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Absent Periods (Amenorrhea)
- The uterus
is a pear-shaped organ located between the bladder and lower
intestine. It consists of two parts, the body and the cervix.
- When a
woman is not pregnant the body of the uterus is
about the size of a fist, with its walls collapsed and flattened
against each other. During pregnancy the walls of the uterus
are pushed apart as the fetus grows.
- The cervix
is the lower third of the uterus. It has a canal opening into
the vagina with an opening called the os, which
allows menstrual blood to flow out of the uterus into the vagina.
off each side of the body of the uterus are two tubes known
as the fallopian tubes . Near the end of each
tube is an ovary.
are egg-producing organs that hold between 200,000 and 400,000
follicles (from folliculus, meaning "sack" in
Latin); these cellular sacks contain the materials needed to
produce ripened eggs, or ova.
- The inner
lining of the uterus is called the endometrium,
and during pregnancy it thickens and becomes enriched with blood
vessels to house and support the growing fetus. If pregnancy
does not occur, the endometrium is shed as part of the menstrual
flow. Menstrual flow also consists of blood and mucus from the
cervix and vagina.
The hypothalamus (an area in the brain) and the pituitary
gland regulate the reproductive hormones. The pituitary
gland is often referred to as the master gland because of its important
role in many vital functions, many of which require hormones. In
women, six key hormones serve as chemical messengers that regulate
the reproductive system.
- The hypothalamus
first releases the gonadotropin-releasing hormone (GnRH)
- This chemical,
in turn, stimulates the pituitary gland to produce follicle-stimulating
hormone (FSH ) and luteinizing hormone (LH) .
progesterone, and testosterone are
secreted by the ovaries at the command of FSH and LH and complete
the hormonal group necessary for reproductive health.
Processes Leading to Menstruation
cycle reflects the changes that occur in the endometrium, the inner
lining of the uterus. Layers of the endometrium are shed at the
end of the cycle as part of menstrual flow. The menstrual cycle
is generally divided into phases:
For a clear picture
of the process it is important to understand how to count days in
a menstrual cycle. Day one is generally considered to be the first
day of bleeding.
- the follicular
- the luteal
(or secretory) phase.
Follicular Phase . The follicular phase includes menstrual
bleeding followed by proliferation (growth and thickening)
of the endometrium. It usually lasts from day one to day 14. The
following processes occur during this time:
The surge of LH at the end of the follicular phase triggers ovulation
by causing the largest follicle to burst and release its egg into
one of the two fallopian tubes. At ovulation (usually day 14 in
a 28-day cycle), the proliferative stage ends and the luteal (secretory)
- The menstrual
flow itself lasts an average of six days. Estrogen and progesterone
levels are at their lowest during this time.
- At the
end of the menstrual flow, the proliferative phase begins, and
the endometrium starts to grow and thicken. FSH levels rise
and stimulate several ovarian follicles to mature over a two-week
period until their eggs nearly triple in size. During this period,
FSH also signals the ovaries to produce estrogen, which, in
turn, stimulates a great surge of LH around day 14.
Luteal (Secretory) Phase or Premenstrual Period. The luteal
(secretory) phase lasts about 14 days. This is also commonly known
as the premenstrual period . The following processes
occur during this time:
- Once ovulation
has occurred, LH causes the ruptured follicle to develop into
the corpus luteum, a mound of yellow tissue that produces progesterone.
together, progesterone and estrogen stimulate the tissue lining
the uterus to prepare a thick blanket of blood vessels where
a fertilized egg can attach and develop. If an egg is fertilized,
this blood-vessel blanket supplies nutrients for the developing
- The corpus
luteum continues to produce progesterone and estrogen.
- When fertilization
does not occur, the corpus luteum degenerates to a form called
the corpus albicans (Latin for "white body"), and estrogen and
progesterone levels drop.
the endometrial lining sloughs off and is shed during menstruation.
No. of Days
Follicular (Proliferative) Phase
Days 1 through 6: Beginning of menstruation to end of blood
Estrogen and progesterone start out at their lowest levels.
FSH levels rise to stimulate maturity of follicles. Ovaries
start producing estrogen and levels rise, while progesterone
Days 7 - 13: The endometrium (the inner portion or lining
of the uterus) thickens to prepare for the egg implantation.
Surge in LH. Largest follicle bursts and releases egg into
Luteal (Secretory) Phase, also known as the Premenstrual Phase
Days 15 - 28:
Ruptured follicle develops into corpus luteum, which produces
progesterone. Progesterone and estrogen stimulate blanket
of blood vessels to prepare for egg implantation.
...If fertilization occurs:
Fertilized egg attaches to blanket of blood vessels which
supplies nutrients for the developing pregnancy. Corpus luteum
continues to produce estrogen and progesterone.
...If fertilization does not occur:
Corpus luteum deteriorates. Estrogen and progesterone levels
drop. The blood vessel lining sloughs off and menstruation
Stages and Features of Menstruation
Onset of Menstruation
(Menarche). The onset of menstruation, called the menarche,
usually occurs at age 12 or 13. One study, however, has indicated
that girls may be starting puberty earlier than in the past. By
the age of eight, 48% of African-American girls and 15% of white
girls were showing pubic hair and developing breast buds. It had
previously been thought that only 1% of girls exhibited such changes
at that age. Alternatively, a study done in England found that the
average age for the onset of menstruation has changed very little
since the 1950s, with the median age being 13 years.
Researchers are looking for reasons for this trend toward earlier
menstruation. Being overweight is a risk factor for early puberty,
and the increasing incidence of childhood obesity in the US may
play a role. Some experts believe, however, that environmental estrogens
found in chemicals and pesticides are major suspects. (Of concern
in this regard are hair products that contain estrogens, which are
being used by some young girls.)
Length of Monthly Cycle. The menstrual cycle can be very
irregular for the first one or two years, usually being longer than
the average of 28 days. It then typically stabilizes to 28 days
until a woman reaches her 40s when the cycle lengthens, reaching
an average of 31 days by age 49. A number of other factors can also
affect cycle length. [ See Table .] In fact, the cycle may
range from 20 to 40 days and still be considered normal, but a variation
of 10 days or more, either more or fewer days, may have an impact
Factors for Shorter Cycles
Factors for Longer Cycles
Regular alcohol use.
Being under 21 and over 44.
Being very thin (also at risk for short bleeding periods).
Competitive athletics (also at risk for short bleeding periods).
Lower socioeconomic groups.
Length of Periods. Periods average 6.6 days in young girls.
By the age of 21, menstrual bleeding averages six days until women
approach menopause. It should be noted, however, that about 5% of
healthy women menstruate less than four days and 5% menstruate more
than eight days. Thin women, particularly those who smoke, tend
to have longer bleeding periods, while athletes tend to have shorter
ones. Women who use oral or injected contraceptives generally have
Normal Absence of Menstruation. Normal absence of periods
can occur in any woman under the following circumstances:
stops during the duration of pregnancy. Some women continue
to have irregular bleeding during the first trimester. This
bleeding may indicate a threatened miscarriage and requires
immediate attention by the physician.
- When women
breast feed they are unlikely to ovulate during the first eight
weeks after delivery. After that time, menstruation usually
resumes and they are fertile again.
starts when the intervals between periods begin to lengthen,
and it ends with menopause itself (the complete cessation of
menstruation). Menopause usually occurs at about age 51, although
smokers often go through menopause earlier.
ARE AMENORRHEA AND OTHER MENSTRUAL DISORDERS?
(Absence of Menstruation)
is the absence of menstruation. There are two categories: primary
amenorrhea and secondary amenorrhea. Such terms are used
only to describe the timing of menstrual cessation; they do not
indicate any cause or suggest any other information.
amenorrhea occurs when a girl does not even start to menstruate.
Girls who show no signs of sexual development (breast development
and pubic hair) by age 14 should be evaluated. Girls who do
not have their periods by two years after sexual development
should also be checked. Any girl who does not have her period
by age 16 should be evaluated for primary amenorrhea.
amenorrhea is a condition in which periods that were previously
regular become absent for at least three cycles.
(Light or Infrequent Menstruation). Oligomenorrhea is a condition
in which menstrual cycles are infrequent. It is very common in early
puberty and not usually worrisome. When girls first menstruate they
often do not have regular cycles for a couple of years. Even healthy
cycles in adult women can vary by a few days from month to month.
In some women, periods may occur every three weeks and in others,
every five weeks. Flow also varies and can be heavy or light. Skipping
a period and then having a heavy flow may occur; this is most likely
due to missed ovulation rather than a miscarriage. Women should
be concerned when periods come less than 21 days or more than 2
to 3 months apart, or if they last more than eight to ten days.
Such events may indicate ovulation problems.
Menorrhagia (Heavy Bleeding). During normal menstruation
women lose about 1 1/2 ounces (60 ml) of blood or less. If bleeding
is significantly heavier, it is called menorrhagia, which
occurs in 9% to 14% of all women and can be caused by a number of
factors. Women often over estimate the amount of blood lost during
their periods. However, women should consult their physician if
one or both of the following occurs:
periods or during pregnancy also warrants a visit to the doctor.
(Spotting or light bleeding between periods is common in girls just
starting menstruation and sometimes during ovulation in young adult
women, but consultation with a physician is nevertheless recommended.)
changing pads or tampons more frequently than every hour or
so. (Clot formation is fairly common during heavy bleeding and
is not a cause for concern.)
regularly last more than eight to ten days.
Dysmenorrhea (Severe Menstrual Cramps). Uterine contractions
occur during all periods, but in some women these cramps can be
frequent and very intense. In such cases the condition is known
as dysmenorrhea. It can be primary or secondary.
Up to 80% of
all women report some symptoms related to fluctuating hormone levels
as menstruation approaches. For about half of these women, symptoms
are mild and do not affect normal daily life. The other half report
symptoms severe enough to impair daily life and relationships.
dysmenorrhea is caused by normal uterine muscle contractions
and affects more than half of menstruating women. It usually
starts two to three years after the periods have started. The
pain usually develops when the bleeding starts and continues
for 32 to 48 hours.
dysmenorrhea is menstrually related pain that is caused by other
medical conditions, usually endometriosis or pelvic abnormalities.
[For more Information see the Report #100,
Premenstrual Syndrome. In general premenstrual syndrome (PMS)
is a set of physical, emotional, and behavioral symptoms that occur
during the last week of the luteal phase (a week before menstruation)
in most cycles. The symptoms should typically resolve within four
days after bleeding starts and not start until at least day 13 in
the cycle. Women may begin to experience premenstrual syndrome symptoms
at any time during their reproductive years. Once established, the
symptoms tend to remain fairly constant until menopause, although
they can vary from cycle to cycle. About 100 symptoms have been
identified with the premenstrual phase. [For more details,
79, Premenstrual Syndrome .]
The most common
cause of primary amenorrhea is delayed puberty due to some genetic
factor that delays physical development. Being short is the most
common sign of this, although sometimes a family history of delayed
menstruation can indicate this situation. Time usually resolves
Hypothalamic Amenorrhea (FHA) and Eating Disorders
amenorrhea (FHA) is the absence of menstruation due to disturbances
in the thyroid gland and hypothalamus-pituitary-adrenal (HPA) system.
FHA may be due to different factors, most unknown. The hypothalamus
and the pituitary gland regulate the reproductive hormones. It triggers
the production and release of steroid hormones ( glucocorticoids),
including the primary stress hormone cortisol. The HPA system
manages appetite and mood as well.
Anorexia and Bulimia. The eating disorders anorexia and bulimia
may be a primary factor in many cases of FHA. Both weight loss and
changes of appetite may cause hormonal abnormalities. Such changes
may be due to a primitive protective biologic mechanism, which was
designed to prevent potentially harmful pregnancies during times
Triad. A syndrome known as the female athlete triad is associated
with hormonal changes that occur with eating disorders. It comprises
anorexia, amenorrhea, and osteoporosis (decrease in bone density)
in young women who excessively exercise. One 2001 study suggested
that repeated exercise modifies the hormonal responses to both activity
and rest and may interfere with cyclic variations in reproductive
hormones, particularly luteinizing hormone (LH). (LH inturn triggers
changes to extreme weight loss and reduced fat stores include
low thyroid levels (hypothyroidism) and excessive stress hormone
levels (hypercortisolism), which in turn reduce reproductive
hormones. Reducing stress hormones, in one study, helped elevate
reproductive hormones in women with FHA.
can occur in young women with eating disorders whose weights
are normal or above normal, indicating that factors other than
low fat stores are responsible for reproductive abnormalities.
Changes in appetite itself may have an effect on chemicals in
the hypothalamus. One such important chemical in this system
that may play a major role in FHA is leptin. Leptin is involved
with regulation of appetite and is released by fat cells. Levels
fall as less fat is stored in the cells. Low levels of leptin
appear to interfere with reproductive hormones, particularly
luteinizing hormone and so may contribute to amenorrhea.
Ovarian Syndrome (PCOS)
syndrome (PCOS) occurs in 6% of women and results in the ovarian
production of high amounts of androgens (male hormones), particularly
testosterone. It appears to be an important cause of many menstrual
disorders. Amenorrhea or oligomenorrhea (infrequent menses) are
quite common. In a 1998 study of teenagers with menstrual disorders,
24% of those with irregular cycles and 44% with oligomenorrhea had
In PCOS, increased androgen production produces high LH levels and
low FSH levels, so that follicles are prevented from producing a
mature egg. Without egg production, the follicles swell with fluid
and form into cysts. Every time an egg is trapped within the follicle,
another cyst forms, so the ovary swells, sometimes reaching the
size of a grapefruit. Without ovulation, progesterone is no longer
produced, whereas estrogen levels remain normal.
The elevated levels of androgens (hyperandrogenism) can cause obesity,
facial hair, and acne, although not all women with PCOS have such
symptoms. Other male characteristics, such as deepening voice and
clitoral enlargement, are rare.
Women with PCOS are also at higher risk for insulin resistance,
a condition associated with diabetes type 2, in which insulin levels
are normal or high but the body cannot use this hormone efficiently.
About half of PCOS patients, in fact, also have diabetes.
In most cases, the cause of PCOS is unknown.
Prolactin Levels (Hyperprolactinemia)
a hormone produced in the pituitary gland that stimulates breast
development and milk production in association with pregnancy. Prolactin
production also reduces gonadotropin hormones and inhibits ovulation.
High levels of prolactin (hyperprolactinemia) in women who are not
pregnant or nursing can also inhibit ovulation, thus causing amenorrhea.
It is the cause of between 10% and 40% of cases of secondary amenorrhea.
Secretions from the breast not related to pregnancy or nursing (called
galactorrhea) is a telltale symptom of high prolactin levels
and should be investigated.
Hyperprolactinemia can be caused by the following:
adenomas. (These are benign tumors that secrete prolactin. They
can cause headache and visual problems as well as breast secretions.)
- Some drugs,
including oral contraceptives and some antipsychotic drugs,
can also elevate levels of prolactin.
failure is caused by the early depletion of follicles before age
40. Levels of follicle stimulating hormone (FSH) are elevated above
normal in women under 40. (Elevated levels of FSH right before menopause
are normal.) A number of conditions may cause this including the
failure is a significant cause of infertility and women who have
this condition have only a 5% to 10% chance to conceive without
pituitary, or thyroid deficiencies.
- Low levels
of certain growth factors, called inhibins, that are produced
by the ovaries.
hypogonadism. This is a condition in which follicle-stimulating
hormone (FSH) is high but estrogen levels are low. The most
common example of this disorder is Turner's syndrome, in which
one of the two X-chromosomes is missing or malfunctioning.
treatments (radiation, chemotherapy, or both).
- Rare causes
include sarcoidosis, mumps, some sexually transmitted diseases,
In some cases, the immune system releases antibodies that attack
the cells that secrete reproductive hormones thus causing ovarian
failure. This condition, called autoimmune mediated hypogonadism,
most often occurs as part of a rare genetic disease called autoimmune
polyglandular syndrome (APS).
hypogonadism is a rare condition in which follicle-stimulating hormone
(FSH) and luteinizing hormone (LH) are underproduced and prevent
the development of functional ovaries. There are no other abnormalities
in hypothalamus-pituitary axis (such as tumors or abnormal stress
hormones or prolactin). In most cases, the causes of hypergonadotropic
hypogonadism are unknown. Genetic factors, including Kallmanns syndrome,
have been identified in about 20% of these cases.
either too much thyroid hormone (hyperthyroidism) or too little
(hypothyroidism), can interrupt cycles. Hypothyroidism can result
in excess prolactin (see above). Most women with hypothyroidism
fail to produce eggs, and they may receive a diagnosis of hypothyroidism
for the first time during a fertility evaluation.
Factors that May Cause or Contribute to Amenorrhea
and emotional stress may block the release of luteinizing hormone,
causing temporary amenorrhea.
Structural Abnormalities. Inborn genital tract abnormalities
may also cause primary amenorrhea. A specific malformation called
Mullerian agenesis, in which no vagina or uterus develops, is rare
but can cause primary amenorrhea. Ashermans syndrome, for example,
is scarring in the uterus that can cause obstructions and secondary
amenorrhea. It may be caused by surgery, repeated injury, or unknown
Obesity. Being extremely overweight is associated
with irregularity, possibly because some estrogen is produced in
fat cells, which may affect the cycle.
Medical Disorders that Cause Secondary Amenorrhea
to one small Indian study, iron deficiency anemia, which occurs
when the body lacks iron to produce red blood cells, may cause amenorrhea
in certain cases. In this study, most women with secondary amenorrhea
associated with LH, FSH, and prolactin abnormalities had moderate
to severe anemia from low iron in the diet. [For more information
on anemia, see the Report Anemia.]
Celiac Sprue. Celiac sprue is an inability to tolerate gluten,
a protein found in wheat, rye, oats, barley, and other grains. Exposure
to gluten damages the lining of the intestinal tract. It is also
associated with late puberty, early menopause, and amenorrhea. This
disorder is now considered more common than previously believed
and may even be linked to non-intestinal symptoms, such as depression,
discolored teeth, and neurologic problems.
Other Medications Conditions. Cushing's disease, which is
a disorder of the adrenal gland, can cause amenorrhea. Other medical
conditions associated with delayed puberty and amenorrhea include
Crohn's disease, sickle cell disease, HIV, kidney disease, and diabetes.
Slow growing tumors that affect the pituitary gland are also rare
causes of amenorrhea.
Normal Causes of Skipped or Irregular Periods
During adolescence, it may take a while for ovulation to occur
regularly. In some cases periods may even stop for several
Pregnancy. A woman should always check for pregnancy
if her period is unduly late, although any stressful situation,
including anxiety over the possibility of pregnancy, can delay
Breastfeeding. When women breastfeed after delivery,
menstruation usually stops. (Some nonmenstural bleeding or
spotting may occur during the time she is breastfeeding, usually
within two months after delivery.) Even while they are still
nursing, most breastfeeding mothers will resume menstruation
after six months. In general, the more intensively a baby
is breastfed, the later the onset of the mother's period.
Two or more consecutive days of bleeding are usually an indicator
that periods have returned. (It should be noted, however,
that ovulation, and therefore, fertility, can occur before
menstruation resumes, although it is less likely within six
months of delivery, particularly if the mother is intensively
Hormonal Contraception. Amenorrhea can occur from
hormonal contraceptives, particularly medroxyprogesterone
(Depo-Provera). Amenorrhea can occur even months after discontinuing
certain contraceptive methods, including oral contraceptive
pills (OCs), depo-medroxyprogesterone acetate (Depo-Provera),
and levonorgestrel (Norplant). (Women should always check
to be sure they aren't pregnant in such cases.)
Perimenopause. In women over 40 who are approaching menopause,
ovulation becomes irregular and may even stop for several
months and then start up again before ceasing completely at
SERIOUS IS AMENORRHEA?
that cause amenorrhea, such as ovulation abnormalities, are major
contributors to infertility. Irregular periods from any cause make
it more difficult to conceive.
with reduced estrogen levels increases the risk for osteoporosis
(loss of bone density). This is may be particularly dangerous from
amenorrhea that occurs in young female athletes and those with eating
disorders. Because bone growth is at its peak in adolescence and
young adulthood, losing bone density at that time is very dangerous,
and early diagnosis and treatment is essential for long-term health.
[For more information, see the Report Osteoporosis.]
of Conditions that Cause Secondary Amenorrhea
Many of the conditions
that cause amenorrhea have other serious complications. For example,
polycystic ovary syndrome is associated not only with infertility
but also with a higher risk for endometrial (uterine) cancer, heart
disease, and diabetes. Hypothyroidism, another common cause of amenorrhea,
carries serious physical and mental risks.
ARE MENSTRUAL DISORDERS DIAGNOSED?
A physician will
perform a pelvic examination to check for pregnancy or any structural
problems. Thinning or dryness of the vaginal tissue would suggest
low estrogen levels. The physician will check for excess hair growth
or enlarged clitoris, which may be signs of polycystic ovaries.
and Personal History
needs to have a complete history of any medical or personal conditions
that might be causing amenorrhea. Some experts believe that with
a good history, a physician can determine the cause in 85% of cases:
of pregnancy, abortion, or miscarriage.
- Any family
history of amenorrhea.
- Any other
unusual symptoms or the presence or history of any conditions
that might indicate a medical cause of amenorrhea.
- The pattern
- Any occurrence
of milky discharge from the breast.
- Any symptoms
such as hot flashes, a reduction in sexual drive, reduction
in breast tissue (which would suggest premature ovarian failure).
use of any medications.
of contraceptive use, including discontinuation. (Some women
do not regain regular periods for several months after stopping.)
- Any mental
or stressful events.
- Any history
of extreme exercise, extreme weight changes, or both.
of uterine surgery.
A pregnancy test
is, of course, the first test performed when a woman with normal
sexual development experiences a cessation of her period.
are often administered, such as the following:
Progestational Challenge Test. The progestational challenge
test uses oral or injected progesterone to test for a functional
uterine lining (endometrium):
Male Hormones. Tests that measure androgen (male hormone) levels
are useful if the patient shows male characteristics (acne or increased
hair growth) and the physician suspects polycystic ovaries.
that occurs up to three weeks after the progesterone dose suggests
that the woman has normal estrogen levels but is not ovulating,
particularly if thyroid and prolactin levels are normal. In
such cases, the physician should be sure to check for stress,
recent weight loss, and any medications. Such results could
also suggest polycystic ovaries or stress.
- A failure
to bleed could indicate an abnormal uterus that prevents outflow
or insufficient estrogen. In such cases, the next step may be
to administer estrogen followed by progestin. If bleeding occurs
after that, then the cause of amenorrhea is related to low estrogen
levels. The physician will then check for ovarian failure, anorexia,
or other causes of low estrogen. If bleeding does not occur,
then the physician would check for obstructions that are preventing
outflow of menstruation.
Prolactin Levels. Prolactin levels may be measured. High
levels could suggest a pituitary tumor or hypothyroidism.
any Underlying Nonhormonal Medical Conditions
other symptoms or history of other conditions, the physician may
perform tests for underlying disorders. Examples include the following:
tests for anemia.
functions tests are important for detecting hypothyroidism.
hormone tests for Cushing's disease or other disorders associated
with low stress hormones.
may sometimes be used to detect certain conditions that may be causing
menstrual disorders. For example, computed tomography (CT) scans
may be used if prolactin levels are elevated and the physician suspects
a pituitary tumor as their cause. In some cases, imaging techniques
may be used to detect obstructions in the uterus or genital tract
if these are suspected.
hysteroscopy are minimally invasive operative procedures that may
be used for detecting obstructions that may be preventing menstrual
outflow. They employ fiberoptic tubes containing tiny surgical instruments
and microcameras that allow a view of the inside of the pelvis and
abdomen (laparoscopy) or uterus (hysteroscopy). [For more information
on these diagnostic techniques, see the Report
Fibroids: Uterine .]
ARE THE HOME REMEDIES FOR AMENORRHEA?
and Therapeutic Support
may help resolve the disorder in some women. A number of stress
management tools and support services are available. [For more information
see the Report Stress.]
Being over or
underweight is a contributor to menstrual disorders and women should
make every effort to maintain a normal weight.
Exercise is very
important in maintaining good health. Although unusually vigorous
exercise can cause menstrual irregularity and even amenorrhea, few
women exercise to the extent that their periods are affected. For
those who do, a recent study found that simply adding calories can
restore regular menstruation in such women. Competitive athletes
do not have to stop exercising to restore fertility. They simply
need to eat more.
In one study,
electrical acupuncture helped restore regular ovulation to more
than a third of women with polycystic ovary syndrome. In general
this approach was beneficial only for women with less severe male
characteristics and hormonal problems.
Some women may
resort to herbal or so-called natural remedies. Although many are
now being produced by recognized manufacturers, none require US
government regulations and no one should take any remedies for medical
conditions without consulting a physician. [ See Box Warnings
on Alternative and So-Called Natural Remedies.]
Agnus Castus Fruit Extract (Chaste Tree Berry). Several
studies are reporting that agnus castus fruit, also known as chaste
tree berry (Vitex), helps alleviate symptoms of PMS. The compounds
in this substance have effects that are similar to female hormones.
One study reported that homeopathic preparations containing agnus
castus helped women with irregular periods, but at this time Chaste
tree berry should not be used by women who wish to conceive or who
are sexually active and not using a reliable form of birth control.
Black Cohosh. Black cohosh (Remidfemin) has been used for
amenorrhea and symptoms of menopause. To date, the product appears
to have few side effects, but some women report headaches. Long
term studies are required to determine its safety and effectiveness.
Like all herbal products, it is not regulated.
Warnings on Alternative and So-Called Natural Remedies
be strongly noted that alternative or natural remedies are
not regulated and their quality is not publicly controlled.
In addition, any substance that can affect the body's chemistry
can, like any drug, produce side effects that may be harmful.
Even if studies report positive benefits from herbal remedies,
the compounds used in such studies are, in most cases, not
what are being marketed to the public.
There have been a number of reported cases of serious and
even lethal side effects from herbal products. In addition,
some so-called natural remedies were found to contain standard
prescription medication. Most problems reported occur in herbal
remedies imported from Asia, with one study reporting a significant
percentage of such remedies containing toxic metals.
The following website is building a database of natural remedy
brands that it tests and rates. Not all are available yet.
The Food and Drug Administration has a program called MEDWATCH
for people to report adverse reactions to untested substances,
such as herbal remedies and vitamins (call 800-332-1088).
ARE THE TREATMENTS FOR AMENORRHEA?
amenorrhea vary widely and depend on the cause. For example, surgery
may be needed to remove vaginal or uterine obstructions. Thyroid
replacement will help women with hypothyroidism. Weight programs
and exercise can restore regular periods in many women who are overweight.
A few approaches for hormonal conditions are discussed here.
Therapies for Amenorrhea
Oral contraceptives (OCs), commonly known collectively as "the
Pill," contain combinations of an estrogen and a progestin (either
a natural progesterone or the synthetic form called progestogen).
These agents block production of male hormones and inhibit receptors
for estrogen in the uterus.
progestin each cause different side effects. [ See Box Side
Effects of Hormonal Contraceptives.]
- OCs are
often used to regulate periods in women with menstrual disorders,
including amenorrhea, dysmenorrhea (severe pain), and menorrhagia
- Oral contraceptives
also protect against ovarian and endometrial cancers.
who have potentially reversible conditions that cause amenorrhea
(such as cancer therapies) should be checked periodically for
return of natural menstruation.
replacement may be very important for young girls with amenorrhea
that is caused by low estrogen levels.
Uncommon but more dangerous complications of OCs include high blood
pressure and deep-vein blood clots (thrombosis), which may contribute
to heart attacks or strokes. It should be noted that a long-term
study of 46,000 British women found no difference in mortality rates
between women who took OCs and those who did not. The most serious
side effects are due to the estrogen in the combined pill. Women
at risk can usually take progestin-only OCs.
Progestins (either natural progesterone or synthetic progestogen)
are used by women with amenorrhea to restore regular cycles. [See
Box Side Effects of Hormonal
Contraceptives.] Various forms include the following:
Clots (Thrombosis). Oral contraceptive use increases the risk
for blood clots, particularly in women with inherited clotting
defects. The risk is highest in the first few months. Whether
the newer generation progestins desogestrel and gestodene pose
a higher risk for blood clots than those containing levonorgestrel
is unclear. If they do, it is very slight, particularly in women
with no other risk factors.
Evidence consistently suggests a higher than normal risk for
stroke in women taking OCs, even at current low estrogen dosages
and even if women have no other stroke risk factors, such as
migraine, high blood pressure, and smoking. (Low dosages pose
a lower risk than high doses, however.) Even so, absolute risk
for a stroke is still extremely low, and low-dose OCs would
add only 4.1 strokes per 100,000 women who have no other risk
factors for stroke. Smoking, migraines, and high blood pressure
add considerably to the risk.
- High Blood
Pressure. High blood pressure that occurs after a woman begins
taking OCs can usually be corrected by discontinuing the medication,
and women who use OCs should not be unduly alarmed. Of some
concern was a study suggesting that OCs may cause a small but
persistent increase in diastolic blood pressure (the
second number in a blood pressure reading), which in turn may
increase the risk for heart disease years later.
Attacks. Smoking and high blood pressure may also increase the
risk for heart attacks in women taking OCs.
Injections of the potent hormonal agents called gonadotropin-releasing
hormone (GnRH) agonists reduce or suppress estrogen levels. They
include nafarelin (Synarel), goserelin (Zoladex), leuprolide (Lupron
Depot), and histrelin (Supprelin). These drugs are effective for
relieving symptoms of severe PMS, endometriosis, fibroids, and menorrhagia.
Some experts believe that GnRH analogs may be useful as first line
therapy in some women with menstrual pain and irregular periods.
These drugs have a number of potentially serious side effects, however,
and they should only be taken if other, more conservative measures
cannot relieve these common problems.
- Oral progestins
include medroxyprogesterone (Provera, Amen, Curretab, Cycrin,
Depo-Provera), norethindrone acetate (Aygestin, Norlutate),
and norgestrel (Ovrel). Oral synthetic progestins, however,
may have unpleasant psychological and physical side effects
such as depression, moodiness, and bleeding.
progestins (called progesterone) may be helpful. A natural oral
form of finely ground (micronized) progesterone (Prometrium),
which is made from wild yams, is available and has fewer side
effects. Crinone, another natural progesterone, is applied as
a sustained-release gel in the vagina and is proving to a be
promising therapy for amenorrhea. The application allows progesterone
to go directly from the vagina to the uterus, and when a woman
also takes estrogen, the combination simulates the natural luteal
phase of the menstrual cycle. There are few side effects and
studies indicate that it is very beneficial for women with secondary
Because estrogen loss can lead to osteoporosis, women ordinarily
do not take GnRH agonists for more than six months. Additional factors
that increase the chance for osteoporosis include smoking, having
polycystic ovarian syndrome, alcohol abuse, long-term use of certain
drugs (such as corticosteroids) that reduce bone density, and a
family history of osteoporosis.
Other common side effects include hot flashes, reduced sexual drive,
headache, nausea and vomiting, memory loss, changes in the skin
and hair, rapid heartbeat, vaginitis, and weight changes. Depression
is common and may be treated with antidepressants. There may be
a temporary increase in cholesterol levels.
GnRH treatments do not prevent pregnancy; their use during
pregnancy also increases the risk for birth defects. Women who are
taking GnRH agonists should use non-hormonal birth control methods,
such as diaphragm, cervical cap, and condoms while on the treatments.
The risks and benefits of long-term therapy are not fully known.
Small studies of women who used leuprolide for up to three years
have not reported any permanent pituitary damage that could affect
fertility. Researchers are also investigating the use of add-back
therapy, which provides doses of estrogen and progestin that physicians
hope are high enough to reduce bone loss, but too low to offset
the beneficial effects of the GnRH agonist. Studies have shown this
regimen to be helpful for endometriosis and fibroids as well.
Effects of Hormonal Contraceptives
and progestin each cause different side effects.
During the first two or three months of use, side effects
from estrogen in the combined pill includes:
the adverse effects of progestins, alone or in combinations,
are due to the fact that they act like male hormones. Such
side effects include the following:
Nausea and vomiting. (Can often be controlled by taking
the pill during a meal or at bedtime.)
Breast tenderness and enlargement.
used in contraceptives are referred to as second generation
(levonorgestrel, norethisterone) and third generation (desogestrel,
gestodene, norgestimate). The third generation progestins
tend to have fewer male-like side effects and may possibly
have a better effect on cholesterol levels than earlier progestins.
(It is unclear whether they pose a higher risk for blood clots
than older progestins.
Spotting and bleeding between periods (break-through bleeding).
Progestin thins the lining of the uterus and prevents
it from shedding. Because of this, menstrual disorders
such as spotting between periods, longer or heavier periods,
or no periods at all (amenorrhea) are common side effects
of any progestin-containing birth control.
Decreased sex drive.
Depression and mood changes (depression and agitation).
of eating disorders is complex and covered elsewhere. [For more
information see the Report #49, Eating
Polycystic Ovary Syndrome
Polycystic ovary syndrome (PCOS) include the following:
- In women
who are both obese and have PCOS, weight loss and a moderate
exercise program caused marked improvements in PCOS symptoms
and in hormone levels after four to 12 weeks of calorie restriction.
(In a 2000 study a high-protein low-carbohydrate diet in combination
with the drug Metformin was effective in restoring regular menstruation
and reducing the levels of male hormones.)
- PCOS has
typically been treated with clomiphene. This drug works by blocking
estrogen, which tricks the pituitary into producing the reproductive
hormones FSH and LH.
(GnRH) administered in pulses, used alone or in combination
with clomiphene, gonadotropins, or oral contraceptives, has
been successful in some cases where clomiphene alone has failed.
- In women
who do not wish to become pregnant or who are not candidates
for these approaches, oral contraceptives (OCs), antiandrogen
drugs, or both are used to restore regular periods and reduce
male-hormone symptoms. (The progestins in any OCs should be
newer ones that are less apt to produce male characteristics.)
(Glucophage) is commonly used to reduce insulin levels in people
with diabetes. It is now showing great promise in reversing
symptoms and restoring regular menstrual cycles and ovulation
in some women with PCOS.
- The drug
cabergoline is reported to normalize androgen levels and menstrual
irregularities in women with this syndrome.
is an anti-male hormone that helps reduce facial hair. It can
cause birth defects and should be used in women who are also
taking an OC.
surgery may be beneficial.
Premature Ovarian Failure
There is no treatment
available that will restore ovarian function in women with premature
ovarian failure. Women in whom pregnancy is possible will require
in vitro fertilization. Hormone replacement therapy may be used
to prevent bone loss and reduce menopause symptoms. Freezing ovarian
tissue is under investigation for women who are at risk for premature
ovarian failure, such as young women with a genetic history of this
condition or those who need to undergo cancer treatments.
for Women with Functional Hypothalamus Amenorrhea
Pivagabine is an investigative agent that acts on the hypothalamus
in the brain and reduces stress hormones. Early studies have reported
that this action may help elevate gonadotropin hormones in women
who have amenorrhea related to anorexia or excess exercise.
Treating Eating Disorders. If anorexia is the cause of FHA,
it should be treated immediately, since severe anorexia can be life-threatening.
[For more information see the Report # 49,
Eating Disorders .]
for Women with Hyperprolactinemia
as dopamine agonists are used for women with hyperprolactinemia
caused by tumors in the pituitary gland. Bromocriptine (Parlodel)
is the standard agent, it reduces prolactin levels by 70% to 100%
and also shrinks tumors. Treatments are given for one to two years
then stopped when prolactin levels are normal. Cabergoline (Dostinex),
another dopamine agonist, is proving to be more effective than bromocriptine
in shrinking tumors and has fewer side effects. Common side effects
include nausea, constipation, headache, dizziness, and fatigue.
(Dopamine agonists are also used in Parkinson's disease.)
Surgery. Surgery may be needed for women who do not respond
to medications or whose tumors are large, but recurrence occurs
in as many as 40% of patients within five years.
for Secondary Amenorrhea Due to Obstructed Outflow
In some cases,
surgery can correct structural problems that are preventing menstrual
flow. One new technique called pressure lavage under ultrasound
guidance (PLUG) may prove to be useful for treating some cases of
mild scarring in the uterus (intrauterine adhesions). This technique
is based on transvaginal sonohysterography, which uses ultrasound
along with saline infused into the uterus to enhance visualization.
Continuous accumulation of saline in the procedure is used to break
up the scars.
ELSE CAN HELP BE OBTAINED FOR MENSTRUAL DISORDERS?
National Women's Health Resource Center, 2425 L Street NW, Washington,
DC 20037. Call (202-293-6045) or on the Internet (http://www.womens-health.com)
National Women's Health Network, 514 10th St. NW, Suite 400, Washington,
DC 20004. Call (202-347-1140) or (202 628 7814) for health information.
Membership is $25 per year and provides a bimonthly newsletter and
access to information. Reports cost $6.00 for members and $8.00
American College of Obstetricians and Gynecologists, Resource Center,
409 12th Street SW, Washington, DC 20024. Call (202638-5577) or
on the Internet (http://www.acog.com/)
RESOLVE, Inc., 1310 Broadway, Somerville, MA 02144-1731. Call (617-623-1156)
or the National HelpLine (617-623-0744) or on the Internet (http://www.resolve.org/)
American Society for Reproductive Medicine (Formerly the American
Fertility Society), 1209 Montgomery Highway, Birmingham, AL 35216-2809.
Call (205-978-5000) or on the Internet (http://www.asrm.com/current/practice/opinion.html)
The Endometriosis Association, 8585 N. 76th Place, Milwaukee, WI
53223 call (800-992-3636) for a general information packet or (414-355-2200)
for specific issues or on the Internet (http://www.endometriosisassn.org/)
This international association provides information, support, and
Fertility Research Foundation, 877 Park Avenue, New York, NY 10021.
Call (212-744-5500) Offers information on treatment, latest research
on male and female infertility.
International Pelvic Pain Society, Women's Medical Plaza, Suite
402, 2006 Brookwood Medical Center Drive Birmingham, Alabama 35209
USA. Call (1-800-624-9676) or (205-877-2950) or on the Internet
Menopause News, 2074 Union Street, San Francisco, CA 94123 USA.
Call (800-241-MENO) or on the Internet (http://wwwwellcom/user/mnews/)