Amenorrhea

Amenorrhea (pronounced ey-men-uh-REE-uh or uh-men-uh-REE-uh) is the medical term for the lack of a menstrual period. Amenorrhea is not a disease, but it can be a symptom of another condition.

Primary amenorrhea occurs when a girl has not had her first period by age 16. Secondary amenorrhea describes women who experience an absence of more than three menstrual cycles after having regular periods.

NICHD supports research on the causes and treatments for primary and secondary amenorrhea as well as the conditions for which secondary amenorrhea is often a main symptom, such as polycystic ovary syndrome (PCOS) and Fragile X-associated primary ovarian insufficiency (FXPOI).

About Amenorrhea

Amenorrhea is the absence of a menstrual period.

Amenorrhea is sometimes categorized as:

  • Primary amenorrhea. This describes a young woman who has not had a period by age 16.
  • Secondary amenorrhea. This occurs when a woman who once had regular periods experiences an absence of more than three cycles. Causes of secondary amenorrhea include pregnancy.

Having regular periods is an important sign of overall health. Missing a period, when not caused by pregnancy, breastfeeding, or menopause, is generally a sign of another health problem. If you miss your period, talk to your health care provider about possible causes, including pregnancy.

What are the symptoms of amenorrhea?

Missing a period is the main sign of amenorrhea.

Depending on the cause, a woman might have other signs or symptoms as well, such as:

  • Excess facial hair
  • Hair loss
  • Headache
  • Lack of breast development
  • Milky discharge from the breasts
  • Vision changes

Who is at risk of amenorrhea?

According to the American Society for Reproductive Medicine, amenorrhea that is not caused by pregnancy, breastfeeding, or menopause occurs in a small percentage (less than 5%) of women during their lifetime.

The risk factors for amenorrhea include:2

  • Excessive exercise
  • Obesity
  • Eating disorders, such as anorexia nervosa
  • A family history of amenorrhea or early menopause
  • Genetics, such as having a change to the FMR1 gene, which also causes Fragile X syndrome1

Citations

    1. Practice Committee of the American Society for Reproductive Medicine (PC-ASRM). (2008). Current evaluation of amenorrhea. Fertility and Sterility, 90, S219–225. Retrieved May 31, 2016, from https://www.asrm.org/globalassets/asrm/asrm-content/news-and-publications/practice-guidelines/for-non-members/current_evaluation_of_amenorrhea.pdf external link (PDF 146 KB)
    2. Master-Hunter, T., & Heiman, D. L. (2006). Amenorrhea: Evaluation and treatment. American Family Physician, 73, 1374–1382. Retrieved May 31, 2016, from http://www.aafp.org/afp/2006/0415/p1374.html external link

What causes amenorrhea?

 

Amenorrhea is often a sign of another health problem rather than a disease itself, and it can happen for many reasons. It can occur as a natural part of life, such as during pregnancy or breastfeeding. It can also be a sign of a health problem, such as polycystic ovary syndrome (PCOS). Because amenorrhea is associated with health conditions that are also linked to infertility, understanding amenorrhea is an important part of NICHD's research on infertility and fertility.

Citations

    1. Pascal, P., Leprieur, E., Zenaty, D., Thibaud, E., Polak, M., Frances, A. M., et al. (2010). Steroidogenic factor-1 (SF-1) gene mutation as a frequent cause of primary amenorrhea in 46,XY female adolescents with low testosterone concentration. Reproductive Biology and Endocrinology, 8, 28.
    2. Lin, K. & Barnhart, K. (2007). The clinical rationale for menses-free contraception. Journal of Women's Health, 16(8), 1171–1180.
    3. American College of Obstetricians and Gynecologists (ACOG) Committee on Practice Bulletins—Gynecology. (2013). Practice bulletin no. 136: Management of abnormal uterine bleeding associated with ovulatory dysfunction. Obstetrics and Gynecology, 122(1), 176–185.
    4. La Torre, D., & Falorni, A. (2007). Pharmacological causes of hyperprolactinemia. Therapeutic and Clinical Risk Management, 3, 929–951. Retrieved May 31, 2016, from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2376090/
    5. ACOG. (2014). ACOG Committee Opinion: Primary ovarian insufficiency in the adolescent. Retrieved May 31, 2016, from https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2014/07/primary-ovarian-insufficiency-in-adolescents-and-young-women external link
    6. ACOG. (2016). Dilation and curettage. Retrieved May 31, 2016, from https://www.acog.org/patient-resources/faqs/special-procedures/dilation-and-curettage external link (PDF 69 KB)
    7. Gordon, C. M. (2010). Functional hypothalamic amenorrhea. New England Journal of Medicine,363, 365–371.
    8. Hormone Health Network. (2011). Amenorrhea. Retrieved May 31, 2016, from https://www.hormone.org/diseases-and-conditions/womens-health/amenorrhea external link
    9. U.S. Department of Health and Human Services Office of Women's Health. (2015). Thyroid disease fact sheet. Retrieved May 31, 2016, from http://womenshealth.gov/publications/our-publications/fact-sheet/thyroid-disease.html
    10. Master-Hunter, T., & Heiman, D. L. (2006). Amenorrhea: Evaluation and treatment. American Family Physician,73, 1374–1382. Retrieved May 31, 2016, from http://www.aafp.org/afp/2006/0415/p1374.html external link

How is amenorrhea diagnosed?

A health care provider will usually ask a series of questions to begin diagnosing amenorrhea, including:1

  • How old were you when you started your period?
  • What are your menstrual cycles like? (What is the typical length of your cycle? How heavy or light are your periods?)
  • Are you sexually active?
  • Could you be pregnant?
  • Have you gained or lost weight recently?
  • How often and how much do you exercise?

Citations

    1. Master-Hunter, T., & Heiman, D. L. (2006). Amenorrhea: Evaluation and treatment. American Family Physician, 73, 1374–1382. Retrieved May 31, 2016, from http://www.aafp.org/afp/2006/0415/p1374.html external link
    2. American College of Obstetricians and Gynecologists (ACOG) Committee on Practice Bulletins—Gynecology. (2013). Practice bulletin no. 136: Management of abnormal uterine bleeding associated with ovulatory dysfunction. Obstetrics and Gynecology, 122(1), 176–185.
    3. Practice Committee of the American Society for Reproductive Medicine (PC-ASRM). (2008). Current evaluation of amenorrhea. Fertility and Sterility, 90, S219–225. Retrieved May 31, 2016, from http://www.asrm.org/uploadedFiles/ASRM_Content/News_and_Publications/Practice_Guidelines
      /Educational_Bulletins/Current_evaluation(1).pdf
      external link (PDF 146 KB)
    4. Visser, J., de Jong, F. H., Laven, J., & Themmen, A. (2006). Anti-Mullerian hormone: A new marker for ovarian function. Reproduction, 139, 1–9. Retrieved May 31, 2016, from http://www.reproduction-online.org/content/131/1/1.long external link
    5. NIH. (2008). NIH research plan on Fragile X syndrome and associated disorders. Retrieved May 31, 2016, from http://www.nichd.nih.gov/publications/pubs/Documents
      /NIH_Research_Plan_on_Fragile_X_and_Assoc_Disorders-06-2009.pdf
       (PDF 439 KB)
    6. Warren, M. P., & Fried, J. L. (2001). Hypothalamic amenorrhea. The effects of environmental stresses on the reproductive system: A central effect of the central nervous system. Endocrinology & Metabolism Clinics of North America, 30, 611−629. Retrieved May 31, 2016, from http://www.ncbi.nlm.nih.gov/pubmed/11571933 external link

What are the treatments for amenorrhea?

The treatment for amenorrhea depends on the underlying cause, as well as the health status and goals of the individual.

If primary or secondary amenorrhea is caused by lifestyle factors, your health care provider may suggest changes in the areas below:

  • Weight. Being overweight or severely underweight can affect your menstrual cycle. Attaining and maintaining a healthy weight often helps balance hormone levels and restore your menstrual cycle.
  • Stress. Assess the areas of stress in your life and reduce the things that are causing stress. If you can't decrease stress on your own, ask for help from family, friends, your health care provider, or a professional listener such as a counselor.
  • Level of physical activity. You may need to change or adjust your physical activity level to help restart your menstrual cycle. Talk to your health care provider and your coach or trainer about how to train in a way that maintains your health and menstrual cycles.

Be aware of changes in your menstrual cycle and check with your health care provider if you have concerns. Keep a record of when your periods occur. Note the date your period starts, how long it lasts, and any problems you experience. The first day of bleeding is considered the first day of your menstrual cycle.

For primary amenorrhea, depending on your age and the results of the ovary function test, health care providers may recommend watchful waiting. If an ovary function test shows low follicle-stimulating hormone (FSH) or luteinizing hormone (LH) levels, menstruation may just be delayed. In females with a family history of delayed menstruation, this kind of delay is common.1

Primary amenorrhea caused by chromosomal or genetic problems may require surgery. Women with a genetic condition called 46, XY gonadal dysgenesis have one X and one Y chromosome, but their ovaries do not develop normally. This condition increases the risk for cancer developing in the ovaries. The gonads (ovaries) are often removed through laparoscopic surgery to prevent or reduce the risk of cancer.2

Treatment for secondary amenorrhea, depending on the cause, may include medical or surgical treatments or a combination of the two.

Citations

    1. Master-Hunter, T., & Heiman, D. L. (2006). Amenorrhea: Evaluation and treatment. American Family Physician, 73, 1374–1382. Retrieved May 31, 2016, from http://www.aafp.org/afp/2006/0415/p1374.html external link
    2. Verkauskas, G., Macianskyte, D., Janciauskas, D., Preiksa, R. T., Verkauskiene, R., & Jaubert, F. (2009). Diagnosis and management of 46,XY mixed gonadal dysgenesis and disorder of sexual differentiation. Medicina,45(5), 357–364. Retrieved May 31, 2016, from http://www.ncbi.nlm.nih.gov/pubmed/19535881
    3. American College of Obstetricians and Gynecologists (ACOG) Committee on Practice Bulletins—Gynecology. (2013). Practice bulletin no. 136: Management of abnormal uterine bleeding associated with ovulatory dysfunction. Obstetrics and Gynecology, 122(1), 176–185.
    4. Practice Committee of the American Society for Reproductive Medicine (PC-ASRM). (2006). Effectiveness and treatment for unexplained infertility. Fertility and Sterility, 86(suppl 4), S111–S114. Retrieved November 22, 2016, from https://www.asrm.org/uploadedFiles/ASRM_Content/News_and_Publications/
      Practice_Guidelines/Educational_Bulletins/effectiveness_and_treatment_for_unexplained
      _infertility(1).pdf
      external link (PDF 102 KB)
    5. NIH. (2010, April). Most young women with menopause-like condition retain store of eggs. Retrieved May 31, 2016, from http://www.nih.gov/news/health/apr2010/nichd-26.htm
    6. Rebar, R. W. (2009). Premature ovarian failure. Obstetrics and Gynecology, 113(6), 1355–1363.
    7. ACOG. (2016). Dilation and curettage. Retrieved May 31, 2016, from http://www.acog.org/~/media/For%20Patients/faq062.pdf?dmc=1&ts=20120606T1418144478 external link (PDF 69 KB)
    8. Gambadauro, P., Gudmundsson, J., & Torrejon, R. (2012). Intrauterine adhesions following conservative treatment of uterine fibroids. Obstetrics and Gynecology International,2012, 1–6. Retrieved May 31, 2016, from http://www.hindawi.com/journals/ogi/2012/853269/ external link

NICHD Amenorrhea Research Goals

NICHD's research efforts related to amenorrhea address its underlying causes and recognize it as an important indicator of women's health. NICHD-supported research focuses on amenorrhea within the context of investigating ovarian function in conditions such as Fragile X-associated primary ovarian insufficiency (FXPOI) and polycystic ovary syndrome (PCOS), as well as infertility.

NICHD research on amenorrhea includes (but is not limited to):

  • Genetics of puberty. NICHD-supported studies on genetic mutations examine how mutations disrupt puberty and affect fertility.1
  • Role of gonadotropin-releasing hormone (GnRH) deficiency in amenorrhea. Researchers are studying the genetic basis of functional hypothalamic amenorrhea to understand if this reversible deficiency, commonly triggered by excessive exercise, nutritional deficits, or stress, is genetically induced.2
  • Impact of, treatment therapies for, and role of FMR1 premutation in FXPOI and ovarian function.3 Research goals related to amenorrhea and ovarian function include:
    • Understanding the role of the FMR1 repeat expansion in ovarian function and reproductive aging
    • Establishing longitudinal studies examining the course of FXPOI from menstrual irregularities to associated symptoms such as estrogen deficiency and consequent osteoporosis, and cardiovascular risk
    • Determining the symptoms that may trigger an FMR1diagnostic test
    • Raising awareness of amenorrhea as an important symptom for conditions such as FXPOI, PCOS, and infertility
  • Effects of gynecologic disorders such as PCOS on fertility rates and the prevention of infertility from these disorders. NICHD research is seeking to understand how these disorders may affect the choice of infertility treatments.3

Citations

    1. Caronia, L. M., Martin, C., Welt, C. K., Sykiotis, G. P., Quinton, R., Thambundit, A., et al. (2011). A genetic basis for functional hypothalamic amenorrhea. New England Journal of Medicine, 364, 215−225. Retrieved May 31, 2016, from http://www.nejm.org/doi/full/10.1056/NEJMoa0911064#t=articleTop external link
    2. NICHD. (2001). Reproductive Health for the 21st Century. Retrieved May 31, 2016, from http://www.nichd.nih.gov/publications/pubs/Documents/Reproductive_Health.pdf (PDF 4.75 MB)
    3. NIH. (2008). NIH research plan on fragile X symptoms and related disorders. Retrieved May 31, 2016, from http://www.nichd.nih.gov/publications/pubs/Documents/NIH_Research_Plan_on_Fragile_X_and_Assoc_Disorders-06-2009.pdf (PDF 439 KB)

Amenorrhea Research Activities and Advances

Through its intramural and extramural organizational units, NICHD supports and conducts a broad range of research projects on amenorrhea and conditions for which amenorrhea is a symptom. Short descriptions of this research are included below.

Citations

  1. Sjaarda, L. A., Mumford, S. L., Kissell, K., Schliep, K. C., Hammoud, A. O., Perkins, N. J., et al. (2014). Increased androgen, anti-Müllerian hormone, and sporadic anovulation in healthy, eumenorrheic women: a mild PCOS-like phenotype? Journal of Clinical Endocrinology and Metabolism, 99(6), 2208–2216. Retrieved November 7, 2016, from https://www.ncbi.nlm.nih.gov/pubmed/24606085
  2. Mumford, S. L., Schisterman, E. F., Siega-Riz, A. M., Gaskins, A. J., Steiner, A. Z., Daniels, J. L., et al. (2011). Cholesterol, endocrine and metabolic disturbances in sporadic anovulatory women with regular menstruation. Human Reproduction, 26(2), 423–430. Retrieved November 7, 2016, from https://www.ncbi.nlm.nih.gov/pubmed/21115506
  3. Hambridge, H. L., Mumford, S. L., Mattison, D. R., Ye, A., Pollack, A. Z., Bloom, M. S., et al. (2013). The influence of sporadic anovulation on hormone levels in ovulatory cycles. Human Reproduction, 28(6), 1687–1694. Retrieved November 7, 2016, from https://www.ncbi.nlm.nih.gov/pubmed/23589536
top of pageBACK TO TOP