Menstruation, absent

• normal delay of onset (up to age 14 or 15)
• lack of an opening in the membrane at the entrance of the vagina (hymen)
• drastic weight reduction
• congenital abnormalities of the genital system
• hypoglycemia
• extreme obesity

SECONDARY AMENORRHEA

• pregnancy
• anxiety over pregnancy may cause a missed period, thereby increasing the anxiety even further
• drastic weight reduction
• vigorous athletics
• obesity
• emotional distress
• menopause (normal for women over 45 years old)
• endocrine disorder
• drugs such as busulfan, chlorambucil, cyclophosphamide, oral contraceptives, phenothiazines, and non-oral contraceptives (such as Norplant and Depo-Provera)
• dilation and curettage ( D & C )

Note: There may be other causes of amenorrhea. This list is not all inclusive, and the causes are not presented in order of likelihood. The causes of this symptom can include unlikely diseases and medications. Furthermore, the causes may vary based on age and gender of the affected person, as well as on the specific characteristics of the symptom such as location, quality, time course, aggravating factors, relieving factors, and associated complaints. Use the Symptom Analysis option to explore the possible explanations for amenorrhea, occurring alone or in combination with other problems.

Home Care:
Treatment depends on the cause. Consult your health car provider to help determine the cause.

For amenorrhea caused by normal delay of menstruation onset, have patience until age 16. For a missed period caused by pregnancy , consult your obstetrician to confirm pregnancy. For a missed period caused by drastic weight loss or obesity , proper diet is recommended. For a missed period resulting from excessive exercise , use moderation and cut back to a more conservative program.

Call Your Healthcare Provider If:

• there is no satisfactory explanation for a missed period.

What to Expect:
The medical history will be obtained and a physical examination performed.

A complete health history will be obtained including a menstrual history. Questions may include:

• menstrual history
  • Are you a woman presently in a menstruating age (over 12 and under 55)?
  • Are you sexually active?
  • Do you use birth control ? What type?

• quality
  • Was the previous menstrual period a normal amount?
  • Are the menses absent or decreased?
  • Do you usually have regular periods?

• time pattern
  • When was your last menstrual period?
  • At what age did you have your first menstrual period?
  • Have you ever had normal periods?

• aggravating factors
  • What medications do you take?
  • How much do you exercise ?

• other symptoms
  • What other symptoms are also present?
  • Is there breast tenderness ?
  • Is there morning nausea and vomiting ?
  • Is there a headache ?
  • Is there a nipple discharge (and not breast feeding)?
  • Is there vision loss ?
  • Is there an unintentional weight gain ?
  • Is there an unintentional weight loss ?
  • Is there vaginal dryness?
  • Is there hair growth in a male pattern?
  • Are there voice changes?
  • Are there changes in the breast size?
  • Is there excessive anxiety ?

A physical examination, including a pelvic examination, will be performed. In patients with secondary amenorrhea , physical and pelvic examinations must rule out pregnancy before diagnostic testing begins. The patient may be encouraged to discuss her fears and, if indicated, may be referred for psychological counseling.

Diagnostic tests that may be performed include:

• endometrial biopsy
• progestin withdrawal
• prolactin level
• serum hormone levels such as testosterone levels
• thyroid function studies
• pregnancy test ( serum HCG )
• FSH ( follicle stimulating hormone level)
• LH ( luteinizing hormone level)
• TSH ( thyroid stimulating hormone ; other thyroid function tests )
• karyotype to rule out the presence of Y chromosome abnormality
• CT scan of the head may be done if a pituitary tumor is suspected

Intervention:
Treatment depends on the cause of the amenorrhea. If it is caused by another systemic disorder, normal menstrual function usually returns after the primary disorder is treated. For example, if the primary disorder is hypothyroidism , then amenorrhea will be cured when the thyroid disorder is treated with thyroid supplements.

Pituitary tumors are usually treated with bromocriptine, a drug that inhibits prolactin secretion. Surgery removal may also be suggested. Radiation therapy is usually reserved for situations where other medical or surgical treatment regimens are not successful.

Hormonal supplements are commonly utilized for those women who do not bleed in response to the progestin challenge test. Daily estrogen supplements are given in conjunction with intermittent progestin for 10 to 14 days per month every 1 to 3 months.

Women who bleed in response to the progestin challenge test are anovulatory--they do not menstruate because they do not ovulate. This common cause of amenorrhea is treated by inducing ovulation with medication such as clomiphene citrate (Clomid)--but only if the patient desires pregnancy.

Young women with primary amenorrhea , found to be caused by developmental abnormalities, may require hormonal supplementation, surgery, or both. In any case, psychosocial support and counseling for the patient and family is necessary to address specific concerns and provide guidance regarding anticipated sexual development.

After seeing your health care provider:
You may want to add a diagnosis related to amenorrhea to your personal medical record.