hyperprolacinaemia?

The commonest cause of secondary amenorrhoea resulting from pituitary problems is hyperprolactinaemia (elevated prolactin levels – normal range up to 500IU/l)). Prolactin is the hormone that promotes milk production (lactation) following childbirth. Hyperprolactinaemia is the state of higher than normal blood levels of this hormone. The main causes of hyperprolactinaemia are:-

  • stress (including seeing the doctor or having a blood test).
  • breast examination can cause prolactin levels to rise.
  • polycystic ovary syndrome (Q7. 2).
  • hypothyroidism (under active thyroid gland) can be associated with sustained moderate elevation of prolactin (>700IU/l).
  • some medicines, including antidepressants, cimetidene and methyldopa, may cause prolactin levels to rise.
  • a tumour of the pituitary gland (prolactinoma) suggesting the need for radiological examination of this area. Tiny pituitary tumours (microadenomas) tend to be associated with moderate elevation of prolactin. Larger tumours (larger than 1cm – macroadenomas) may be associated with prolactin levels greater than 5000 IU/l. At one time plain x-ray images were obtained but more modern sophisticated techniques (computerised tomography [CT]) or magnetic resonance imaging [MRI] are usually employed these days (Q4.10). Galactorrhoea (inappropriate milk production) occurs in about a third of women with hyperprolactinaemia, although there is no correlation between prolactin levels and the amount of milk produced.
  • diseases of the chest can be associated with hyperprolactinaemia on rare occasions.

Investigating amenorrhoea.

A minimal set of hormone investigations is likely to include:

FSH, LH, prolactin levels and thyroid function tests. Luteinising hormone (LH) levels rise just before ovulation (Q 2. 14;Figure 2. 3) and a high level with normal FSH should be assessed according to whether a spontaneous period occurs two weeks later (LH Surge Figure 2.3). Otherwise a high LH may suggest polycystic ovary syndrome (Q7.2). When both LH and FSH are elevated (hypergonadotrophic hypogonadism), the menopause should be suspected (1). Occasionally, in younger women with amenorrhoea and hypogonadotrophic hypogonadism (Low gonadotrophin levels resulting in reduced ovarian hormone output), pregnancy or resumption of periods can occur and the diagnosis is resistant ovary syndrome. In these circumstances it seems as if there were no eggs timed for release during the episode of amenorrhoea (Q 2.3).

 

The Menstrual Cycle – The inter-relationship of the female hormones and the uterine lining.

  • Low levels of gonadotrophins will result in low oestrogen levels and amenorrhoea (hypogonadotrophic hypogonadism). This may be seen in weight associated amenorrhoea.
  • Kallman’s syndrome is a combination of hypogonadotrophic hypogonadism and colour blindness.
  • An ultrasound examination of the pelvis has become virtually routine.
  • Oestradiol, SHBG and testosterone levels are often also helpful.
  • A progestogen challenge test provides some evaluation of oestrogen production. Dydrogesterone (Duphaston) or medroxyprogesterone acetate (Provera) are taken for five days. A withdrawal bleed between 2 and 5 days later is normal and regarded as a ‘positive’ result. A positive progestogen challenge test indicates that oestrogen levels have been enough to cause sufficient thickening of the lining of your womb for shedding to occur. A negative progestogen challenge test (assuming pregnancy has been excluded) indicates low oestrogen levels. Blood oestrogen levels fluctuate so that laboratory estimations are of limited value.

What is karyotyping?

Analysis of the chromosomes (genes – chromosomes) is called karyotyping. This is usually re quested as an important investigation of primary amenorrhoea or premature ovarian failure. Chromosomal abnormalities (gene defects) may account for primary amenorrhoea in 70% of women.

What is testicular feminisation syndrome (androgen insensitivity syndrome)?

There are several causes of male pseudohermaphroditism (Q5. 2) the best known being testicular feminisation syndrome or androgen insensitivity syndrome (the tissues that should develop into the male sex organs do not respond to the male hormones). The child appears to be a girl. In puberty she does not have periods (primary amenorrhoea Q6.4). There is normal breast development but poor pubic and axillary (armpit) hair production. The vagina is shortened. The gonads are testes that can usually be felt in the groins. There is a risk of these becoming malignant and surgical removal is recommended.

What is the resistant ovary syndrome?

Some women may experience infrequent or absent periods for a while and their gonadotrophins may be elevated indicating an impending menopause. If these women are trying to conceive, treatments to encourage egg release (ovulation induction -) are unlikely to be successful. Their best chance of a baby is with IVF-egg donation .

When there is prolonged amenorrhoea and elevated gonadotrophins and subsequently periods or a pregnancy occur, we call this the resistant ovary syndrome. At one time, laparoscopy with ovarian biopsy was frequently performed for young women with apparent premature ovarian failure to establish whether the ovaries still had some eggs left. This investigation is now generally considered to have little practical value.

Even when there has been prolonged amenorrhoea, there is no absolute guarantee that there are no eggs due for later release.

A twenty-two-year old lady developed amenorrhoea. Investigation before she moved to London showed elevated gonadotrophins leading to a diagnosis of premature ovarian failure. She was advised that future spontaneous pregnancy could not be ruled out. For some years she took a cyclical hormone preparation but then felt in need of a change. Soon after her new cyclical preparation was introduced, she reported that she missed a withdrawal bleed. Her astute general practitioner arranged a pregnancy test, which to everyone’s delight, proved to be positive. She went on to have a healthy son. Three months after delivery her periods had not returned and her hormone profile was again typical for ovarian failure (menopause). Cyclical HRT was reintroduced.

The forty-one year old wife of a doctor seemed to have a premature menopause on clinical and hormone assessment and she took HRT. One year later she had triplets!

For those who do not wish to become pregnant, contraception should be used.

What are autoantibodies?

The body’s immune system (Q3.1) generally produces antibodies to counter foreign antigens (e.g. viruses). There are some clinical condition characterised by the body producing antibodies against its own tissues autoimmune diseases. It is believed that these autoantibodies are triggered by the production of antibodies by the immune system to counter bacteria or viruses and that these antibodies by misfortune may also cross-react with the body’s own tissues if part of their chemistry is similar to that of the virus or bacterium. Premature menopause can be associated with autoantibodies and appropriate investigations may, therefore, provide an explanation although they do not alter the management options.

What is premature ovarian failure?

Premature ovarian failure is defined as cessation of menstruation together with elevated gonadotrophin levels before the age of 40 years. It is generally estimated that 1% of women will have premature ovarian failure. Clearly if the ovaries are removed at surgery, or if they are subjected to radiotherapy or chemotherapy, ovarian failure may result. About a quarter of women presenting with secondary amenorrhoea in their late thirties will prove to have premature ovarian failure. The most frequent abnormality to be found when investigating premature ovarian failure is autoantibodies (Q6.16)Chromosome abnormalities can be found in about 3% of women with premature ovarian failure.

If a hormone test suggests a diagnosis of premature ovarian failure, it is advisable to repeat the test. The diagnosis of premature ovarian failure can be devastating to a woman particularly if her family has not been completed so careful and sympathetic counselling is essential. The possibility of the resistant ovary syndrome should also be explained (Q6.15).  The long-term health risks of oestrogen deficiency (Chapter 26) are increased for those with premature menopause and the virtues of hormone replacement should be emphasised.

A fifteen year old girl was referred to me as her periods had stopped. Her menarche (first period) occurred when she was ten and when she was fourteen she was investigated under the care of one of my colleagues who diagnosed a large ovarian cyst. A 10cm cyst was removed from her left ovary and some ovarian tissue was conserved. The right ovary and both tubes were healthy. The tumour was innocent and not hormone producing. Following surgery her periods did not resume. Hormone tests on several occasions have demonstrated high FSH and low oestradiol levels consistent with a premature menopause. She has been happy with a cyclical HRT preparation.

A lady of twenty-two stopped seeing her periods. All appropriate hormone tests were consistent with the menopause on several occasions. She took cyclical HRT for eight years and had regular withdrawal bleeds. On one occasion, in 1997, she failed to see a withdrawal bleed and her pregnancy test proved to be positive. We monitored her pregnancy carefully and, much to everyone’s delight, she went on to deliver a healthy son. A few months after delivery her hormone picture was again consistent with the menopause.

A thirty-one year old lady presented with amenorrhoea and infertility. Her hormone tests on two occasions demonstrated high FSH and low oestradiol levels indicating a premature menopause. We recommended HRT and discussed IVF with donated eggs.

What uterine abnormalities are associated with amenorrhoea?

On rare occasions there may be congenital absence of the uterus. Endometrial ablation (endometrial ablation) will reduce or stop periods. Clearly hysterectomy (removal of the uterus) or bilateral oophorectomy (removal of both ovaries) will result in amenorrhoea. If you have had a hysterectomy (hysterectomy) and your ovaries were conserved (not removed), the most obvious symptom of the menopause, which is cessation of periods, can no longer be used to indicate when ovarian function has fallen. A hormone test can be recommended at least every two years so that when your ovaries are no longer active, hormone replacement can be considered.

What is asherman’s syndrome?

Amenorrhoea following endometrial curettage with no other obvious cause for amenorrhoea would suggest Asherman’s syndrome. The endometrium (lining of the womb) is replaced by scar tissue the diagnosis being confirmed by hysteroscopy.

Hysteroscopy and hysteroscopic surgery have been the gold standard of diagnosis and treatment respectively for this condition. This syndrome occurs mainly as a result of trauma to the gravid uterine cavity, which leads to the formation of intrauterine and/or intracervical adhesions. Despite the advances in hysteroscopic surgery, the treatment of moderate to severe Asherman syndrome still presents a challenge. Furthermore, pregnancy after treatment remains high risk with complications including spontaneous abortion, preterm delivery, intrauterine growth restriction, placenta accrete or praevia, or even uterine rupture.

What are the long-term effects of prolonged amenorrhoea?

It has been shown that prolonged amenorrhoea is associated with reduction in bone mineral density. This reduction is directly related to the duration of amenorrhoea. Oestrogen replacement can restore a significant amount of bone mass. An early menopause increases the risk of coronary heart disease which may be countered by hormone replacement (Chapter 27).

Smoking, poor quality diet, lack of exercise and abnormal weight (excess or reduced) are additional risk factors for ill health in later life and appropriate measures to counter these are to be particularly recommended for those who have prolonged amenorrhoea.

 

How can my amenorrhoea be treated?

The primary objective is to treat the underlying cause.

Hormone replacement therapy should be considered to avoid prolonged oestrogen deficiency (Q6.20) if you have premature menopause(Q6.17). If you are not sexually active HRT (Chapter 28) would provide adequate oestrogen.

If you are sexually active and you wish to avoid pregnancy, the combined oral contraceptive pill would have two-fold benefit.

When there is associated infertility, every effort should be made to correct the underlying disorder before addressing fertility issues. Amenorrhoea suggests anovulatory infertility (Q9.17).

Prolonged weight-related amenorrhoea will be associated with the risks of oestrogen deficiency (Chapter 26) and hormone replacement therapy or a combined oral contraceptive pill should be considered. The primary objective is to encourage a more nutritious diet.

Most of the information available on hormone replacement relates to the vast number of women who have a normal menopause (in their early fifties). There is very little data for women taking hormone replacement earlier in their lives. It would seem that for each year that the body has natural oestrogen either as a result of a late natural menopause or as result of hormone replacement, there is a slightly increased risk of breast cancer. This increased risk is small and the majority of women who develop breast cancer whilst taking hormone replacement would have developed the cancer even if they had never taken hormone replacement (Q 27.15). For those who have a premature menopause, and who do not take hormonal treatment, the risk of breast cancer is reduced. It is difficult to extrapolate evidence from one group and apply it to another. Nevertheless, the current opinion seems to be that if a woman with a premature menopause takes hormone replacement until the age of fifty, the risks of breast cancer increase to those of a woman who has a natural menopause at the age of fifty.

The risks of a woman with a premature menopause having sustained oestrogen deficiency are reduced bone density and cardiovascular disease (Chapter 26). From the information currently available, the benefits of hormone replacement are thought to be greater than the risks.

What are the causes of infrequent periods?

Some women normally have long cycles. We consider a cycle of 35 days duration to be normal. Most of the causes of secondary amenorrhoea (amenorrhoea causes) can also result in infrequent periods (oligomenorrhoea). Whereas polycystic ovary syndrome only accounts for about 25% of amenorrhoea, it is found more frequently with oligomenorrhoea about 90%. Other causes include weight change (particularly diet related weight loss), stress (e.g. exams or bereavement), frequent strenuous exercise, some medications (particularly antidepressants), progestogen-only pills (Q14. 4) or the LNG-intrauterine system (Mirena). Periods tend to be less frequent before the menopause. Chronic ill-health from any cause may be associated with decreased or absent periods.

How are infrequent periods investigated?

The investigation of infrequent periods is similar to that described for absent periods (Q6.6).

How are infrequent periods treated?

As with amenorrhoea (Q6.21), treatment will depend on causation and fertility requirements. Cyclical progestogens (Q33.10)  may be used to regulate the cycle artificially.

Do I need birth control if my periods are absent or infrequent?

Yes. Ovulation occurs two weeks before the next period is due. It would be impossible to predict when this is likely to occur. Although infrequent periods indicate that you are not releasing your eggs regularly, you can never be sure, and protection is essential if you do not wish to conceive.

Support Groups

 

Anorexia and Bulimia Care

PO Box 30

Ormskirk

Lancashire

L39 5JR

 

Daisy Chain Premature Menopause Self-Help Network

PO Box 2829

Blandford Forum

DT11 8NZ

 

EDA (Eating Disorder Association)

First Floor

Wensum House

103 Prince of Wales Road

Norwich

NR1 1DW

Tel 01603 621414

Youthline 01603 765050

 

Weight Watchers UK

Kidwells Park House

Maidenhead,

Berkshire

SL6 8YT

Tel:01628 777077

 

Women’s Nutritional advisory Service

PO Box 268

Lewes

East Sussex

BN7 1QN

Tel: 0273 487366

Members of a support group, provide each other with various types of help and information for a particular shared difficulty.

The support may take the form of providing relevant information,

  • relating personal experiences,
  • listening to others’ experiences,
  • providing sympathetic understanding and
  • establishing social networks.

A support group may also provide ancillary support, such as serving as a voice for the public or engaging in advocacy.

Support groups maintain interpersonal contact among their members in a variety of ways.

Support groups also maintain contact through printed information rich newsletters, telephone chains, internet forums, and mailing lists.

Support groups offer companionship and information for people coping with diseases or disabilities. Support groups may not be appropriate for everyone, and some find that a support group actually adds to their stress rather than relieving it.

Evaluation of the quality of Web sites is discussed in(Q4.27)). You may find that several general women’s health sites may help you (internet information). The following are more specialised relevant Web sites:-

 

This is the personal website of David A Viniker MD FRCOG, retired Consultant Obstetrician and Gynaecologist – Specialist Interests – Reproductive Medicine including Infertility, PCOS, PMS, Menopause and HRT.
I do hope that you find the answers to your women’s health questions in the patient information and medical advice provided.

– Specialist Interests – Reproductive Medicine including Infertility, PCOS, PMS, Menopause and HRT.

I do hope that you find the answers to your women’s health questions in the patient information and medical advice provided.

The aim of this web site is to provide a general guide and it is not intended as a substitute for a consultation with an appropriate specialist in respect of individual care and treatment.

David Viniker retired from active clinical practice in 2012. He will be providing SEO Courses in London based on his experience with website promotion. This will help you to promote your website.
In 1999, he setup this website – www.2womenshealth.com – to provide detailed
information many of his patients requested. The website attracts thousands of visitors every day from around the world.

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