What is Secondary Amenorrhea?

Secondary amenorrhea is a condition where a woman, who has already started her menstrual cycle, stops having periods for six months or more. While some experts believe that not having periods for just three months can be diagnosed as amenorrhea, the American College of Obstetricians and Gynecologists uses the six-month rule.

What Causes Secondary Amenorrhea?

Secondary amenorrhea, or the stopping of menstrual periods, can be caused by three main things: hormonal imbalances, damage to the endometrium (the lining of the uterus), or blockages that prevent menstrual bleeding from leaving the body. Hormonal disturbances can disrupt your regular menstrual cycle. Physical harm to the endometrium can stop it from growing properly. Obstructions in the path that menstrual blood takes out of the body can also cause this condition.

Risk Factors and Frequency for Secondary Amenorrhea

Pregnancy, breastfeeding, and menopause are all normal life events that can cause a woman to stop having menstrual periods, a condition known as secondary amenorrhea. Aside from these, other causes result in about 2% to 5% of cases of secondary amenorrhea.

Signs and Symptoms of Secondary Amenorrhea

Secondary amenorrhea is a condition where a woman, who normally has regular menstrual cycles, stops getting her periods. The investigation process for secondary amenorrhea includes understanding a woman’s complete menstrual history. Key pieces of information include the type of birth control being used since some birth control methods that contain progestin can prevent the growth of the womb lining, potentially causing secondary amenorrhea. It’s also vital to establish if the patient’s periods have always been infrequent and irregular, indicating that she may not be ovulating, or if the cessation was sudden.

Also, understanding if there were any events such as childbirth, surgery, trauma, pelvic infection, or a dilation and curettage procedure before the amenorrhea commenced is important. Symptoms like headaches, visual changes and unusual milk production (galactorrhea) could suggest an overproduction of prolactin from a pituitary gland tumor. It’s also essential to evaluate symptoms associated with thyroid problems, which may include fatigue, weight changes, skin/hair/nail changes, sensation of a rapidly beating heart (palpitations), and a faster than normal heart rate. The presence of excessive body or facial hair and acne could indicate polycystic ovary syndrome. It’s also key to inquire about the patient’s levels of stress and physical exercise routines since too much of either may lead to a condition called hypogonadotropic hypogonadism.

A physical examination will involve calculating the Body Mass Index (BMI) and checking for signs of illness or condition like acanthosis nigricans, hirsutism, acne, and virilization.

Testing for Secondary Amenorrhea

The first step in examining any patient with secondary amenorrhea, a condition where a woman who previously had normal menstrual cycles stops having them for several months, is a urine pregnancy test. This is because, regardless of age, anyone who has a menstrual cycle can potentially become pregnant. All methods of contraception have a chance to fail.

If the pregnancy test is negative, doctors will then look to other signs such as the presence of masculine characteristics, acne, and a long history of infrequent and irregular periods. These symptoms might suggest a condition known as polycystic ovarian syndrome (PCOS). A woman may be diagnosed with PCOS if she has at least two out of these three symptoms: masculine characteristics or excess androgen hormones, irregular or missing periods, or accumulation of small immature egg follicles in the ovaries that can be observed in an ultrasound. In this case, if the woman has signs of masculine characteristics and irregular or missing periods, she can be diagnosed with PCOS without needing further lab tests or imaging.

If the symptoms do not align with PCOS, a thyroid-stimulating hormone (TSH) test should be ordered. Both overactive and underactive thyroid can lead to menstruation issues.

If the TSH test is normal, the next step is to check the prolactin hormone level in the blood. An increased prolactin level might signify a non-cancerous tumour in the pituitary gland, a condition known as prolactinoma.

If prolactin levels are normal, the next procedure is a progestin challenge. In this situation, the patient is given an oral hormone tablet (most commonly, medroxyprogesterone). After the treatment, the patient should experience a slight bleeding, mimicking menstrual bleeding. If there’s no bleeding, this means that there is either insufficient estrogen hormone to stimulate the growth of the womb lining, or the lining of the womb has been damaged and is not able to grow, or the menstrual blood flow has been blocked.

If the patient also has masculine features and experiences this ‘withdrawal bleed’, conditions like PCOS, ovarian or adrenal gland tumours, or Cushing syndrome may be suspected.

If no withdrawal bleed occurs, the next step involves an estrogen-progestin challenge, which includes giving the patient combined oral contraceptives. If the lining of the womb is healthy and the outflow is not blocked, then stopping the oral contraceptives should also lead to a ‘withdrawal bleed’. If the patient doesn’t bleed after the progesterone treatment but does after one month of contraceptives, this might suggest a decrease in sex hormones, a condition known as hypogonadism, which then requires a follicle-stimulating hormone (FSH) and estradiol test.

If FSH level is high and estradiol level is low, ovarian failure is suspected. High FSH indicates that the pituitary gland is trying to stimulate the ovaries to produce estrogen, but the ovaries are not responsive.

Low levels of both FSH and estradiol suggest dysfunction in the hypothalamus, the part of the brain that controls the hormonal balance, or the pituitary gland, which is commonly due to stress, exercise, or damage to the pituitary gland (Sheehan’s syndrome).

If there’s no withdrawal bleed after a month of contraceptives, damage to the lining of the womb (Asherman’s syndrome) or blockage to the outflow of menstrual blood might be suspected. A transvaginal ultrasound may be conducted to check for trapped menstrual blood in the uterus (hematometra). A hysteroscopy, a procedure that involves examining the inside of the uterus, would be the subsequent step to examine Asherman’s syndrome. If any trapped blood is released while dilating the cervix, this could suggest cervical stenosis, a narrow or constricted cervix, as the cause and might also potentially cure the condition.

Treatment Options for Secondary Amenorrhea

The treatment for amenorrhea, or the absence of a menstrual period, varies according to what’s causing it. Here are some possible causes and treatments:

1. Polycystic ovarian syndrome (PCOS): This is a hormonal disorder common among women of reproductive age. It can be managed through weight loss, medication for insulin resistance such as metformin, and medication to control the menstrual cycle. These might include birth control pills or devices that contain progestin, a female hormone.

2. Hypothyroidism: This is a condition where the thyroid gland does not produce enough thyroid hormones. Treatment usually involves replacing the missing hormones with a medicine called thyroxine.

3. Hyperthyroidism: This is when your thyroid is making too much of the thyroid hormones. Treatment might involve the use of thioamides – medications that reduce the production of thyroid hormones; ablative therapy, which uses medication or radiation to kill excess thyroid cells; or surgery to remove part of the thyroid gland.

4. Hyperprolactinemia: This is a condition of excess prolactin, a hormone responsible for milk production. Treatment might involve medications like bromocriptine or cabergoline, or surgical removal of tumours in the pituitary gland that are causing the excess prolactin.

5. Ovarian failure: This happens when ovaries fail to function properly, and it might be managed with hormone replacement therapy. This depends on factors such as the patient’s age, symptoms, and other health risks.

If the cause of amenorrhea is due to a problem with the hypothalamic-pituitary system (parts of the brain that control hormone production), lifestyle changes or hormone replacement may help.

Asherman syndrome, caused by scar tissue formation in the womb, could be treated with a procedure called hysteroscopic lysis, which breaks down the adhesions.

If amenorrhea is due to a narrowing of the cervix (known as cervical stenosis), it may require cervical dilation, a procedure to widen it.

There are several medical conditions that can be associated with specific symptoms. These include:

Loss of appetite or anorexia
Various anxiety disorders
Congenital adrenal hyperplasia, a genetic disorder affecting the adrenal glands
Depression
Abnormalities in the level of follicle-stimulating hormone, a hormone important in sexual development
Iatrogenic Cushing syndrome, a condition caused by overuse of certain medications
Deficiency of luteinizing hormone, another hormone important in sexual development
Ovarian insufficiency, when the ovaries don’t produce enough estrogen
Pregnancy
Prolactinoma, a noncancerous tumor of the pituitary gland that produces a hormone called prolactin

Preventing Secondary Amenorrhea

The most common reason for a woman to stop having her period, called amenorrhea, is pregnancy. It’s important for young women to keep track of their menstrual cycles and use birth control to prevent unplanned pregnancies. Additionally, it is significant to regularly discuss women’s health history during doctor’s visits because amenorrhea could be due to an issue with the hormones, known as an endocrinological disorder. If a woman notices her menstrual cycle becoming irregular, she should get in touch with her healthcare provider.