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What is Amenorrhea and what causes it

What is Amenorrhea 

The amenorrhea is the absence of menstruation in a woman of reproductive age. The word “amenorrhea” comes from the Greek has for privation, even for months and rhein to sink.

Between 2% and 5% of women would be affected by amenorrhea. It is a symptom of which it is important to know the cause. The absence of menstruation is quite natural when, for example, the woman is pregnant, breast-feeding or approaching menopause. But apart from these situations, it can be a revealing sign of chronic stress or even a health problem like anorexia or a thyroid disorder.

Types of No Rules

Primary amenorrhea: when at age 16, the rules have not yet been triggered. Secondary sexual characteristics (development of breast, pubic hair and armpits and distribution of adipose tissue in the hips, buttocks and thighs) may nevertheless be present.

Secondary amenorrhea: when a woman has already been menstruating and ceases to be menstruating for one reason or another, over a period equal to at least 3 intervals of previous menstrual cycles or 6 months without menstruation.

When to consult when there are no rules?

Often, not knowing why you are suffering from amenorrhea is a concern. The following persons should consult a physician:

– Women with primary or secondary amenorrhea;

– in the case of post-contraceptive amenorrhea, a medical evaluation is necessary if the amenorrhea persists for more than 6 months in women who have been on a contraceptive pill, with a Mirenahormonal IUD, or more than 12 months after the last injection of Depo-Provera.

Important. Sexually active women who do not take hormonal contraceptives should take a pregnancy test if their periods have been delayed for more than 8 days, even when they are “certain” not to be pregnant. Note that bleeding that occurs under hormonal contraceptive (especially the false rules generated by the birth control pill) are not evidence of lack of pregnancy.

Diagnosis of Amenorrhea

In most cases, clinical examination, a pregnancy test and sometimes an ultrasound of the sexual organs are sufficient to guide the diagnosis.

A wrist radiograph (to assess pubertal development), hormonal assays or chromosomal sex is performed in rare cases of primary amenorrhea.

 Causes of lack of rules

There are many causes of amenorrhea. Here are the most frequent in descending order.

The pregnancy. The most common cause of secondary amenorrhea, it should be the first suspected in a sexually active woman. Surprisingly, this cause is often discarded without prior verification, which is not without risk. Some treatments for amenorrhea are contraindicated in pregnancy. And with the 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 and 13 years, but can vary greatly depending on ethnicity, geographical location, diet, and health status.

In developed countries, delayed puberty is common in young women who are very thin or athletic. It would appear 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 bodies of these young women naturally protect themselves and report that their fitness is inadequate to support a pregnancy.

If their secondary sexual characteristics are present (appearance of the breasts, pubic hair and armpits), there is no worry to have before the age of 16 or 17 years. If signs of sexual maturation are still absent at age 14, a chromosomal problem (a single sex chromosome X instead of 2, a disease called Turner’s syndrome) should be suspected, a development of the reproductive system or a hormonal problem.

Breastfeeding. Often, women who are breast-feeding do not have menstruation. However, it should be noted that they can still have ovulation during this period, and therefore a new pregnancy. Breast-feeding suspends ovulation and protects against pregnancy (99%) only if:

– The baby is exclusively breast- feeding;

– The baby is less than 6 months old.

The onset of menopause. Menopause is the natural stop of menstrual cycles occurring in women aged 45 to 55 years. The production of estrogens gradually diminishes, which means that the menstruation becomes irregular and then disappears completely. Ovulations may occur sporadically during the 2 years following cessation of menstruation.

Taking a hormonal contraception. The “rules” that occur between 2 pill packs are not rules related to an ovulatory cycle, but bleeding from “deprivation” when tablets stop. Some of these pills reduce bleeding which, sometimes, after a few months or years of taking, may no longer occur. The Mirena® Intrauterine Device (IUD), Depo-Provera® Injection, Continuous Contraceptive Pill, Norplant and Implanon Implants can cause amenorrhea. It is not serious and testifies to contraceptive efficacy: the user is often in “hormonal state of pregnancy”, and does not ovulate. It therefore has no cycle, no rules.

Stopping the use of contraception (birth control 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 is restored. It is called post-contraceptive amenorrhea. Indeed, hormonal contraceptive methods reproduce the hormonal state of pregnancy, and can therefore suspend the rules. These may therefore take some time to return after stopping the method, such as after a 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.

Stress or psychological shock. Psychogenic amenorrhea results from psychological stress (death in the family, divorce, loss of employment) or any other type of stress (travel, major changes in lifestyle, etc.). These conditions can temporarily affect the functioning of the hypothalamus and cause a cessation of menstruation as long as the source of stress persists.

Rapid weight loss or pathological feeding behavior. Too low body weight can lead to decreased estrogen production and stoppage of menstruation. In the majority of women who suffer from anorexia or bulimia, menstruation stops.

Excessive secretion of prolactin through the pituitary gland. Prolactin is a hormone that promotes the growth of the mammary gland and lactation. An excess of secretion of prolactin through the pituitary can be caused by a small tumor (which is always benign) or by certain drugs (antidepressants, in particular). In the latter case, its treatment is simple: the rules reappear a few weeks after the drug stopped.

Obesity or excess weight.

Taking certain medications such as oral corticosteroids, antidepressants, antipsychotics or chemotherapy. Substance abuse can also cause amenorrhea.

The 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 transient or lasting amenorrhea.

The following causes are much less frequent.

An abnormal development of sexual organs of non-genetic origin. The androgen insensitivity syndrome is the presence, in a XY (genetically male) subject, of sex organs of female appearance due to the lack of sensitivity of cells to male hormones. These “intersex” women with a feminine appearance consult at puberty for primary amenorrhea. Clinical examination and ultrasound allows the diagnosis: they have no uterus, and their sexual glands (testicles) are located in the abdomen.

Chronic or endocrine diseases. An ovarian tumor, a polycystic ovary syndrome, hyperthyroidism, hypothyroidism, etc. Chronic diseases with significant weight loss (tuberculosis, cancer, rheumatoid arthritis or other systemic inflammatory disease, etc.).

Medical treatment. 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 (imperforation), this may be accompanied by painful amenorrhea in the pubescent girl: the first menstruation remains trapped in the vaginal cavity.

Evolution and possible complications

The duration of amenorrhea depends on the underlying cause. In most cases, amenorrhoea is reversible and is easily treated (except, of course, amenorrhea related to genetic abnormalities, non-operable malformations, menopause or ablation of l uterus and ovaries). However, when long-term amenorrhea is left untreated, the cause may eventually reach reproductive mechanisms.

In addition, amenorrhea associated with a lack of estrogen (amenorrhea caused by demanding sports or eating disorders) increases the risk of osteoporosis in the long term – thus fractures , instability of the vertebrae and lordosis  – since estrogens play an essential 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 1. If the moderate exercise practice helps prevent osteoporosis, excess exercise, on the other hand, has the opposite effect if not balanced by higher caloric intake.

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