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Amenorrhea (missing periods) – Causes

by Josephine Andrews
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Amenorrhea (missing periods) is natural during pregnancy, breastfeeding and after menopause. In other life situations, hormonal disorders, organic complications, an eating disorder such as anorexia and mental stress can be the reason if the menstrual period does not occur. Read everything you need to know about the causes, consequences and treatment of amenorrhea here.

quick overview

  • What is amenorrhea? The absence of the female menstrual period.
  • Causes : natural causes are pregnancy, lactation and menopause; pathological causes are, for example, stress, (too) low body weight,
  • Treatment: depending on the cause of the pathological amenorrhea, e.g. B. Stress reduction, relaxation techniques, hormone administration, training reduction, weight gain , surgical intervention in tumors
  • Consequences: inability to become pregnant; psychological problems (feeling of inferiority, not feeling “as a woman”)

Amenorrhea: definition

Doctors call amenorrhea the absence of menstruation. This is completely natural during pregnancy and breastfeeding. Before puberty, girls don’t have their periods either. And with the menopause, egg cell maturation is exhausted, which also allows the menstrual cycle to gradually subside – until there is no period at all.

In addition to these natural causes of amenorrhea, missed periods can be the result of an illness or (hormonal) disorder. Doctors distinguish between two forms of this pathological (pathological) amenorrhea :

  • primary amenorrhea : This is present in women who have never had a menstrual period up to the age of 16.
  • Secondary amenorrhea : This is when the menstrual period stops for more than three months, but the affected women previously had a normal cycle.

Amenorrhea: causes and possible diseases

The woman’s menstrual cycle is kept going by an interplay of various hormones (such as GnRH, FSH , LH , oestrogens), which are controlled primarily by two brain regions – the hypothalamus and the pituitary gland ( pituitary gland ). Amenorrhea is very often caused by a disruption in this complex hormonal regulatory system.

In addition, organic disorders such as organ malformations can also be responsible for the absence of menstrual bleeding.

The most important causes of primary and secondary amenorrhea are presented in more detail below (natural causes of amenorrhea such as pregnancy or menopause are not discussed).

Primary amenorrhea

Usually, young girls get their first menstrual period between the ages of 11 and 13. If this does not occur by the age of 16, doctors speak of primary amenorrhea. The causes for this are mostly congenital.

For example, certain chromosomal disorders can lead to the ovaries not responding to hormonal signals from the brain or the sex organs not developing properly. This is the case, for example, with Turner syndrome , Klinefelter syndrome or androgen receptor defects. The hereditary lack of functional egg cells (gonad dysgenesis as in Turner syndrome or Swyer syndrome) as well as malformations in the genital area are possible causes of primary amenorrhea. The same applies to intersexuality (here, the genetically determined sex and the developed sex organs do not match).

Occasionally, serious diseases such as cancer and its therapy, disorders of the thyroid or the adrenal cortex , autoimmune diseases such as type 1 diabetes or rheumatoid arthritis in childhood are the reason for primary amenorrhea.

Secondary amenorrhea

Important reasons for secondary amenorrhea include:

  • Stress: An important trigger for amenorrhea are, for example, emotional tension, serious crises, time pressure, travel and important decisions to be made. Exactly how the soul influences hormone production is not yet fully understood. However, stress directly affects the hypothalamus and can cause GnRH levels to drop, disrupting the cycle. Mental stress can trigger amenorrhea, especially in women who already have a rather irregular menstrual cycle.
  • Competitive sports: Excessive training also means stress for body and soul and causes the GnRH level to drop.
  • Severe weight loss or low body weight: If the woman’s body fat percentage falls below a critical value, the organism no longer produces enough hormones that trigger ovulation. If the weight is too low, pregnancy would be dangerous for both mother and child. That’s why the body doesn’t allow it to happen in the first place – it skips the period. Especially in connection with anorexia nervosa and bulimia , (too) low weight can bring the cycle to a standstill.
  • Severe mental and physical illnesses: They are also strong stressors that can reduce GnRH production, among other things.
  • Incorrectly implanted egg: If a fertilized egg implants outside the uterus (extrauterine pregnancy), the hormonal effects on the body are similar to those of a normal pregnancy – there is no menstruation.
  • Polycystic ovarian syndrome ( PCO syndrome ): In this case, hormone production in the ovaries and in other hormone-producing tissues is disrupted. Among other things, numerous fluid-filled sacs ( cysts ) develop on the ovaries . Ovulation often does not occur, and then menstrual bleeding as well.
  • Thyroid diseases: They also disrupt the hormonal balance. Both an overactive and an underactive thyroid gland can prevent menstrual bleeding.
  • Increased prolactin production: The hormone prolactin inhibits the menstrual cycle during pregnancy and breastfeeding and stimulates milk production in the breast . In Chiari-Frommel syndrome, prolactin production remains high even after breastfeeding – milk flow persists for months to years, and amenorrhea occurs. Certain medications and tumors can also boost prolactin production.
  • premature menopause: In some women, the ovaries stop functioning before their 40th birthday. Doctors then speak of premature menopause .
  • Inflammation of the brain: If it occurs in the area of ​​the pituitary gland or the hypothalamus, it can disrupt its function – the period will not occur.
  • Tumors: Both benign and malignant tumors can prevent menstruation. These include tumors on the ovaries, but also in the brain (especially in the area of ​​the hypothalamus and pituitary gland).
  • Disorder of the ovaries : e.g. B. due to cysts, surgery, tumors or radiation. Even if the ovaries (ovaries) do not respond to the hormonal control by the brain, this can prevent a menstrual period.
  • Damage to the lining of the uterus: The lining of the uterus can be so badly damaged by surgery (e.g. during a scrape ) or inflammation that it can no longer build up sufficiently. Then the menstrual period stops.
  • Chronic kidney failure: Chronic kidney failure has a significant impact on the entire organism. Among other things, it can impair the function of the sexual organs.
  • Adrenal diseases: Such diseases can be associated with an overproduction of the stress hormone cortisol ( Cushing’s syndrome ). This disrupts the cycle to the point of stopping menstruation.
  • Medications: Hormone preparations, cancer medication, psychotropic drugs, cortisone and antihypertensive drugs can disrupt the menstrual cycle.
  • Discontinuation of hormonal contraceptives: Especially after the three-month injection, menstruation can temporarily stop. This happens more rarely after stopping the “ pill ” (post-pill amenorrhea).
  • Deliveries with heavy blood loss: They can be caused, for example, by a certain functional weakness of the pituitary gland, the so-called Sheehan syndrome. In affected women, menstrual bleeding lasts an unusually long time after giving birth (and breastfeeding).

Amenorrhea treatment: what does the doctor do?

The treatment of amenorrhea depends on the cause behind the symptom. For example, a hormone disorder can be regulated in many cases by administering hormone preparations. If tumors or malformations of the sex organs are to blame for the amenorrhea, often only surgery can help. If amenorrhea occurs as a result of psychological stress or a disorder, psychotherapy can be the treatment of choice.

In order to be able to initiate the right treatment, the doctor must first determine the exact cause of the amenorrhea.

diagnosis

The first important step in the clarification of amenorrhea is the collection of the medical history ( anamnesis ). In conversation with the patient, the doctor collects important information, for example when the last menstrual period was or whether the woman has ever had a menstrual cycle. He may also ask if there is a possibility of pregnancy and if there are any other symptoms besides amenorrhea.

The anamnesis interview is followed by a gynecological examination , which also includes a vaginal swab and an ultrasound examination of the abdominal organs.

Hormone measurements can also provide important information about the causes of amenorrhea. Prolactin, progesterone , estrogens, the male sex hormones (androgens) and the hormones FSH and LH produced by the pituitary gland are determined. If a disturbed thyroid function is suspected as the cause of the amenorrhea, the doctor takes a close look at the blood levels of the thyroid values ​​(TSH, T3, T4).

There are also certain function tests . A few examples: For the so-called progestin test, the patient takes a progestin preparation for a few days. If bleeding occurs after weaning, this shows that the lining of the uterus was actually sufficiently developed – i.e. sufficient amounts of estrogen were produced beforehand, because this stimulates the structure of the lining of the uterus. The amenorrhea must then have other causes.

If the test is negative, an estrogen-progestin test is an option. This makes it possible to check whether the lining of the uterus can be sufficiently activated at all. The doctor first gives the patient estrogens, which stimulate the growth of the lining of the uterus, and then progestin. If bleeding occurs as a result, this indicates that the lining of the uterus is intact.

Depending on the suspected cause of the amenorrhea, further investigations may be necessary. These include, for example, imaging procedures – such as when a tumor in the brain is suspected – or a laparoscopy to assess the condition of the ovaries.

Amenorrhea Treatment: What You Can Do Yourself

Amenorrhea is often psychological. In this case, anything that strengthens your psyche and brings it back into balance can help. This includes relaxation techniques such as autogenic training , progressive muscle relaxation or meditation. But sport is also a good way to reduce stress and regain your inner balance. This is because the body increasingly produces those hormones that reduce or neutralize the stress hormones (e.g. serotonin , endorphins).

If, on the other hand, too intensive sports training is behind the amenorrhea, you should slow down during training. If you do not have a menstrual period because you are too thin or are on an extreme diet, you should try to gain some weight again – fatty tissue plays an important role in the formation of estrogen. If your amenorrhea is the result of an eating disorder such as anorexia, you should definitely seek professional help. Anorexia is a life-threatening disease that can only be overcome with psychotherapeutic help.

Amenorrhea: Consequences

If there is no menstrual bleeding, this can have various consequences for the woman concerned.

  • no pregnancy: A woman cannot become pregnant without an intact menstrual cycle. So if the menstrual period stops for a longer period of time, the desire to have children remains underfulfilled.
  • Problems in the partnership: Missing a period can make women feel less feminine. The frustration of not becoming pregnant due to amenorrhea can also, in the worst case, break up a long-term partnership.

Indirectly, amenorrhea can have another consequence: If the absence of menstrual bleeding is due to a lack of estrogen, this can make the bones more brittle over time – there is a risk of osteoporosis .

Amenorrhea: when do you need to see a doctor?

If you don’t have a period, a visit to the doctor (gynaecologist) is advisable. This is especially true when

  • you may be pregnant.
  • You have missed your period three times in a row.
  • You have not had your first menstrual period after your 16th birthday.
  • You miss your periods after you start taking a new medicine.
  • You have stopped bleeding after stopping the Pill or any other hormonal contraceptive.
  • You have stopped menstruating after an operation.
  • In addition to the absence of the period, you notice other symptoms such as abdominal pain , pain during sex , chest pain or milky secretions from the breasts.
  • In addition to amenorrhea, you also notice signs of masculinization ( virilization ) such as hair loss , a deeper voice, thicker and more male-oriented body hair (such as beard and chest hair).

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