When a woman who is not in her menopause stops seeing her menses for a number of cycles, she is said to be experiencing “Amennorrhea.” Normal menstrual cycle is between 21days to 35days in which menses flow for between 2days to 6days. Amenorrhea is a normal feature in females who are in their menopause, pregnant or pre-puberty.
Amenorrhea is a symptom with many potential causes and is simply noticed as the absence of menstrual cycle. Amenorrhea has been categorised as primary amenorrhea and Secondary amenorrhea.
Primary Amenorrhea is when at the age of 14years – 16years, menses is absent as well as the development of other secondary sexual characteristics in a girl. Normally a girl is expected to have seen her first menses (menarche) before 15years and have started developing other secondary sexual characteristics like breasts.
Secondary Amenorrhea, on the other hand, is the absence of menstruation for 3 consecutive cycles or 6 months in a woman who previously had regular menses. It is also defined as absence of menstruation for 12months in a woman with history of oligomenorrhea (infrequent menstruation).
Risk factors for developing Amenorrhea in females include
- Family history of Amenorrhea
- Eating disorders (anorexia nervosa or bulimia)
- Athletic and vigorous exercise
What are the causes of Amenorrhea in females?
There are several reasons why a woman can stop seeing her menses. The possible causes of Amenorrhea in women to look out for include the following :
- Natural causes including pregnancy, breastfeeding and menopause or pre-puberty.
- Lifestyle factors like excessive exercise, stress and low body weight can interrupt hormonal functions resulting in Amenorrhea.
- Developmental defects of the lower genital tract like the occlusion of the hymen, vagina or cervix.
- Embryological abnormalities and developmental defects of the upper genital tract including the uterus. E.g syndrome of gonadal dysgenesis, pseudo Turner syndrome, testicular feminization syndrome, and female pseudohemaphroditus.
- Uterine and endometrial causes like tuberculous suppuratitve endometritis and Asherman’s syndrome (trauma to endometrium).
- Ovarian failure can cause premature menopause. Ovarian tumours and other ovarian abnormalities like polycystic ovarian syndrome can cause menstruation to stop.
- Non gonadal endocrine diseases like thyroid disease (hyperthyroidism or hypothyroidism), diabetes mellitus, and adrenal diseases such as cushing’s syndrome and congenital adrenal hyperplasia.
- Hypothalamic diseases like pseudo cyesis, and persistent corpus luteum syndrome can cause Amenorrhea.
- Pituitary causes like galactorrhea-amenorrhea syndrome, primary and secondary hypopituitarism.
- Drug induced Amenorrhea is from contraceptive use and other medications including antipsychotics, antidepressants, cancer chemotherapy, allergy and blood pressure drugs.
Clinical diagnosis for Amenorrhea
The parameters used for the clinical diagnosis of Amenorrhea to ascertain the exact cause involves several things which include
- Comprehensive history taking of the patient including menstrual history, medical and surgical history, growth and nutrition history, drug history, family history and social history is first step towards obtaining a clinical diagnosis of the possible cause of Amenorrhea the woman is experiencing.
- A very detailed general head to toe physical examination involving inspection and palpation for possible organo-metabolic causes of Amenorrhea as well as pelvic examinations to rule out genital tract causes.
- Use of laboratory investigations to corroborate clinical findings is very paramount. Laboratory tests like pregnancy test, thyroid function test, ovarian function test, prolactin test, male hormone tests are all indicated for diagnosing Amenorrhea in women. The use of imaging studies such as ultrasound scan, CT scan, MRI, laparoscopy and hysteroscopy have been very helpful to the diagnostic process.
How Amenorrhea is Managed
The management of Amenorrhea in women is directed to and dependent on the specific cause of the problem as diagnosed clinically. There are a number of medical and surgical interventions that can be used to address each possible pathological cause of Amenorrhea.
For the more simpler causes of Amenorrhea, lifestyle changes in diet and exercise can bring about restoration of normal menstruation.
In women whom estrogen levels are low, estrogen replacement is important to prevent loss of bone density. If estrogen and progesterone are given cyclically, normal menstrual rhythm will be restored.
Medscape : “Amenorrhea ”
S. Campbell and A. Monga (2006),: Gynaecology by Ten Teachers, “Amenorrhea” (18th edition)