Forms of amenorrhea and fertility

Not getting your period is a condition called amenorrhea. It’s important for fertility because not having a menstrual cycle with monthly ovulation and bleeding means you can’t get pregnant. In this factsheet, you’ll learn about the different causes of amenorrhea and which treatments can help your periods get back to normal. 

What Is Amenorrhea?

Amenorrhea is the medical term for when a woman doesn’t get her monthly period. There are times in life when this is supposed to happen, like when you’re pregnant, breastfeeding, or after menopause. But amenorrhea can also be caused by hormonal issues, structural problems with the reproductive organs, lifestyle factors or genetic disorders. The term comes from the Greek words “a”, “men”, and “rhoia” meaning “no monthly flow”. It is not a disease and it does not mean that you are infertile. 3-4% of women have amenorrhea.


Why is Amenorrhea Important in Infertility?

A majority of women with amenorrhea don’t ovulate. Without ovulation and periods, it’s not possible to get pregnant. When amenorrhea is due to a hormonal imbalance, it can also lead to miscarriage or other problems with a future pregnancy.


Types of Amenorrhea

 

There are two different types of amenorrhea:

  1. When you don’t get a period by the time you reach 15, this is called primary amenorrhea. Less than 0.1% of women have this type of amenorrhea.
  2. When you don’t get a period for 6 months or 3 cycles and you previously had a regular period before, this is called secondary amenorrhea. About 4% of women have this type of amenorrhea.

Amenorrhea can be temporary or permanent. A woman normally menstruates every 23 to 35 days. In general, if your period is irregular or if there are more than 35 days between periods, your doctor will check you for amenorrhea. 

Causes of Amenorrhea

There are many causes of amenorrhea. Let’s go through each of them:

  • Contraceptives: Some forms of contraception, including some birth control pills, injectables, implants, or intrauterine devices (IUD) can cause amenorrhea. And after you stop taking the pill, it can take some time for your body to produce the hormones for ovulation and menstruation again. If you still don’t have a regular period 6 months after stopping the pill, it should be checked by a doctor.
  • Medications: Certain medications for psychosis, depression, blood pressure, allergies, and cancer therapies including chemo and radiation can lead to amenorrhea. 
  • Stress: High stress can affect hormone regulation, getting in the way of ovulation and periods.
  • Weight changes: Very low body weight, eating disorders, and exercising too much can interfere with hormone levels and menstruation. Competing in sports increases the risk for amenorrhea.
  • Structural problems with reproductive organs: Scarring on the uterus (such as from gynecologic surgeries), missing reproductive organs, or blockages in the vagina can prevent menstrual bleeding.

Hormonal issues can also lead to amenorrhea. Sometimes, there is a problem with your hypothalamic-pituitary-gonadal axis. This is the dialogue between two parts of your brain, the hypothalamus and pituitary gland (which produces hormones) and your ovaries. Other hormonal causes include:

  • Premature ovarian failure: Also known as premature menopause or premature ovarian insufficiency, this is when the amount of eggs in your ovaries depletes before you reach 40, causing menstruation to stop. 
  • Polycystic ovary syndrome (PCOS): High levels of male hormones and cysts on the ovaries affect ovulation.
  • Thyroid issues: When the thyroid gland is overactive (hyperthyroidism) or underactive (hypothyroidism), amenorrhea can happen.
  • Pituitary tumor: If you have a noncancerous growth on your pituitary gland, it can get in the way of the hormones needed for menstruation.

How Amenorrhea Is Diagnosed

Doctors use different tests to check for amenorrhea and find out what’s causing it. First you will get a pelvic exam to check for any structural issues with your reproductive organs. After getting a pregnancy test to rule that out as the possible cause, you’ll get a variety of blood tests to check your hormone levels:

  • Follicle-stimulating hormone (FSH): Levels show if your ovaries are working as they should and if you may have PCOS.
  • Prolactin: A pituitary tumor leads to higher prolactin levels, interfering with menstruation ovulation.
  • Thyroid-stimulating hormone: Levels show if your thyroid is working as it should.

You may also get blood tests to see if genetic abnormalities may be leading to amenorrhea.

After getting the results of your blood tests back and depending on any other symptoms you have, your doctor might recommend further imaging tests such as ultrasound or magnetic resonance imaging (MRI) to get to the bottom of your missed periods.

 

Treatment of Amenorrhea

As there are so many potential causes of amenorrhea, the treatment will depend on why it’s happening. Some treatments aim to re-start your period through birth control pills or other types of hormonal therapies. For instance, hormonal treatments are used to help with fertility issues. But medications used for some ovulatory disorders (like clomiphene) may not work because of the problems with the dialogue between the hypothalamus and pituitary gland. To make you ovulate, gonadotropin-releasing hormone or a combination of luteinizing hormone (LH) and follicle-stimulating hormone (FSH) can be injected. If your period doesn’t start again after these hormonal treatments, your doctor may discuss options for assisted reproduction treatments, such as intrauterine insemination (IUI) and in vitro fertilization (IVF). Unfortunately, if primary ovarian failure is the cause of your amenorrhea, there’s no treatment that can increase your egg reserve.

Because lifestyle can be a factor, strive to maintain a healthy weight, and avoid extremes of being over or underweight and exercising too much. Be sure that you’re getting enough rest to manage stress levels too. Try some relaxation techniques like meditation, yoga, and taking warm baths. If you need it, don’t hesitate to reach out to family, friends, or a mental health professional to help you learn new strategies to reduce stress.

Takeaway

If you’ve missed several periods in a row, check-in with your doctor to find out what may be causing it. Depending on why you have amenorrhea, treatments can help your periods come back so you can get pregnant.

 

Sources

https://www.asrm.org/globalassets/asrm/asrm-content/news-and-publications/practice-guidelines/for-non-members/current_evaluation_of_amenorrhea.pdf. Current evaluation of amenorrhea. The Practice Committee of the American Society for Reproductive Medicine. Accessed 6th December2021. 

https://www.drugs.com/health-guide/amenorrhea.html. Amenorrhea, Harvard Health Topics. Accessed 11th December2021.

https://www.healthline.com/health/secondary-amenorrhea#diagnosis. Secondary Amenorrhea, Healthline. Accessed 8th December2021.

Rebar R. Evaluation of Amenorrhea, Anovulation, and Abnormal Bleeding. [Updated 2018 Jan 15]. In: Feingold KR, Anawalt B, Boyce A, et al., editors. Endotext [Internet]. South Dartmouth (MA): MDText.com, Inc.; 2000-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK279144/

Shufelt CL, et al: Hypothalamic Amenorrhea and the Long-Term Health Consequences. Semin Reprod Med. 2017;35(3):256-262. doi:10.1055/s-0037-1603581.

Sophie Gibson ME, et al: Where Have the Periods Gone? The Evaluation and Management of Functional Hypothalamic Amenorrhea. J Clin Res Pediatr Endocrinol. 2020 Feb 6;12(Suppl 1):18-27. doi: 10.4274/jcrpe.galenos.2019.2019.S0178. PMID: 32041389; PMCID: PMC7053439.

https://www.mayoclinic.org/diseases-conditions/amenorrhea/symptoms-causes/syc-20369299. Amenorrhea. Mayo Clinic. Accessed 26 January 2022.

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