All about amenorrhea

Menstruation is a result of a complex synchronization of interacting hormones. When the delicate balance is disrupted, people can experience something called amenorrhea, or prolonged period loss.

Amenorrhea represents a general absence of menstruation and can be either temporary or permanent. There are various causes and types of amenorrhea, and it can be a symptom that highlights an underlying imbalance in one’s hormone levels.

Read on to learn the answers to the following questions:

• What are the types and main causes of amenorrhea?
• What other symptoms commonly occur with amenorrhea?
• What risk factors often lead to amenorrhea?
• How are other conditions and complications related to amenorrhea?

What are the different types of amenorrhea?

While a missing period is an easy symptom to check off yourself, not everyone who experiences amenorrhea is dealing with the same issue. There are several main types of amenorrhea, all with different causes.

Primary amenorrhea is when an individual hasn't gotten their first period within 5 years of the first signs of puberty or by the age of 15. This is most commonly due to genetic reasons but can also be due to a hormone imbalance. Primary amenorrhea is rare, only affecting an estimated 0.1% of people with ovaries in the US.

Secondary amenorrhea is when an individual previously had regular periods but they stop for three or more consecutive months or when an individual previously had irregular periods and they stop for six consecutive months. This can be due to pregnancy, menopause, stress, or other illnesses.

Functional Hypothalamic Amenorrhea (FHA) is a subtype of secondary amenorrhea in which individuals lose a regular period due to insufficient calorie intake, excessive exercise, or high stress levels. FHA is most common in athletes, individuals with eating disorders, over-stressed people.

How do I know if I have amenorrhea?

Although amenorrhea is defined solely by a lack of regular menstruation, there are a few physiological signs that commonly accompany the condition.

In general, accompanying symptoms include:

• Hair loss
• Vision changes
• Excess facial hair
• Pelvic pain
• Headache
• Milky nipple discharge
• Acne

What are the causes of amenorrhea?

Missing one’s period tends to be a sign of hormonal fluctuations; sometimes these fluctuations are natural and other times they reflect imbalances and other illnesses.

Naturally-occurring amenorrhea

As mentioned, not all period loss is a sign that something is wrong. Pregnancy, post-birth, and menopause are all examples where amenorrhea is expected.

• Pregnancy: Why do we lose our period when we are pregnant? While growing a baby during pregnancy, the endometrium —the bloody tissue that is the source of the period— becomes a placenta and serves as the gateway of nutrients between mother and baby.
• Lactational amenorrhea: Lactational amenorrhea, also known as postpartum infertility, is when an individual stops menstruating while breastfeeding. This tends to be a temporary condition that lasts around 6 months or longer depending on the intensity of breastfeeding.
• Menopause: During our reproductive years, our bodies get a monthly period. This stops when we enter menopause. Menopause is the time in an individual’s life, usually around 45 or after, in which menstruation stops. This is due to decreasing levels of estrogen and progesterone in the body that naturally occur with age.

Contraceptives or medications

Some forms of medication is known to stop our monthly cycle.

• Birth Control Pills, IUDs, and other hormonal drugs: Some people lose their periods while taking supplementary hormones; these include oral contraceptives, intrauterine devices that secrete hormones into the uterus, and other hormonal pills. The delicate hormonal balance necessary to stimulate complete menstruation is altered or disrupted by the supplemented hormones. Under some of these hormonal treatments, amenorrhea can be normal and expected. And, even if you do get a period on your form of contraception, you should be aware that this is a “withdrawal bleed” and not a true period because your body is not ovulating and experiencing a true menstrual cycle.
• Other medications: Other medications can also cause period loss. Sometimes the following medications can be the hidden cause of amenorrhea:

• Antipsychotics
• Cancer chemotherapy
• Antidepressants
• Blood pressure drugs
• Allergy medications

Lifestyle factors

Lifestyle factors most commonly are at the root cause of FHA, or functional hypothalamic amenorrhea.

When our body is put under stress, our body may stop menstruating regularly. This can be seen as an evolutionary response in which our body prioritizes supporting or balancing other aspects of our physiological health rather than menstruation.

• Excessive exercise: Some individuals will lose their period when they participate in rigorous physical activity for long periods of time. This may be due to a change in metabolic rate related to low body fat percentage, high energy expenditure, and high stress on the body.
• Low body weight: When an individual is at an excessively low body weight and body fat percentage, hormone levels in the bloodstream fluctuate. Since fat cells secrete estrogen, when body fat levels are very low, estrogen levels can drop below what is necessary to trigger menstruation. This is why an important part of treating FHA tends to include increasing body fat percentages.
• Stress: Mental and emotional stress can trigger changes in cortisol (the stress hormone) secretion and functionality of the hypothalamus  — a part of the brain associated with hormone regulation. When the hypothalamus is disturbed by stress, the hormones coordinating the menstrual cycle become imbalanced and lead to amenorrhea. When stress is the root cause of amenorrhea and the stress subsides, regular menstruation resumes.

Whether amenorrhea is caused by emotional or physical distress, it is imperative to create a holistic treatment that addresses the underlying foundation creating the stress. This can include treatment for disordered eating, stress management, decreasing physical activity levels, and other forms of therapeutic lifestyle changes.

Hormonal imbalances

Other medical conditions can cause hormonal imbalances that lead to amenorrhea:

• Polycystic Ovarian Syndrome (PCOS): People with PCOS tend to have certain hormonal levels that are persistently high. Since regular menstruation requires a cycle of fluctuating hormone levels, PCOS can cause amenorrhea.
• Premature menopause: Although menopause is a natural part of life that ends ovulation and menstruation, some individuals may lose their periods at an earlier age due to a lower ovarian egg supply.
• Thyroid issue: With either an overactive or underactive thyroid gland, one can have hormonal fluctuations and imbalances that lead to amenorrhea.
• Pituitary tumor: The pituitary gland plays a vital role in the hormonal signaling pathway used to generate a menstrual cycle. When there is a tumor in the pituitary, proper hormonal signaling pathways can become disrupted.

Organ structural complications

Problems with the structure of sexual organs can lead to amenorrhea.

• Uterine scarring: Sometimes after procedures in the uterus such as a cesarean section, a dilation and curettage (D&C), or treatment for uterine fibroids, the uterus’ lining can form scarring. This scarring can inhibit the normal formation and shedding of the uterine lining.
• Lack of reproductive organs: Occasionally problems arise during fetal development and babies can be born without the major parts of their reproductive systems. Since the reproductive organs are not present or fully developed, some individuals may not be able to have menstrual cycles.
• Other structural abnormalities: There are a variety of other problems that can arise with the uterus, fallopian tubes, and ovaries that prevents our menstrual cycle from occurring.

Who is at risk of developing amenorrhea?

While anyone can experience amenorrhea due to a temporary hormone imbalance or health issue, there are certain groups who should be more aware of their risk.

Eating disorders

Individuals with disordered eating are more likely to develop amenorrhea, specifically FHA. This can result from caloric restriction, excessive exercise, or a combination of the two.

It should be noted that someone who appears to be healthy and a “normal” weight can still be struggling with disordered lifestyle patterns that are disrupting their menstrual cycle.  Some people may only lose their period if they are intensely exercising for hours every day and severely restricting their food intake, while others may lose their period with less extreme diet and exercise habits.

Rigorous athletic training

Even people that are eating enough may experience amenorrhea if they are athletes. Putting your body under high physical stress due to intense physical activity can lead to functional hypothalamic amenorrhea.

Family history

If other people in your family have experienced amenorrhea, you may be more likely to inherit certain genes that predispose you to developing amenorrhea.

What are the long term effects of amenorrhea?

If you miss a cycle or two, your body can rebound without serious complications. But, losing your period for an extended period of time can lead to a variety of more problematic issues.

Infertility

Without menstrual cycles, an individual is unable to become pregnant. Prolonged amenorrhea, especially if due to preventable lifestyle factors, can make it more difficult to get pregnant and you will need to factor in time for regulating your cycle into your family planning.

Osteoporosis and osteopenia

Estrogen plays an important role in maintaining healthy bones as well as healthy menstrual cycles. Low estrogen levels that cause amenorrhea can also put an individual at risk of low bone density, or osteopenia. Osteopenia can eventually put you at risk for osteoporosis, which is an even more advanced form of bone loss. Especially as we age, maintaining bone density is important for our quality of life and overall health in preventing injuries and bone fractures.

Sources:

https://www.pollie.co/blog/thyroid-and-fertility

https://www.pollie.co/blog/pcos

https://www.pollie.co/blog/functional-hypothalamic-amenorrhea-in-athletes

https://www.mayoclinic.org/diseases-conditions/amenorrhea/symptoms-causes/syc-20369299#:~:text=Amenorrhea%20

https://academic.oup.com/jcem/article/102/5/1413/3077281

https://www.factsaboutfertility.org/an-overview-of-lactational-amenorrhea-and-fertility/

https://my.clevelandclinic.org/health/diseases/3924-amenorrhea

https://www.pollie.co/blog/functional-hypothalamic-amenorrhea-in-athletes

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