The amenorrhea is the absence of menstruation in a woman of reproductive age. The word “amenorrhea” comes from the Greek has to deprivation Men for months and rhein to flow.
Between 2% and 5% of women would be affected by amenorrhea. This is a symptom of which it is important to know the cause. The absence of menstruation is quite natural when, for example, a woman is pregnant, breastfeeding or approaching menopause. But apart from these situations, it can be a tell-tale sign of chronic stress or a health problem such as anorexia or a disorder of the thyroid gland.
Types of absence of rules
- Primary Amenorrhea: When at age 16, the rules have not yet been triggered. Secondary sexual characteristics (development of the chest, pubic and armpit hair and distribution of fat to the hips, buttocks and thighs) may nevertheless be present.
- Secondary Amenorrhea: when a woman has had and has been menstruating for one reason or another for at least 3 periods of previous menstrual cycles or 6 months without menstruation.
When to consult when we have no rules?
In many cases, not knowing why we have amenorrhea is a concern. The following persons should consult a doctor :
– women with primary or secondary amenorrhoea;
– in the case of post-contraceptive amenorrhea, a medical evaluation is necessary if amenorrhea persists for more than 6 months in women who have been on a contraceptive pill, who have had a Mirena hormonal IUD, or more than 12 months after the last injection Depo-Provera.
|Important. Sexually active women who are not taking hormonal contraceptives should have a pregnancy test if they have been menstruating for more than 8 days, even when they are “some” not pregnant. Note that bleeding that occurs under hormonal contraceptives (especially false rules generated by the birth control pill) is not evidence of pregnancy.|
Diagnosis of Amenorrhea
In most cases, the clinical examination, a pregnancy test and sometimes an ultrasound of the sexual organs are sufficient to guide the diagnosis.
A radiograph of the wrist (to evaluate pubertal development), hormonal assays or research of the chromosomal sex are made in rare cases of primary amenorrhea.
Causes of the Absence of Rules
The causes of amenorrhea are numerous. Here are the most frequent in descending order.
- The pregnancy. The most common cause of secondary amenorrhea, it must be the first suspected in a sexually active woman. Surprisingly, this case is often dismissed without due diligence, which is not without risk. Some treatments indicated to treat amenorrhea are contraindicated in pregnancy. And with commercially available tests, the diagnosis is simple.
- A delay of puberty without gravity. This is the most common cause of primary amenorrhea. The age of puberty is normally between 11 years and 13 years, but can vary greatly depending on ethnicity, geographic location, diet, and health status.In developed countries, delayed puberty is common among young women who are very thin or athletic. It seems that these young women do not have enough fat to allow the production of estrogen hormones. Estrogens allow the thickening of the uterine wall, and later menstruation if the egg has not been fertilized by a spermatozoon. In a way, the body of these young women protects themselves naturally and signals that their physical form is inadequate to support a pregnancy.
If their secondary sexual characteristics are present (appearance of the breasts, pubic hair and armpits), there is no concern to be had before the age of 16 or 17 years. If the signs of sexual maturation are still absent at age 14, a chromosome problem (a single sex chromosome X instead of 2, a disease called Turner syndrome) must be suspected. Development of the genital tract or a hormonal problem.
- Breastfeeding. Often breastfeeding women have no menstrual period. However, it should be noted that they can still have ovulation during this period, and therefore a new pregnancy. Breastfeeding suspends ovulation and protects against pregnancy (99%) only if:
– the baby exclusively takes the breast;
– the baby is less than 6 months old.
- The arrival of menopause. Menopause is the natural cessation of menstrual cycles occurring in women aged 45 to 55 years. The production of estrogen gradually decreases, so that menstruations becomes irregular and then disappear completely. Ovulation may occur sporadically for up to 2 years after stopping menstruation.
- Taking a hormonal contraception. The “rules” that occur between 2 platelets of pills are not rules related to an ovulatory cycle, but bleeding from “deprivation” to stopping the tablets. Some of these pills reduce bleeding that may not occur after a few months or years of use. The Mirena Intrauterine Intrauterine Device (IUD), the injectable Depo-Provera, the Continuous Contraceptive Pill, the Norplant and Implanon implants can cause amenorrhea. It has no gravity and is evidence of contraceptive effectiveness: the user is often in the “hormonal state of pregnancy”, and does not ovulate. It does not have a cycle or rules.
- Stop taking a contraceptive (contraceptive pills, Depo-Provera, Mirena hormonal IUD) after several months or years of use. It may take a few months before the normal cycle of ovulation and menstruation recovers. It is called post-contraceptive amenorrhea. Indeed, hormonal contraceptive methods reproduce the hormonal status of pregnancy, and can therefore suspend the rules. These may take some time to come back after stopping the method, as after pregnancy. This is particularly the case in women who had a very long cycle (more than 35 days) and unpredictable before taking the contraceptive method. Post-contraceptive amenorrhea is not problematic and does not compromise subsequent fertility.
- The practice of a discipline or a demanding sport such as marathon, bodybuilding, gymnastics or professional ballet. The “amenorrhea of the sportswoman” is attributable to the lack of fatty tissue and the stress to which the body is subjected. There is a lack of estrogen in these women. It can also be for the body not to waste energy unnecessarily since it often undergoes a diet low in calories. Amenorrhea is 4 to 20 times more common among athletes than in the general population.
- Stress or psychological shock. Psychogenic amenorrhea is the result of psychological stress (death in the family, divorce, loss of employment) or any other type of important stress (a trip, major changes in lifestyle, etc.). These conditions may temporarily interfere with the functioning of the hypothalamus and cause a cessation of menstruation as long as the source of stress persists.
- Rapid weight loss or pathological eating behavior. Too little body weight can lead to a decline in estrogen production and a cessation of menstruation. In most women with anorexia or bulimia, menstruation stops.
- Excessive secretion of prolactin by the pituitary. Prolactin is a hormone that promotes growth of the mammary gland and lactation. An excess of secretion of prolactin by the pituitary gland may be caused by a small tumor (which is always benign) or by some drugs (antidepressants, in particular). In the latter case, its treatment is simple: the rules reappear a few weeks after stopping the drug.
- Obesity or overweight.
- Taking certain medications such as oral corticosteroids, antidepressants, antipsychotics or chemotherapy. Addiction can also cause amenorrhea.
- Uterine scars. Following an intervention to treat uterine fibroids, endometrial resection or sometimes caesarean section, there may be a significant decrease in menstruation, or even temporary or lasting amenorrhea.
The following causes are much less common.
- An abnormal development of sex organs of non-genetic origin. The syndrome of insensitivity to androgens is the presence, in a XY (genetically male) subject, of sexual organs of female appearance due to the lack of sensitivity of cells to male hormones. These “intersexed” people with a female appearance consult at puberty for primary amenorrhea. The clinical examination and ultrasound allows the diagnosis: they have no uterus, and their sex glands (testicles) are located in the abdomen.
- Chronic or endocrine diseases. An ovarian tumor, polycystic ovary syndrome, hyperthyroidism, hypothyroidism, etc. Chronic diseases that are accompanied by significant weight loss (tuberculosis, cancer, rheumatoid arthritis or other systemic inflammatory disease, etc.).
- Medical treatments. For example, surgical removal of the uterus or ovaries; chemotherapy and radiotherapy of cancers.
- An anatomical anomaly of the sexual organs. If the hymen is not perforated (imperforate), it can be accompanied by a painful amenorrhea in the pubescent girl: the first rules remain trapped in the vaginal cavity.
Evolution and possible complications
The duration of amenorrhea depends on the underlying cause. In the majority of cases, amenorrhea is reversible and easily treated (except, of course, amenorrhea due to
Genetic abnormalities, unoperable malformations, menopause or removal of uterus and ovaries). However, when long-term amenorrhea is not treated, the cause may eventually reach reproductive mechanisms.
In addition, amenorrhea associated with a lack of estrogen (amenorrhea caused by demanding sports or an eating disorder) makes it more likely to cause long-term osteoporosis – hence fractures, vertebral instability. And lordosis – since estrogens play a vital role in preserving bone structure. It is now well known that female athletes who suffer from amenorrhea have a lower bone density than normal, which is why they are more prone to fractures. If moderate exercise helps to prevent osteoporosis, the excess exercise, in turn, has the opposite effect if it is not balanced by a higher calorie intake.
Symptoms of Amenorrhea
In a woman who has never had a period
- No menstruation at 14 years of age and no development of secondary sexual characteristics.
- No menstruation at the age of 16 despite the presence of development of secondary sexual characteristics.
- Absence of menstruation over a period equal to at least 3 intervals of previous menstrual cycles or 6 months without menstruation.People at risk
All women are likely to be amenorrhoeic at some point in their lives. See the list of causes above.
Here are the most common ones.
- A significant weight loss.
- A prolonged stress.
- The intensive practice of a sports activity.
- A deficient diet.
In the case of ovarian dysfunction in a young woman, hormonal treatment will be suggested for the development of sexual characteristics and fertility, and to prevent osteoporosis in the long term.
For women who have undergone surgical removal of the uterus and ovaries very early (before the presumed age of menopause), hormone replacement therapy including estrogens and progestins may be proposed to prevent osteoporosis and other conditions. Consequences attributable to the lowering of circulating hormone levels. This treatment can be interrupted around 55 years.
Caution: This treatment cannot be prescribed to women who have had the uterus or ovaries removed for hormone-dependent cancer. It cannot be prescribed to women who have undergone ovarian castration by radiotherapy or chemotherapy for breast cancer.
Apart from these situations, no hormonal treatment is effective to cause the return of the rules.
In addition, “regularization of the cycle”treatments (for example, the taking of a synthetic progestin in the second part of the cycle for women with irregular periods who would like a regular cycle to conceive) do not rest on any scientific basis. They can even help to accentuate menstrual cycle disorders by compromising the spontaneous occurrence of ovulations. It is not the regularity of the cycle that counts, but the respect of the cycle as it is in a given woman.
When amenorrhea is due to elevated prolactin secretion associated with a benign pituitary tumor, bromocriptine (Parlodel) is a very effective drug that lowers prolactin levels and allows the return of menses. This is the same treatment that is given just after giving birth to women who do not want to breastfeed.
If amenorrhea is accompanied by a psychological disorder, it is possible that the doctor offers psychotherapy. The parallel use of hormonal treatments may be discussed, depending on the age of the woman, the duration of amenorrhea and the adverse effects of hormonal deficiency (if it exists). However, psychotropic drugs should be avoided because they can lead to amenorrhea.
An amenorrhea associated with anorexia necessitates a follow-up by a multidisciplinary team including nutritionist, psychotherapist, psychiatrist, etc. The anorexia often affects teenage girls and young women.
In case of significant psychological trauma (rape, loss of a loved one, accident, etc.) or personal conflicts (divorce, financial difficulties, etc.), an amenorrhea lasting several months, or even years, can take place, especially in a woman whose psychic balance was already fragile. The best treatment is to consult a psychotherapist.
If amenorrhea is caused by a malformation of the reproductive system, surgery can sometimes be undertaken (in case of imperforation of the hymen for example). But if the malformation is too important (Turner’s syndrome or insensitivity to androgens), the surgery will only have a cosmetic and comfort function by changing the appearance and functionality of the undeveloped sexual organs, but will not “return” the rules.