Amenorrhea

The main symptom of amenorrhoea is the absence of menstrual periods for at least three months. Depending on the underlying cause, other symptoms of amenorrhoea may include:

• Hair loss
• Headache
• Visual disturbances
• Tiredness
• Lack of breast development
• Discharge from the breast
• Excess facial hair
• Sleep disturbances
• Vaginal dryness
• Pelvic pain
• Acne
• Deepening of the voice

Amenorrhea is often a sign of another health problem rather than a disease itself, and it can happen for many reasons. This can occur as a natural part of life such as during pregnancy, breastfeeding, and menopause. However, the absence of menstruation can also indicate a problem within the ovaries, uterus, hypothalamus, and pituitary gland, or an abnormality of the genital tract. Amenorrhea has also been linked to infertility, some medications, and lifestyle factors. There are two types of amenorrhea: primary and secondary.

Primary amenorrhea (failure of menses by the age of 16)

It can be due to the following reasons:

• Genetic abnormalities: Sometimes, this causes the ovaries to stop functioning. A genetic syndrome linked to the absence of an X chromosome is called Turner’s syndrome, characterized by ovarian insufficiency due to defects in the development of genitals, which can delay or disrupt menstruation. Another genetic cause of primary amenorrhea is Mayer–Rokitansky–Küster–Hauser (MRKH) syndrome, where the mullerian ducts develop abnormally, resulting in the absence of a uterus and cervix. Patients with MRKH have functioning ovaries and secondary sexual characteristics but may experience primary amenorrhea due to the absence of a functioning uterus.
• Problems with the hypothalamus or pituitary gland: Hormonal issues from problems with the hypothalamus or the pituitary gland can cause amenorrhea or delay the onset of menstruation.
• Imperforate hymen: This disorder occurs when a hymen has no opening, completely obstructing the vagina.
• Transverse vaginal septum: This birth defect results in a wall of tissue running horizontally across the vagina, blocking all or part of it.
• Constitutional delay of puberty: This is a transient state associated with prolonged childhood and delayed pubertal growth spurt. It is not attributed to any disease but is considered a modification of the timeline of puberty. Although it is more common in boys, girls with delayed puberty present with secondary sexual characteristics after age 14 and menarche after age 16. This may be due to genetics or family history. This diagnosis is made when other causes have been ruled out.

Secondary amenorrhea (not having periods for at least 6 months after menstruating normally)

This can result from various causes, including:

• Natural causes: Pregnancy is the most common natural cause of secondary amenorrhea, along with breastfeeding and menopause. Breastfeeding, or lactational amenorrhea, is due to elevated prolactin and low levels of luteinizing hormone (LH) in the blood. LH plays an important role in sexual development and functioning, suppressing ovarian hormone secretion. The duration of lactational amenorrhea depends on how often a woman breastfeeds.
• Health conditions: Several health conditions can lead to secondary amenorrhea, such as:
  • Pituitary tumors: The pituitary gland regulates the production of hormones affecting many body functions. Tumors of the pituitary gland are usually noncancerous but can interfere with normal hormonal regulation of menstruation.
  • Thyroid issues: The thyroid produces hormones that control metabolism and plays a vital role in puberty and menstruation. Both upregulation and downregulation of the thyroid gland can cause menstrual irregularities, including amenorrhea.
  • Polycystic ovary syndrome (PCOS): PCOS is a hormonal disorder common among women of reproductive age, causing changes in the menstrual cycle, increased facial and body hair, cysts in the ovaries, and infertility. Most women with PCOS either have amenorrhea or experience irregular periods, called oligomenorrhea.
  • Hypothalamic amenorrhea: This condition occurs when the hypothalamus slows or stops releasing gonadotropin-releasing hormone (GnRH), the primary hormone for starting the menstrual cycle.
  • Low body weight: Women who perform excessive exercise or lose significant weight are at risk of developing Functional Hypothalamic Amenorrhea (FHA). In such cases, women do not consume enough calories to maintain normal menstrual cycles.
  • Hyperandrogenaemia: This condition involves high levels of male sex hormones affecting the female reproductive system, potentially caused by tumors of the ovary or adrenal gland, or certain congenital conditions.
  • Premature menopause: Menopause usually begins around age 50, but some women may experience a diminished ovarian supply of eggs before age 40, leading to early cessation of menstruation.
• Medications and therapies: These include:
  • Birth control pills: Some birth control pills may cause missed periods or complete absence of menstruation. Injectable contraceptives and hormonal intrauterine devices (IUDs) can also cause amenorrhea. After stopping these methods, it may take months to restart a regular menstrual cycle.
  • Recreational drugs: Regular use of opiates (such as heroin) has been known to cause amenorrhea in long-term users.
  • Antipsychotic drugs: Medications used to treat schizophrenia can cause amenorrhea due to hormonal imbalances.
  • Radiation and chemotherapy: Certain cancer treatments can destroy estrogen-producing cells and eggs in the ovaries, leading to amenorrhea.
• Poor nutrition: Nutritional deficiencies may affect the functioning of the hypothalamus and pituitary gland, leading to amenorrhea.
• Stress: Stress can affect hormone levels in the body and lead to hypothalamic amenorrhea.

There are various factors that can put one at the risk of developing amenorrhea. Some of the risk factors include:

• Eating disorders: These disorders are psychological conditions that lead to unhealthy eating habits, often beginning with an obsession with food, body weight, or body shape. Anorexia nervosa is one of the most well-known eating disorders, where individuals typically perceive themselves as overweight, despite being dangerously underweight. Another disorder, bulimia nervosa, involves episodes of consuming unusually large amounts of food in a specific time frame. Both disorders predominantly affect women during adolescence and early adulthood. When an eating disorder is present, the most common cause of missed periods is hypothalamic amenorrhea (HA).
• Excessive exercise: Engaging in excessive exercise may reduce the frequency of hormone release or decrease the amount of hormone released during each pulse. The likelihood of amenorrhea increases when excessive exercise is combined with low-calorie intake or a low body fat percentage.
• Family history: A family history of delayed or irregular menstruation may indicate a genetic predisposition to amenorrhea.
• Structural abnormalities: Girls with congenital abnormalities, such as poorly developed genital and pelvic organs, are at risk of developing amenorrhea.
• Tumors and their treatments: After undergoing chemotherapy or radiotherapy, ovarian failure may occur, leading to the absence of menstruation.

1. Physical Examination and Medical History

2. Lab Tests

3. Imaging Tests

4. Hysteroscopy

5. Karyotyping

A woman can prevent amenorrhea by following programs:

• Maintaining a healthy weight
• Exercising regularly
• Eating a well-balanced diet
• Managing stress
• Getting regular and adequate sleep
• Being aware of your menstrual cycle (to recognize if you miss a period)

Treatment is mainly dependent on the cause of amenorrhea and the health status of a person:

Medication

• If amenorrhea is due to estrogen deficiency, estrogen can be administered.
• Dopamine agonists: Bromocriptine and cabergoline are effective for treating hyperprolactinemia (increased levels of prolactin). They restore normal endocrine function and ovulation.
• In women with polycystic ovarian syndrome (PCOS), metformin can be given to induce ovulation.
• Birth control pills or other types of hormonal medication, including oral contraceptives, may be prescribed to restore the menstrual cycle and provide estrogen replacement to women with amenorrhea. Before administering oral contraceptives, withdrawal bleeding is induced with an injection of progesterone, or oral administration of 5-10 mg of medroxyprogesterone can be recommended for 10 days.
• Estrogen replacement therapy (ERT) helps balance hormonal levels and restart the menstrual cycle in women with primary ovarian insufficiency (POI). Hormone replacement therapy works by replacing the estrogen hormone that is no longer being produced by the body.
• Treatment of hypo or hyperthyroidism: Replacement therapy with levothyroxine to correct hypothyroidism and antithyroid drugs like methimazole to correct underlying hyperthyroidism.

Surgical Treatment

• In the case of a pituitary tumor, medications may be recommended to shrink the tumor. If medication does not work, surgery may be necessary to remove the tumor. Most of the time, pituitary tumors are removed through the nose and sinuses, but sometimes radiation therapy may be used to shrink the tumor.
• Women with intrauterine adhesions require dissolution of the scar tissue. Removal of the scar tissue during a procedure called hysteroscopic resection can help restore the menstrual cycle.

Herbal remedies

Some herbs mimic estrogen-like effects and are sometimes used to treat amenorrhoea symptoms. In addition to traditional treatments, several home remedies may provide symptomatic relief:

• Fenugreek (Methi): Considered a solution for various menstrual cycle and reproductive issues, fenugreek has shown positive results in milk production, amenorrhea, and relief from menstrual cramps.
• Saffron (Kesar): An antioxidant that acts as a toxin-flushing and stress-reducing agent, saffron's therapeutic effects are attributed to its relaxant effect on smooth muscles and its ability to stimulate menstruation.
• Chamomile (Babunah ke phul): Used as a relaxant and antispasmodic, chamomile can be taken as a supplement or drunk as tea. It may help alleviate amenorrhea caused by stress and anxiety.
• Turmeric (Haldi): Known for its ancient medicinal properties, turmeric helps heal internal injuries and serves as a uterine stimulant to regulate menstrual flow.
• Lemon (Nimbu) balm: This herb is utilized in treating amenorrhea and other menstrual problems, promoting the menstrual cycle and easing menstrual cramps.
• Blue cohosh: Blue and black cohosh are phytoestrogenic herbs commonly used to treat menopause symptoms in middle-aged women. A phytochemical called opsonin in this herb stimulates blood flow in the pelvic region, effectively treating amenorrhea and other gynecological conditions.

The causes of amenorrhea can lead to various complications, including:

• Infertility: Amenorrhea can result in difficulties in becoming pregnant. Primary amenorrhea or secondary amenorrhea lasting several months may indicate an underlying disease or chronic condition that can contribute to infertility. Hormonal imbalances causing amenorrhea may also lead to miscarriage or other pregnancy-related issues.
• Psychological stress: The absence of regular menstrual flow, especially when peers are menstruating, can be stressful. This is particularly true for women who are trying to conceive and planning a family.
• Osteoporosis: Estrogen is crucial for maintaining bone health. If amenorrhea results from low estrogen levels or issues with estrogen production, women may be at increased risk for weak or brittle bones.
• Pelvic pain: Structural problems causing amenorrhea may also lead to pain in the pelvic area.

• Yoga and Exercise: Practicing yoga and exercising three times a week can enhance blood circulation, promote a sense of freshness, and prevent fatigue. These activities are effective in reducing stress and pressure on the body, and they have been shown to alleviate stress, manage anxiety, and assist in pain management.
• Acupuncture: Acupuncture is a traditional Chinese medicine technique that involves inserting finely pointed needles into specific areas of the body known as acupuncture points. This practice may help improve hormonal imbalances associated with amenorrhea. Additionally, the needles are believed to stimulate specific nerves and muscles, releasing natural pain-relieving hormones in the body.
• Massage: Massage therapy can increase circulation and relieve pain from pelvic congestion. However, it primarily addresses physical symptoms like pain rather than the underlying causes of the condition.
• Nutritional Approach: A healthy diet that limits processed foods and includes heart-healthy fats (unsaturated fats) instead of saturated fats is recommended. Incorporating a wholesome diet rich in grains, vegetables, and omega-3 fatty acids is beneficial. A very low-fat diet can increase the risk of amenorrhea. Supplemental calcium, Vitamin D3, magnesium, and Vitamin K should be considered, as women with irregular periods are at a higher risk of developing weak and brittle bones (osteoporosis). These vitamins and minerals may help maintain bone strength.
• Vitamin B6: Vitamin B6 (pyridoxine) plays a crucial role in normal brain development and in maintaining the health of the nervous and immune systems. It may help reduce elevated prolactin levels, a hormone released by the pituitary gland that is often found in increased amounts in women with amenorrhea.
• Chiropractic Care: Chiropractic care focuses on the neuromusculoskeletal system, including bones, nerves, muscles, tendons, and ligaments. This natural, safe, and effective therapy can relieve menstrual cycle symptoms and enhance fertility. It aims to alleviate pain and improve overall bodily function.
• Hot Water Bath: A hot water bath can relieve pain associated with the absence of the menstrual cycle. The muscle relaxant properties of heat can enhance blood circulation and reduce muscle tension.

Self-management can help in taking care of yourself.

Know about your condition: Amenorrhoea can sometimes affect mental health, leading to anxiety and depression. Talking to loved ones can alleviate emotional distress and contribute to an effective treatment plan.

Exercising daily: Regular exercise increases blood circulation and helps relieve tension and stress.

Take your medicine on time: Adhering to medication schedules provides a sense of control and awareness regarding the condition.

Communicate openly with your doctor: Individuals with amenorrhoea should feel free to ask any questions related to their concerns.

Lower stress levels: Practicing meditation and yoga can help reduce stress and promote happiness.

Ensure adequate sleep: Quality sleep activates and calms both the body and mind, reducing feelings of fatigue.