Amenorrhoea: what it is, symptoms, cause

By Cristiano Antonino On Jan 18, 2023

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Amenorrhoea is the absence of menstruation, a condition that can occur physiologically in certain phases of a woman’s life: before puberty, during pregnancy and, for a more or less long period, during breast-feeding, after menopause

Outside the circumstances just described, the lack of menstrual flow is to be considered a pathological condition.

In such cases amenorrhoea may be generated:

pathologies that cause an alteration in the general condition
diseases specific to the genital apparatus
severe physical or psychological stress
drugs such as antipsychotics, chemotherapy, antidepressants, antihypertensives or even common hormonal contraceptives.

Amenorrhoea, i.e. the lack of menstrual flow, can be distinguished into:

primary, when menarche (or first menstruation) has not yet occurred by the time the child reaches 16 years of age
secondary, when menstruation is absent for more than 6 months in women with previous irregular flows or for the duration of 3 cycles in the case of women with regular menstrual cycles.

Young women with an absence of menstruation are assessed for primary amenorrhoea if

the first menstruation did not occur at 16 years of age in cases with normal growth and development of secondary sexual characteristics.
they still show no signs of puberty (e.g. breast development) at the age of 13.

Patients of childbearing age are assessed for secondary amenorrhoea if they have already menstruated and report

absent menstrual cycles for more than 3 months if previous menstrual cycles were regular, or for more than 6 months if previous menstrual cycles were irregular
less than 9 menstrual cycles per year
a sudden change in the menstrual cycle.

The assessment of secondary amenorrhoea must evidently include a pregnancy test

The medical history of the condition must verify

whether menstruation has ever occurred (to distinguish primary from secondary amenorrhoea) and, if so, when menarche appeared
when patients have reached certain important signs of growth, including telarche (breast development during puberty)
whether flows have ever been normal
when the last regular menstrual period occurred
how long menstruation lasts and how abundant it is
whether the flow is accompanied by significant discomfort (which may raise suspicion of structural abnormalities)
whether patients experience mood swings and cyclic breast soreness.

The anamnesis must also include specific questions about the possible intake of drugs such as:

cancer chemotherapy drugs (e.g. alkylating drugs such as bendamustine, cyclophosphamide and ifosfamide)
sexual hormones that can induce virilisation (e.g. androgens, oestrogens, high-dose progestins, over-the-counter anabolic steroids)
contraceptives
medicines that affect dopamine (e.g. antihypertensives, antipsychotics, opiates, tricyclic antidepressants, anticonvulsants)
systemic corticosteroids
over-the-counter products and supplements, some of which contain bovine hormones or interact with other drugs
substance abuse.

Finally, possible risk factors should be examined, such as

family history of amenorrhoea or early menopause
obesity or severe underweight
eating disorders, such as anorexia and bulimia
a diet too low in nutrients
excessive physical exercise (as can happen to some female athletes, for example, if they practise sport too intensively)
stress and severe fatigue.

The absence of menstruation is the symptom par excellence that identifies amenorrhoea

However, there may also be signs of an extragenital nature such as:

acne, oily skin and hair
hypertrichosis (increased hair on the body and face), or hair loss
galactorrhoea, i.e. the discharge of milk-like fluid from the nipples.

For patients with secondary amenorrhoea, symptoms may include hot flushes, vaginal dryness, sleep disturbances, fragility fractures, and decreased libido.

Causes and complications

Outside of physiological causes, such as pregnancy and lactation, the triggers for amenorrhoea can be varied and divided into four macro-classes

anatomical abnormalities of the uterus and vagina; malformations of the uterus may be congenital or the result of surgery, radiation or infection. The main anatomical abnormalities of the vagina are imperforate hymen, vaginal septa and partial development of the vagina
primitive ovarian abnormalities; these may be linked to chromosomal diseases such as Turner syndrome or Swyer syndrome. Then there is a condition – Premature ovarian failure, POF or premature menopause – in which for complex reasons the ovaries stop functioning prematurely (before the age of 40). In other circumstances the ovaries are absent due to congenital or surgical factors, or damaged as a result of infections, autoimmune diseases, radiotherapy or chemotherapy treatments
dysfunction of the ovaries related to other pathologies; these are healthy ovaries that ‘work poorly’ because the ovaries’ activity is in turn affected by hormones produced by other glands such as the hypothalamus, pituitary, adrenal glands and thyroid. These causes include: anorexia nervosa, prolactin-producing pituitary adenomas, tumours and brain trauma, cushing’s syndrome, Addison’s disease, hypothyroidism or hyperthyroidism, hyperandrogenemia and polycystic ovary syndrome
extra-genital causes, such as states of severe malnutrition capable of inducing the interruption of menstrual function, as well as nervous and psychic factors, sudden violent emotions, daily stress and too intense sports practice in female athletes. Also in the sports field, amenorrhoea, associated with osteoporosis and eating disorders, composes a clinical picture known as the ‘female athlete triad’. This condition can be seen among professional female athletes and, more generally, among women who do a lot of physical activity without following a diet that is adequate for their real needs.

Amenorrhoea, depending on the causes that generate it, can also have serious complications, such as

pelvic pain, if amenorrhoea is linked to a malformation of the reproductive system
infertility and pregnancy disorders, as the absence of menstruation may be linked to ovulation failure or hormonal imbalances
a higher risk of cardiovascular disease and osteoporosis if amenorrhoea is caused by oestrogen deficiency.

Treatment of amenorrhoea

The treatment of amenorrhoea must obviously take into account the aetiological factors involved, as well as the patient’s age.

Diagnosis generally requires a gynaecological examination with pelvic examination and other tests, such as pregnancy tests and blood hormone assays, particularly those generated by the thyroid, ovaries and pituitary gland.

If necessary, tests such as ultrasound, MRI and hysteroscopy may also be necessary to identify any abnormalities in the reproductive organs.

Depending on the underlying cause, amenorrhoea may require the use of different therapies, sometimes hormonal, unless the absence of flow is related to physiological factors (in which case no intervention is required).

If amenorrhoea is generated by obesity or excessive thinness, or by excessive exercise, a diet plan to reach a healthy weight and appropriate exercise programmes are suggested respectively.

In some cases, such as congenital anomalies or tumours, surgery will be necessary.