During the fertile period of a woman's life it can happen that every now and then menstruation is delayed or skipped altogether. But when your period doesn't just appear for several months in a row, then it means that something is not working in the right way and it is advisable to consult a specialist, also to avoid compromising fertility.
If we exclude physiological conditions such as pregnancy, lactation and menopause, the lack of menstruation in a woman or girl who has already had other menstrual cycles it is called amenorrhea, more precisely secondary amenorrhea. The reasons that can lead to an absence of menstruation for several months can be many, including eating disorders, very stressful periods for the woman, but also pathologies such as polycystic ovary syndrome. Above all for those looking for a child this condition could be very frustrating indeed. Let's try to answer the most common doubts with the help of Prof. Lorenza Driul, Director of the Obstetrics and Gynecological Clinic of the Integrated University Health Unit of Udine.
In this article
- primary and secondary amenorrhea: what are they?
- amenorrhea is a symptom
- the diagnosis of secondary amenorrhea
- the causes of secondary amenorrhea
- if the diet is unbalanced
- beware of excessive physical activity
- stress can also cause amenorrhea
- amenorrhea and polycystic ovary syndrome
- amenorrhea: the wake-up call of early menopause
- oncological problems and infertility
- the other possible causes of amenorrhea
- the treatment of amenorrhea
- amenorrhea and pregnancy: is it possible to get pregnant?
- the prevention of amenorrhea
Primary and secondary amenorrhea: what are they?
Let's make a first distinction between primary and secondary amenorrhea.
'L'primary amenorrhea - explains Dr. Driul - is the non-appearance of the menarche, that is the first menstruation, after the age of 16. "Primary amenorrhea, a very rare condition, is generally due to congenital malformations or genetic anomalies. Between main causes in fact we find:
- malformation of the uterus or vagina;
- pituitary or hypothalamic tumor;
- Turner syndrome;
- or imperforato;
- Müllerian agenesis.
'L'secondary amenorrhea, on the other hand, it can occur in women who have already had other regular menstrual cycles previously and is characterized by the disappearance of menstruation due to more than 6 months".
So what to do if menstruation skips for too many months?Read also: What to do if the girl misses her period
Amenorrhea is a symptom
When menstruation skips for shorter or longer periods, unless it is a pregnancy, our body is telling us that something is not working right. As we will see shortly, the causes can be many, but it is important to understand that amenorrhea is primarily a symptom. "We have to remember that amenorrhea is a symptom, a clinical sign that should not be underestimated, which is why it is essential to try to understand the cause, so as to correctly set any therapy ".
If menstruation skips for more than six months, it is therefore necessary to talk to your doctor or gynecologist who will assess the situation and try to understand what causes the amenorrhea.
The diagnosis of secondary amenorrhea
What should the doctor or gynecologist do to understand the causes of amenorrhea? The first fundamental step, as Dr. Driul reports, is anamnesis.
"First of all we start from the anamnesis and then from the collection of the patient's clinical history. Very often, in fact, secondary amenorrhea can be linked to physical or mental stress, But also to major nutritional deficits, both in excess and in defect. When dealing with a patient with amenorrhea, the key aspect is to start with her medical history and from the patient's story itself, after which the gynecologist's role is to investigate the cause of this symptom through the visit, ultrasound and hormonal dosages ".
A careful and accurate medical history must consider:
- family and personal history to understand if you are familiar with some pathologies;
- the characteristics of previous menstrual cycles and the date of the last menstruation;
- taking medications;
- daily habits such as nutrition and physical activity;
- previous chemotherapy or radiation therapy;
- recent changes in body weight;
- symptoms of reduced estrogen production such as night sweats.
Once the medical history has been taken, the doctor will evaluate the presence of clinical signs concerning hyperandrogenism, hyperprolactinaemia and estrogenisation. Through the trans-vaginal or trans-abdominal ultrasound it will then be possible to have one complete view of the reproductive system in order to exclude malformative or genetic causes.
The causes of secondary amenorrhea
Once all the necessary checks it will therefore be possible to understand what "does not work" correctly. Menstruation, in fact, is the final result of a series of phenomena that require the normal functioning of the hypothalamic-pituitary axis, of the uterus and of the ovary. In case of alterations at the level of one of these sites it can occur a break in menstruation.
If we exclude pregnancy and breastfeeding, the most common causes when menstruation skips for more than six months they are:
- malfunction ofhypothalamus, in turn caused by stress, excessive exercise, eating disorders, radiotherapy, chemotherapy;
- malfunction ofpituitary gland, linked for example to an excess of prolactin production;
- malfunction of the thyroid, in case of hypothyroidism or hyperthyroidism;
- polycystic ovary syndrome;
- premature menopause;
- use of drugs such as birth control pills or antidepressants.
If the diet is unbalanced
The importance of diet, understood as diet, should never be underestimated when it comes to problems related to the menstrual cycle. "Eating disorders have different nuances and one of the first signs we notice is precisely that of amenorrhea. Malnutrition, weight loss, excess weight, but also unbalanced diets or unmotivated fasting can cause menstruation to be missed for even long periods of time "specifies Dr. Driul.
When a woman loses a lot of weight, for example, your body goes into a sort of "energy saving" and begins to reduce the amount of hormones involved in the functioning of the menstrual cycle. This type of mechanism can also have repercussions on the fertility of the woman, for this reason first the menstrual cycle is restored and the higher the possibility for a woman to be fertile and therefore to be able to face a pregnancy. Once the weight and nutrition return to normal, with a little patience, the menstrual cycle also returns to normal.
Beware of excessive physical activity
Sometimes eating disorders can also occur accompanied by avery intense physical activity which can cause amenorrhea.
Likewise, so too sport at a competitive level it can affect the menstrual cycle by making it irregular or blocking it altogether. "This is an aspect that I would like to underline - explains Dr. Driul - especially for younger women who maybe play competitive sports. Be careful because an excess of physical activity can lead to amenorrhea and it is absolutely not a thing to be underestimated".
Stress can also cause amenorrhea
Also the psycho-emotional stress Due to a particularly difficult moment in a woman's life or excessively heavy lifestyles can cause the menstrual cycle to become blocked. In this case we speak of stress hypothalamic amenorrhea and it is due to a dysfunction of the hypothalamus, just as it happens for excessive physical activity or eating disorders.
The absence of menstruation should be interpreted as one adaptive response of the female body to excessive stress and to solve it it is necessary, as Dr. Driul says, "to find the right balance in everyday life between work commitments and the right rest".
Amenorrhea and polycystic ovary syndrome
Among the most common causes when it comes to amenorrhea we also find polycystic ovary syndrome. This syndrome affects on average 10% of the female population it can lead to irregular menstruation, moderate obesity and hirsutism.
If the doctor or gynecologist suspects that the cause of the amenorrhea is precisely the polycystic ovary, for confirm the hypothesis it will be necessary:
- analyze the clinical history of the woman;
- evaluate the presence of visible clinical signs of hyperandrogenism such as acne or distribution of hair in areas where they are generally not present in women;
- perform a trans vaginal or trans abdominal ultrasound.
Amenorrhea: the wake-up call of early menopause
If menstruation stops occurring for a few months, it could also be the wake-up call of premature menopause (or premature ovarian failure), a bad event for all those women who wish to have a child. "A premature menopause can be spontaneous, or it can unfortunately be caused by the effects of chemotherapy and radiotherapy linked to oncological problems," explains Driul.
In Del Paese it is estimated that approx 1 in 100 women experience premature ovarian failure which could erase any hope of becoming pregnant. The causes they can be genetic, dysmetabolic, endocrinological or linked to autoimmune diseases. THE symptoms with which it manifests itself, in addition to the absence of menstruation, are subjective but among the most common we find:
- hot flashes;
- night sweats;
- lack of concentration;
In women with early menopause, that is before the age of 40, there are rarely effective treatments to restore fertility. If early ovarian failure is diagnosed in time, therapy could be attempted induction of ovulation, although unfortunately satisfactory results are achieved in less than 10% of cases.Read also: Menopause and early menopause
Oncological problems and amenorrhea
As regards instead the anticancer therapies such as chemo and radiotherapy, unfortunately these are interventions that irreversibly damage the egg cells contained in the ovary, thus causing a early menopause. "Nowadays, however - explains Dr. Driul - we have the possibility to think of one cryopreservation of oocytes to allow these women, once the disease is over, to be able to face a pregnancy. A very important possibility for all women who want a child ".
Other possible causes of secondary amenorrhea
As we have seen so far, the causes of amenorrhea can be very many. In addition to those listed so far, amenorrhea can also be linked to the secretion of a hormone called prolactin. "If the doctor suspects that the amenorrhea is caused by an overproduction of prolactin (hyperprolactinaemia), then he will prescribeblood chemistry tests. In cases of hyperprolactinemia, the woman is usually recommended a therapy that regulates the release of prolactin ".
Other times, however, the cause of amenorrhea is a thyroid malfunction, whether it is hypothyroidism or hyperthyroidism. In this case, the patient's evaluation must also be done with the support from an endocrinologist.
"What needs to be clear is that amenorrhea is just the tip of the iceberg"reiterates Dr. Driul." You always have to go to the bottom and understand what the real problem is. For those looking for a child, but also for all other women, it is necessary to go to find the causes of amenorrhea because in front of this clinical sign the reasons can be really many and for return the cycle to regular it takes time. Once the causes of amenorrhea have been identified, the therapeutic possibilities are different ".Read also: High prolactin, how to cure it
Treatment of amenorrhea
Precisely because there are many possible causes of secondary amenorrhea, there is no one-size-fits-all therapy. Treatment of amenorrhea depends on the cause which led to the development of this condition.
For example, in the case of eating disorders, excessive physical activity or psycho-emotional stress, treatment will certainly include the support of a psychologist or psychotherapist as also suggested by the Endocrine Society's Guidelines on Hypothalamic Amenorrhea.
"Over the years, the behavior of us doctors towards amenorrhea, especially when linked to eating disorders and behavioral problems, has changed a lot", says Dr. Driul. "Once we tended to recommend, in agreement with fellow psychiatrists, the birth control pill, but then we realized that it wasn't the best solution, or at least it wasn't the only possible therapy ".
Taking the pill and the subsequent appearance of a pseudo menstruation they can in fact give to the woman an illusion of normality which however does not help to get out of the problem. The right psychological support, on the other hand, is the most effective solution. "Today we try to go straight to the real problem. Of course, more time is needed for recovery because it is not an immediate thing, but in this way we are going to intervene precisely on the cause of the amenorrhea and when the menstrual cycle finally returns it is a sign of victory and balance "explains the Dr. Driul.
If the amenorrhea was caused by the polycystic ovary syndrome one can intervene with drug therapy associated with a balanced diet and physical activity.
In short, as Dr. Driul says "the therapy to resolve the amenorrhea must be" weighed "on the patient, there is no one-size-fits-all cure give it".
Amenorrhea and pregnancy: is it possible to get pregnant?
The presence of amenorrhea it is not always an indication of infertility, although conception can be more complex and frustrating for the woman. If you have amenorrhea and want to have a baby, you must first understand what caused the amenorrhea.
Eating disorders, excessive physical activity, stress
The presence of amenorrhea does not always indicate infertility, although conception can be more complex and frustrating for the woman. If you have amenorrhea and want to have a baby, you must first understand what caused the amenorrhea.
Polycystic ovary syndrome and thyroid disease
If the amenorrhea instead derives from polycystic ovary syndrome or thyroid disease, getting pregnant can be much more complicated and it is therefore necessary for the woman to undergo regular checks and follow the therapy proposed by the doctor.
Thanks to the treatment for the regulation of prolactin, the woman can easily face a pregnancy if she wishes.
If a woman suffers from premature menopause it is very difficult to get pregnant because this type of menopause is exactly the same as the classic menopause that occurs around the age of 50. Sometimes, however, there have been recoveries of ovarian function, albeit transitory, with the possibility of pregnancy. If early ovarian failure is diagnosed in time, you can go to a center that specializes in fertility problems and consider whether it is possible to start ovulation induction therapy to try to get pregnant.Read also: Why Can't I Get Pregnant? All the answers
The prevention of amenorrhea
Amenorrhea can only be prevented if the triggers can be controlled and thus avoided, as in the case of:
- food disorders;
- excessive physical activity;
"To prevent amenorrhea - explains Dr. Driul - it is important to pay attention tonutrition and lifestyle always trying to maintain a body mass adequate for the proper functioning of our body and the hormones involved in the menstrual cycle. Last but not least, one is needed stress reduction".
Sources used for the article:
- Advice from Dr. Lorenza Driul, Director of the School of Specialization in Gynecology at the University of Udine
- Endocrine Society, Hypothalamic Amenorrhea Guideline Resources, 2022