If a teenaged girl doesn’t get her period by the age of 16, she has primary amenorrhea (or absence of menses), which is typically caused by structural or chromosomal abnormalities or functional problems with the hypothalamus or pituitary gland.  But when a woman who’s previously had her period stops menstruating for three months or longer, and she’s not pregnant or in menopause, it’s called secondary amenorrhea. While secondary amenorrhea can have many causes, it’s important for a woman to find out why her periods have stopped.

“Ovulation is a vital sign of general good health,” says Nathan Kase, MD, professor of obstetrics, gynecology, and reproductive science at the Icahn School of Medicine at Mount Sinai Medical Center in New York City. “Almost every organ in the body can disrupt the cascade that initiates and sustains normal menstrual cycles.”

“It’s not normal for a woman to not have periods,” says Cynthia Austin, MD, an obstetrician/gynecologist at the Cleveland Clinic in Ohio. “When a woman isn’t getting her period, it means she’s not ovulating regularly, and it’s important to learn why.”

Amenorrhea can lead to bone loss, including osteoporosis, says Mitchell S. Kramer, MD, chairman of the department of obstetrics and gynecology at Northwell Health’s Huntington Hospital in Huntington, New York. “Infertility is certainly another risk as well,” he says.

The good news, says Dr. Kase, is that nearly all amenorrhea in this country is reversible. Also, it’s not uncommon for a woman to miss a few periods now and then, so she shouldn’t automatically assume something is wrong. “It is not unusual in our society for a woman to have intervals of irregular periods and it doesn’t necessarily mean they have a serious disease,” Dr. Kase says. “But if it doesn’t spontaneously return, generally within six months, very accurate methods are readily available to identify, stabilize, and, if necessary, manage the situation positively with treatment.”

What Causes Amenorrhea?

When a woman is ovulating regularly, she is making enough of a hormone called estrogen that promotes uterine lining regrowth following the last menstruation. During this time, about once each month, an egg is released from one of the ovaries. That’s called ovulation. If the egg is not fertilized or an early embryo is not implanted in the prepared lining, then that “unused” uterine lining is shed—and a period is the result. A malfunction in any of the organs directly involved in stimulating ovulation (including signals from specific sites in the brain (the hypothalamus for instance), the anterior pituitary gland (which issues the required sequence and quantity of hormones to stimulate the ovary), and the ovary itself, can disrupt the process of ovulation.

“The most common cause of irregular periods in young women is polycystic ovary syndrome,” says Dr. Austin. Other causes of secondary amenorrhea, assuming the woman is not pregnant or going through menopause, are anorexia and excessive exercise, Dr. Kramer explains. “If a young woman is an elite gymnast before she starts menstruating, then menstruation may be delayed due to low body weight,” Dr. Austin says. “Even when they stop gymnastics, they may not get regular periods, so there is a real risk for young gymnasts.”

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Jenaca Beagley, MSN, APRN, NP-C, CDE, a nurse practitioner at Center for Change in Orem, Utah an eating disorder treatment facility says anorexia can also cause amenorrhea. “While the majority of underweight females will stop having a menstrual period as a direct result of malnutrition, some will not,” she explains. “Others who restrict calories but are still at what would be considered a ‘normal’ body weight, can stop having a monthly period as a symptom of starvation without being clinically underweight.”

The good news is, amenorrhea triggered by anorexia is usually a temporary condition. If a girl’s periods have stopped and the likely cause is anorexia, they should resume once she gains weight, Beagley says. “Eating disorders may induce different menstrual patterns, but in my experience after a patient starts to be consistent with nutrition and is at a healthy weight, periods usually return within 6 months,” she says.  “If this does not happen patients are usually referred for further assessment and testing which may include checking hormone levels or ultrasound to look at the uterus and ovaries.”

Diagnosing Amenorrhea

Often the first step in reaching a diagnosis are simple blood tests that can rule out pregnancy as well as menopause, Dr. Kramer says.

Once these are ruled out, your health care provider will order tests to determine why you’re not ovulating.

One simple test is a progesterone withdrawal test, Dr. Kase explains. The female patient is given an orally-active dose of the ovarian hormone, progesterone.  If she gets her period, that’s evidence her uterus is working, but she is not ovulating. “The ovaries are making estrogen but not ovulating,” Dr. Kase says. Next, tests are also done to see whether the pituitary gland is producing two vital hormones called follicle stimulating hormone (FSH) and luteinizing hormone (LH). “If levels of FSH are high, then something is likely wrong with the ovaries,” Dr. Kase says. “If they are low, then the ovaries are not getting the stimulation they need for ovulation to occur.” Imaging studies of the pituitary gland are then needed to clarify why the egg developing hormone FSH is not available and to identify the reason for this deficiency, he adds.

Treating Amenorrhea

The treatment for amenorrhea will depend on what is causing it, Dr. Kramer says. “Most commonly, it can be treated hormonally,” he says.

Treatment for polycystic ovary syndrome can vary, but a woman trying to get pregnant may be given medication to help her ovulate. If she is overweight, she may be told to lose weight.1

A woman who has a very low body weight will be told to increase her body fat, he says. In other words, she needs to gain weight. Treatment for anorexia may require inpatient care at a specialized facility which includes intensive therapy, nutrition education and medical care.

Medications may be necessary, and depending on the cause of the amenorrhea, other treatments may include surgery to remove ovarian cysts or uterine adhesions that might be causing the amenorrhea.

A woman who’s not getting her period and wants to get pregnant should consult with a gynecologist and possibly a reproductive endocrinologist.  But women with amenorrhea should not assume they cannot conceive, Dr. Kramer says. “After a careful workup and evaluation to determine the cause of the amenorrhea, they will be given appropriate, cause-specific treatment,” he says.

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Last Updated: Sep 4, 2019