Amenorrhea

Amenorrhea is a menstrual condition characterized by absent menstrual periods for more than three monthly menstrual cycles. In an adolescent, amenorrhea can be a sign of a medical problem or a side effect of certain medications.

There are two types of amenorrhea:

  • Primary amenorrhea, in which menstruation does not occur by age 15.
  • Secondary amenorrhea is due to some physical cause and usually has a later onset. An adolescent with secondary amenorrhea begin normal and regular menstrual periods, which later become increasingly abnormal and irregular, or are absent completely.

If a teen has not started menstruating by age 15, or menstrual cycles have stopped or become irregular, they should be examined by a doctor with expertise diagnosing and treating young people with menstrual issues.

Causes of amenorrhea

Amenorrhea in adolescents may be caused by a variety of factors.

Pregnancy and breastfeeding

People do not ovulate while they are pregnant, thus, menstruation stops temporarily. Breastfeeding can also affect menstruation, causing less frequent and lighter periods.

Medications

While birth control methods can affect the frequency and intensity of a person’s menstrual cycle — even after they’ve been discontinued — other medications can cause menstrual irregularity. These medications include: antidepressants, blood pressure drugs, chemotherapy to treat cancer or antipsychotics.

Lifestyle factors

Lifestyle factors can have a significant impact on a person’s menstrual cycle. The three most common are:

  • Low body weight — Adolescents with eating disorders, such as anorexia or bulimia often experience amenorrhea as a result of low body weight or disordered eating behaviors. Essentially, the body “shuts down” its reproductive system because it is severely malnourished.
  • Excessive exercise — Young athletes also often experience amenorrhea due to excessive exercise, low body fat and stress.
  • Stress — Significant mental stress can also affect the hypothalamus, the part of the brain that controls hormones that regulate the menstrual cycle. Once stress decreases, often regular periods return.

Hormonal imbalance

Hormone imbalances can also cause amenorrhea. The three most common in adolescents are:

  • Thyroid underactivity (hypothyroidism) and overactivity (hyperthyroidism), which causes either not enough thyroid hormone or too much thyroid hormone to flow in the bloodstream, leading the body’s metabolism to either be too slow or too fast.
  • Polycystic ovarian syndrome, which causes high or sustained hormone levels rather than the changes seen during a normal menstrual cycle.
  • Tumor in the pituitary gland, which can interfere with normal hormone regulation which can affect menstruation.

Structural problems

In rare cases, problems with the sexual organs themselves can cause amenorrhea. These may include:

  • Birth defect, anatomical abnormality, or other medical condition. If a young person has not started to menstruate by age 15, they should be examined by an adolescent expert to determine if a birth defect, anatomical abnormality, or other medical condition is present.
  • Structural abnormality. In some cases, a vaginal obstruction — such as a membrane or wall — may block blood from flowing out of the uterus and cervix and prevent typical menstrual bleeding.
  • Uterine scarring. Some young people may experience uterine scarring that prevents the normal construction and shedding of the uterine lining. This condition, known as Asherman’s syndrome, is more likely after treatment for uterine fibroids, a cesarean section or dilation and curettage (D&C).
  • Lack of reproductive organs. In very rare cases, a young person’s reproductive system may not have developed normally and they may have been born without a major part of the reproductive system, such as the uterus, cervix or vagina. Because of this physical difference, they can’t have menstrual cycles. 

Diagnosis and testing

Adolescents with amenorrhea should be referred to clinicians who have expertise in Adolescent Medicine. At Children’s Hospital of Philadelphia (CHOP), these young people are evaluated by our Adolescent Medicine specialists.

At CHOP, we welcome parents and caregivers as key partners in supporting a young person’s care during and after treatment for amenorrhea.

The diagnosis of amenorrhea begins with a series of questions about the patient’s overall medical history, menstruation cycle, sexual activity, any pregnancies, exercise frequency and any significant weight gain or loss.

To help young people develop the skills needed to be responsible for their own health, clinicians typically ask to spend time alone with patients during each visit. This helps young people become comfortable talking with their healthcare providers about their concerns and allows patients to ask questions that may be more difficult to say in front of their parents and caregivers. We respect the privacy and confidentiality of our young patients, while ensuring that young people are safe and connected to the appropriate services and resources they need.

A physical examination will follow the interview, along with a pelvic examination if appropriate. Because a diagnosis of amenorrhea can only be certain when other potential causes for halted menstruation are ruled out, additional tests may be needed.

These tests may include:

  • Thyroid function test to determine if the thyroid is working properly
  • Ovarian function test to measure certain hormones in the blood to see if the ovaries are working properly
  • Androgen test to see if high levels of androgens (like testosterone) are present, which may indicate polycystic ovarian syndrome
  • Hormone challenge test to see if lack of estrogen has caused periods to stop
  • Ultrasound to see if reproductive organs are present and shaped normally
  • Rarely, Magnetic resonance imaging (MRI) to examine the reproductive organs and check for a pituitary tumor
  • Chromosome evaluation to determine if any cells are missing, extra or rearranged

Treatment of amenorrhea

Treatment for amenorrhea may require a coordinated approach. At Children’s Hospital of Philadelphia, Adolescent Medicine specialists work closely with specialists from endocrinology, radiology, surgery, nutrition and others as needed to accurately diagnose and treat young people with menstrual issues.

Treatment for amenorrhea will be determined by the adolescent's specialist based on:

  • The adolescent's age, overall health and medical history
  • Extent of the condition
  • Cause of the condition (primary or secondary)
  • The adolescent's tolerance for specific medications, procedures or therapies
  • Expectations for the course of the condition
  • The adolescent's opinion or preference

If the adolescent’s condition is caused by lifestyle factors, the clinician may recommend changes such as:

  • Dietary modifications to help the adolescent gain or lose weight with the goal of attaining and maintaining a healthy weight. This can balance hormone levels and restore the adolescent’s normal menstrual cycle.
  • Reducing stress in the adolescent’s life. A healthcare provider may recommend stress-reducing tips or talking to a professional therapist.
  • Check physical activity level. Talk to the healthcare provider and coach/trainer about how to maintain a balance between training, nutrition and healthy menstrual cycles.

If the amenorrhea cannot be treated with lifestyle modifications, clinicians may recommend hormonal medications to regulate the menstrual cycle.

Surgery is rarely used to treat amenorrhea but may be used to remove uterine scarring or to remove a pituitary tumor.