Amenorrhoea is the absence of periods, either because they never started or because they have stopped for more than three to twelve months
Amenorrhoea is normal before puberty, in pregnancy, lactation and after menopause
Amenorrhoea is a symptom and not a diagnosis, therefore always look for the underlying cause
Diagnosis is made using a combination of history, physical examination and laboratory investigations
The treatment will vary widely, since it is related to the underlying cause of the problem
What is amenorrhoea?
Amenorrhoea means the absence of periods (menstruation), either because they never started, or because they have ceased.
By definition, the first day of a period is day one of a cycle. A menstrual cycle lasts from the first day of a period to the first day of the next. The typical cycle of an adult female is 28 days, although cycles can range between 21 and 35 days. Once a menstrual pattern has been established, the variation does not normally exceed five days.
The average duration of menstrual flow is five days, with a blood loss varying between 20 and 80 ml, usually heavier on the second day.
Amenorrhoea as a medical condition is categorized as follows:
no menstruation by age 14 (if combined with absent secondary sexual development), no menstruation by age 16, or no menstruation two years after development of breasts and/or pubic/axillary hair.
no menstruation for at least three months in a woman who previously had regular monthly periods, or no menstruation for at least six to 12 months in a woman who previously experienced irregular periods.
What causes amenorrhoea?
Amenorrhoea indicates that the normal physiological processes which control menstruation have failed. This may indicate an abnormality at any level of the reproductive tract.
Menstruation is controlled through hypothalamic-pituitary-ovarian interaction and requires a functional endometrium (lining of the womb) and an open outflow tract (cervix and vagina). The hypothalamus is a part of the brain which interacts with the pituitary gland, situated at the base of the brain, from where signals are sent to the ovaries to allow them to function normally.
It is important to remember that amenorrhoea is not a diagnosis, but merely a symptom (sign) of a number of possible disorders, involving several organ systems.
Amenorrhoea is normal (physiological) when it occurs in a girl before puberty, during pregnancy, early lactation, long-acting hormonal contraception (Depo Provera) and after the menopause.
At any other time it is considered abnormal and needs to be evaluated.
How is amenorrhoea assessed?
Primary and secondary amenorrhoea can be due to several causes. Primary amenorrhoea may be caused by congenital and anatomical abnormalities or by malfunction of the hormonal system. Periods may be delayed until the age of 16, but physiological delay must always be a diagnosis of exclusion. In other words, other causes must be looked for before it is assumed to be normal.
Girls who have not menstruated and show no signs of puberty by the age of 14 and those who have not menstruated by the age of 16, despite secondary sexual maturation, should be investigated, preferably by the experts in the field of reproductive medicine to ensure favourable outcome.
Girls for whom all investigations are normal should be reassured and should have regular follow-up visits to the doctor.
Even subtle hormonal changes may result in symptoms and signs of the underlying problem. The most important part of the medical assessment is a history and full physical evaluation. This will include the height, weight, hair distribution and other pubertal signs (such as pubic hair and breast development).
When the history is taken, there will be questions about possible psychological disturbances, diet and exercise habits, lifestyle, environmental stresses, a family history of genetic abnormalities and abnormal growth and development.
Patients with primary or secondary amenorrhoea will be asked about symptoms, which may indicate an increased secretion of androgens (male sex hormones), also referred to as hyperandrogenism.
On clinical examination, there may be signs of virilisation (masculinisation) including increased facial hair, male-pattern balding, voice deepening and an enlarged clitoris. Patients with hyperandrogenism may experience an increased libido (urge for sexual activity). There may also be a decrease in female secondary sexual characteristics including decreased breast size and atrophy of the vagina. The thyroid gland must also be examined at all times.
Galactorrhoea (the production of breast milk without pregnancy or birth) is another sign which may occur in association with amenorrhoea, further indicating the need for detailed investigations and proper treatment.
The doctor will arrange for a number of special investigations which may include a pregnancy test, a pelvic ultrasound, hormonal studies of different glands, radiological imaging of the pituitary gland and chromosomal studies.
How is amenorrhoea treated?
The treatment depends entirely on the cause of the problem and will vary widely from lifestyle modification, reconstructive surgery, hormonal therapy, and any other additional treatment modalities. Most importantly, the treatment should never aim at treating the symptom and it must seek to address each individual patient’s needs. Furthermore, long term follow up on the issues of sexuality, fertility options, and long term medical complications associated with some causes of amenorrhoea, must be emphasized.
When to see a doctor
Any girl who has not started her periods and does not show signs of puberty by the age of 14 should urgently see a doctor.
Any girl who has not started her periods by the age of 16 should see a doctor as a matter of great urgency.
Any girl or woman who starts her periods normally, but then stops for more than three to twelve months in the absence of pregnancy or menopause should see a doctor.
Any girl or woman who develops masculine characteristics (such as facial hair and a deep voice), or has milk like secretion from the breasts while not breastfeeding, with visual disturbances and/or headaches in association with amenorrhoea should make an appointment with a doctor without delay.
Reviewed by Professor Bert Scaetzing, MD, FCOG(SA), FRCOG, PhD, part time consultant
Reviewed by Dr Thabo Matsaseng MB ChB, FCOG(SA), NMCP,Cert Reproductive Medicine(SA), Reproductive Medicine Specialist, Dept of Obstetrics & Gynaecology, Tygerberg Academic Hospital, University of Stellenbosch, (October 2010)