No Period But Not Pregnant: Secondary Amenorrhea

I'm 18 years old and menstruation has been fairly normal for me for the last 6 years or so. My problem is that I haven't had my period for the last 5 months. I'm not sexually active, so I know I cannot be pregnant. I've had no problems until now, and I've never visited a gynecologist.

Amenorrhea: The Clinical Term for Lack of Menstruation
Lack of a menstrual period is called amenorrhea. When this occurs in a woman who has never had a period it is called primary amenorrhea. In cases like yours, where there has been cycles in the past, it can be called secondary amenorrhea.

Of course, not every missed period warrants a clinical diagnosis and evaluation. Most physicians will consider missed periods a potential problem after 6 months, in a woman who has had regular cycles before. If a woman was irregular before, than twelve months is the usual timeframe.

Possible Cause of Secondary Amenorrhea
Benign Causes
The most common cause is pregnancy. It is also common at both ends of woman's menstrual history--in early adolescence and just before menopause.

Hormonal Causes
In order to menstruate, hormones must pass from a gland called the hypothalamus to the pituitary, to the ovaries. This chain of hormonal events must also stimulate the lining of the uterus, called the endometrium. If there is any breakdown of the normal chain of events, there will be secondary amenorrhea.

Hypothalamic Problems
All of these factors listed below lead to the lack of normal stimulation of the hypothalamus. Thus, the chain fails to get started in the first place. Returning to normal body weight, removing the offending drugs, or reducing stress, usually solves the problem.

  • Anorexia Nervosa
  • Simple Weight Loss
  • Anxiety Reactions
  • Marijuana Use
  • Medications -- tricyclic antidepressants and phenothiazines
Pituitary Problems
There are several different reasons for pituitary failure, which in turn, leads to secondary amenorrhea.
  • Simmond's disease--when the pituitary fails for without any particular cause (idiopathic).
  • Sheehan's syndrome--when the pituitary is damaged from massive bleeding caused by stresses of childbirth.
  • Microadenomas--tumors that interfere with the function of the pituitary.

Other Causes
Polycystic Ovarian Disease
This is the most common cause of secondary amenorrhea. Women with this problem do not ovulate, and are thus infertile. They tend to show signs of excess testosterone, as well as excess estrogen. They are often obese, but this can occur in normal weight women as well.

Signs and Symptoms: Large Breasts, excess cervical mucous, acne, male pattern hair growth (face, lower abdomen, thighs and chest), and heavy vaginal bleeding.

Premature Ovarian Failure (Early Menopause)
This is often suspected by women themselves, but actually quite rare.

Signs and Symptoms: Hot flashes, breast atrophy, decreased sex drive, and vaginal dryness.

Secondary Amenorrhea is a symptom, not a disease in and of itself. In order to determine which of many causes is responsible, your doctor will start with a history. She will review any other symptoms you have, and relevant medical history. She will examine you for signs of bodily changes that occur with the various causes. If indicated, she will order tests to measure your hormone levels. If the problem is suspected as being at the level of the endometrium (lining of the uterus), then progestins will be given and then stopped to evaluate it. This is called a Progestin Withdrawal test.

Treatment will be tailored to the cause. It will focus on eliminating causative agents, be they lifestyle, tumor, or medications. Alternatively, it will focus on replacing inadequate hormone production at the appropriate level.

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