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* Please note that most treatment modalities listed below are based on conventional medicine. PreventDisease.com does not advocate the use of any pharmaceutical drug treatments. Long-term drug therapy is very detrimental to human health. All drug information is for your reference only and readers are strongly encouraged to research healthier alternatives to any drug therapies listed.

Menstruation: Absent Periods (Amenorrhea)



WHAT IS MENSTRUATION?


Reproductive Organs .
  • 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.

  • Leading 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.

  • Ovaries 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.
Reproductive Hormones.

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) .

  • Estrogen, progesterone, and testosterone are secreted by the ovaries at the command of FSH and LH and complete the hormonal group necessary for reproductive health.



Reproductive Processes Leading to Menstruation


The menstrual 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:
  • the follicular phase,

  • ovulation, and

  • the luteal (or secretory) phase.
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.

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 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.
Ovulation. 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) phase begins.

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.

  • Acting 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 pregnancy.

  • 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.

  • Finally, the endometrial lining sloughs off and is shed during menstruation.

Typical Menstrual Cycle


Menstrual Phases

Typical No. of Days

Hormonal Actions

Follicular (Proliferative) Phase

Days 1 through 6: Beginning of menstruation to end of blood flow.

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 remains low.



Days 7 - 13: The endometrium (the inner portion or lining of the uterus) thickens to prepare for the egg implantation.



Ovulation

Day 14:

Surge in LH. Largest follicle bursts and releases egg into fallopian tube.

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 begins.





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 on fertility.

Risk Factors for Shorter Cycles

Risk Factors for Longer Cycles

Regular alcohol use.

Being under 21 and over 44.

Stressful jobs.

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 shorter periods.

Normal Absence of Menstruation. Normal absence of periods can occur in any woman under the following circumstances:
  • Menstruation 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.

  • Perimenopause 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.



WHAT ARE AMENORRHEA AND OTHER MENSTRUAL DISORDERS?




Amenorrhea (Absence of Menstruation)


Amenorrhea 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.
  • Primary 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.

  • Secondary amenorrhea is a condition in which periods that were previously regular become absent for at least three cycles.



Other Menstrual Disorders


Oligomenorrhea (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:
  • Regularly 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.)

  • Periods regularly last more than eight to ten days.
Bleeding between 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.)

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.
  • Primary 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.

  • Secondary dysmenorrhea is menstrually related pain that is caused by other medical conditions, usually endometriosis or pelvic abnormalities. [For more Information see the Report #100, Dysmenorrhea.]
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.

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 .]



WHAT CAUSES AMENORRHEA?




Delayed Puberty


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 the problem.



Functional Hypothalamic Amenorrhea (FHA) and Eating Disorders


Functional hypothalamic 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 of famine.
  • Hormonal 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.

  • Amenorrhea 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.
Female Athlete 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 ovulation.)



Polycystic Ovarian Syndrome (PCOS)


Polycystic ovarian 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 PCOS.

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.



Elevated Prolactin Levels (Hyperprolactinemia)


Prolactin is 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:
  • Hypothyroidism.

  • Pituitary 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.



Premature Ovarian Failure


Premature ovarian 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 following:
  • Adrenal, pituitary, or thyroid deficiencies.

  • Low levels of certain growth factors, called inhibins, that are produced by the ovaries.

  • Hypergonadotropic 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.

  • Cancer treatments (radiation, chemotherapy, or both).

  • Rare causes include sarcoidosis, mumps, some sexually transmitted diseases, and tuberculosis.

  • Autoimmunity. 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).
Premature ovarian failure is a significant cause of infertility and women who have this condition have only a 5% to 10% chance to conceive without fertility treatments.



Idiopathic Hypogonadotropic Hypogonadism


Idiopathic hypogonadotropic 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.



Thyroid Problems


Thyroid problems, 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.



Other Factors that May Cause or Contribute to Amenorrhea


Stress. Physical 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 factors.

Obesity. Being extremely overweight is associated with irregularity, possibly because some estrogen is produced in fat cells, which may affect the cycle.



Other Medical Disorders that Cause Secondary Amenorrhea


Anemia. According 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


Adolescence. During adolescence, it may take a while for ovulation to occur regularly. In some cases periods may even stop for several months.

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 a period.

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 breast feeding.)

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 the menopause.




HOW SERIOUS IS AMENORRHEA?




Infertility


Many conditions that cause amenorrhea, such as ovulation abnormalities, are major contributors to infertility. Irregular periods from any cause make it more difficult to conceive.



Osteoporosis


Amenorrhea associated 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.]



Complications 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.



HOW ARE MENSTRUAL DISORDERS DIAGNOSED?




Physical Examination


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.



Medical and Personal History


The physician 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:
  • History 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 of menstruation.

  • 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).

  • Regular use of any medications.

  • History 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.

  • History of uterine surgery.



Ruling out Pregnancy


A pregnancy test is, of course, the first test performed when a woman with normal sexual development experiences a cessation of her period.



Reproductive Hormonal Tests


Hormonal tests 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):
  • Bleeding 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.
Tests for 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.

Prolactin Levels. Prolactin levels may be measured. High levels could suggest a pituitary tumor or hypothyroidism.



Determining any Underlying Nonhormonal Medical Conditions


Depending on other symptoms or history of other conditions, the physician may perform tests for underlying disorders. Examples include the following:
  • Blood tests for anemia.

  • Thyroid functions tests are important for detecting hypothyroidism.

  • Stress hormone tests for Cushing's disease or other disorders associated with low stress hormones.

  • Tests for autoantibodies.



Imaging Techniques


Imaging technique 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.



Invasive Techniques


Laparoscopy and 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 .]



WHAT ARE THE HOME REMEDIES FOR AMENORRHEA?




Social and Therapeutic Support


Reducing stress 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.]



Weight Control


Being over or underweight is a contributor to menstrual disorders and women should make every effort to maintain a normal weight.



Exercise


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.



Acupuncture


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.



Herbal Remedies


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.

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.



WHAT ARE THE CONVENTIONAL TREATMENTS FOR AMENORRHEA?

* Please note that most treatment modalities listed below are based on conventional medicine. PreventDisease.com does not advocate the use of any pharmaceutical drug treatments. Long-term drug therapy is very detrimental to human health. All drug information is for your reference only and readers are strongly encouraged to research healthier alternatives to any drug therapies listed.


Treatments for 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.



Hormonal Therapies for Amenorrhea


Oral Contraceptives. 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.
  • OCs are often used to regulate periods in women with menstrual disorders, including amenorrhea, dysmenorrhea (severe pain), and menorrhagia (heavy bleeding).

  • Oral contraceptives also protect against ovarian and endometrial cancers.

  • Patients who have potentially reversible conditions that cause amenorrhea (such as cancer therapies) should be checked periodically for return of natural menstruation.

  • Estrogen replacement may be very important for young girls with amenorrhea that is caused by low estrogen levels.
Estrogen and progestin each cause different side effects. [ See Box Side Effects of Hormonal Contraceptives.]

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.
  • Blood 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.

  • Stroke. 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.

  • Heart Attacks. Smoking and high blood pressure may also increase the risk for heart attacks in women taking OCs.
Progestins. 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:
  • 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.

  • Natural 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 amenorrhea.
GnRH Agonists. 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.

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.

Side Effects of Hormonal Contraceptives

Estrogen 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:

  • Nausea and vomiting. (Can often be controlled by taking the pill during a meal or at bedtime.)

  • Headaches.

  • Dizziness.

  • Breast tenderness and enlargement.

  • Weight gain.
Most of 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:
  • 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.

  • Fatigue.

  • Decreased sex drive.

  • Acne.

  • Depression and mood changes (depression and agitation).

  • Weight gain.

  • Headaches.

  • Breast tenderness.
Progestins 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.

 



Treating Eating Disorders


The treatment of eating disorders is complex and covered elsewhere. [For more information see the Report #49, Eating Disorders .]



Treating Polycystic Ovary Syndrome


Treatments for 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.

  • Gonadorelin (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.)

  • Metformin (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.

  • Spironolactone 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.

  • Ovarian surgery may be beneficial.



Managing 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.



Treatments for Women with Functional Hypothalamus Amenorrhea


Pivagabine. 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 .]



Treatments for Women with Hyperprolactinemia


Agents known 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.



Procedures 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.

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