Are you wondering why your menstruation has ceased? LET’S TALK ABOUT AMENORRHOEA (Absence or cessation of Menstruation).

WHAT IS AMENORRHOEA?

Amenorrhoea is the absence or cessation of menstruation. It can be divided into two types: primary and secondary amenorrhoea.

Primary amenorrhoea is the failure to establish menstruation by the time of the expected menarche.

Some experts define it as the failure to establish menstruation by 15 years of age in those with normal secondary sexual characteristics (such as breast development), or by 13 years of age in those with no secondary sexual characteristics.

Others define it as the failure to establish menstruation by 16 years of age in those with normal secondary sexual characteristics, or by 14 years of age in those with no secondary sexual characteristics.

Secondary amenorrhoea is the cessation of menstruation in women with previous menses. Definitions vary as to how long and include:

The cessation of menses for 3 months in women with previously normal menstruation, or for 6 months in women with previous oligomenorrhoea [Klein, 2013]. Oligomenorrhoea (not covered in this topic) is defined as menses occurring less frequently than every 35 days.

The cessation of menses for 3 months in women with previously normal menstruation, or for 9 months in women with previous oligomenorrhoea.

The cessation of menstruation for at least 6 months in women with previously normal and regular menses, or for 12 months in women with previous oligomenorrhoea.

[BMJ, 2018a; Edmonds, 2012; Practice Committee of the American Society for Reproductive Medicine, 2008; Alberta Medical Association, 2008a].

 SECONDARY AMENORRHOEA IS SUSPECTED IF:

Cessation of menstruation for 3–6 months in women with previously normal and regular menses.

Cessation of menstruation for  6–12 months in women with previous oligomenorrhoea.

WHAT ARE THE CAUSES OF SECONDARY AMENORRHOEA?

• Causes of secondary amenorrhoea in those with no features of androgen (Androgens are a group of sex hormones, they help start puberty and play a role in reproductive health and body development) excess include:
  • Pregnancy.
  • Lactation.
  • Menopause.
  • Chemotherapy.
  • Radiotherapy.
  • Autoimmune disease.
  • Chronic systemic illness (such as severe cardiac, renal, or liver disease; inflammatory bowel disease; coeliac disease; AIDS; or cancer).
  • Cranial irradiation, infection or head injury.
  • Central nervous system tumours (such as craniopharyngiomas or metastases).
  • Prolactinoma and other hormone-secreting pituitary tumours.
  • Head injury and cranial irradiation.
  • Hypopituitarism (for example, after traumatic brain injury).
  • Sheehan's syndrome (pituitary infarction after major obstetric haemorrhage).
  • Sarcoidosis.
  • Tuberculosis.
  • Cervical stenosis.
  • Asherman's syndrome (intrauterine adhesions).
  • Contraceptives — extended-cycle combined oral contraceptives, injectable progesterone, implantable etonogestrel (Nexplanon®), and levonorgestrel intrauterine system (Mirena®) may cause amenorrhea.
  • Drugs (such as antipsychotics, which can cause increased prolactin levels) and illicit drug use (in particular cocaine and opiates, which can cause hypogonadism).
  • Surgery (hysterectomy, endometrial ablation, and ovarian surgery).
  •  
• Physiological causes:
• Premature ovarian insufficiency, for example, due to:
• Hypothalamic dysfunction due to stress, excessive exercise, and/or weight loss (functional hypothalamic amenorrhea).
• Other hypothalamic causes, including:
• Pituitary causes, including:
• Uterine causes, including:
• Thyroid disease (hypothyroidism (Low thyroid level) or hyperthyroidism (High Thyroid level)).
• Iatrogenic causes, including:
• Causes of secondary amenorrhoea in those with features of androgen excess (such as hirsutism (where women have thick, dark hair on their face, neck, chest, tummy, lower back, buttocks or thighs), acne and virilization (is a condition in which a female develops characteristics associated with male hormones (androgens) include:

• Polycystic ovary syndrome (is a condition in which the ovaries produce an abnormal amount of androgens, male sex hormones that are usually present in women in small amounts. The name polycystic ovary syndrome describes the numerous small cysts (fluid-filled sacs) that form in the ovaries).

• Cushing's syndrome (Cushing's syndrome is a disorder that occurs when your body makes too much of the hormone cortisol over a long period of time. Cortisol is sometimes called the “stress hormone” because it helps your body respond to stress).
• Late-onset congenital adrenal hyperplasia.
• Androgen-secreting tumours of the ovary or adrenal gland (rare).

 COMPLICATIONS OF AMENORRHOEA INCLUDE:

Osteoporosis: (This is a health condition that weakens bones, making them fragile and more likely to break)— evidence from observational studies indicates that women with amenorrhoea associated with oestrogen deficiency (In particular premature ovarian failure, weight loss, anorexia nervosa, and excessive exercise) are at increased risk of osteoporosis. This increased risk persists even if normal menses are resumed, especially in adolescents because they may not attain a desirable peak bone mass.

Cardiovascular disease (CVD): — women with amenorrhoea associated with oestrogen deficiency may be at increased risk of CVD. Although this has not been studied specifically, the increased risk associated with a low oestrogen state in postmenopausal women is well documented.

Infertility — women with amenorrhoea do not usually ovulate. Ovulatory disorders are one of the main causes of infertility in the UK. Pregnancy may be achieved by some women either by treatment of the underlying disorder or by assisted reproduction.

Psychological distress — amenorrhoea often causes considerable anxiety, altered self-image, and loss of self-esteem. Many women have concerns about loss of fertility, loss of femininity, or unwanted pregnancy.

[ Csermely et al, 2007; Rees, 2009; NICE, 2017; NICE, 2017].

PLEASE REFER TO YOUR PRIMARY CARE PROVIDER FOR ASSESSMENT, DIAGNOSIS AND TREATMENT.

REFERENCE

• ACOG (2017) Committee Opinion No.702: female athlete triad. Obstetrics and Gynecology 129(6).
• Alberta Medical Association (2008a) Laboratory endocrine testing guidelines: amenorrhea (without hirsutism) and menopause. Alberta Medical Association.
• Alberta Medical Association (2008b) Laboratory endocrine testing guidelines: hypercalcemia. Alberta Clinical Practice Guidelines. Alberta Medical Association. 
• BMJ Best Practice (2018a) Assessment of primary amenorrhoea. BMJ Publishing Group. 
• BMJ Best Practice (2018b) Assessment of secondary amenorrhoea. BMJ Publishing Group. 
• Csermely, T., Halvax, L., Vizer, M., et al. (2007) Relationship between adolescent amenorrhea and climacteric osteoporosis. Maturitas 56(4), 368-374.
• Edmonds, D.K. (2012) Puberty and its disorders. In: Edmonds, D.K. (Eds.) Dewhurst's textbook of obstetrics & gynaecology. 8th edn. Chichester: Wiley-Blackwell, 471-484.
• Fogel, C.I. (1997) Endocrine causes of amenorrhea. Lippincott's Primary Care Practice 1(5), 507-518.
• Fourman, L.T. and Fazeli, P.K. (2015) Neuroendocrine causes of amenorrhea--an update. Journal of Clinical Endocrinology and Metabolism 100(3), 812-824.
• Gordon, C., Ackerman, K. and Berga, S. et al. (2017) Functional hypothalamic amenorrhea: an Endocrine Society clinical practice guideline. Journal of Clinical Endrocrinology and Metabolism 102(5), 1413-1439.
• Klein, D. and Poth, M. (2013) Amenorrhea: an approach to diagnosis and management. American Family Physician 87(11), 781-788.
• NICE (2017) Fertility problems: assessment and treatment. National Institute for Health and Care Excellence. 
• Practice Committee of the American Society for Reproductive Medicine (2008) Current evaluation of amenorrhea. Fertility and Sterility 90(5 Suppl), S219-S225.
• RCOG (2014) Long-term consequences of polycystic ovary syndrome. Royal College of Obstetricians and Gynaecologists. 
• Rees,M.C.P. (2003) Women's health. In: Waller,D., McPherson,A. (Eds.) Menstrual problems. edn. Oxford: Oxford University Press., 1-45.
• Rees, M., Stevenson, J., Hope, S., et al. (Eds.) (2009) Management of the menopause: the handbook. 5th edn. London: Royal Society of Medicine Press & British Menopause Society Publications.