Amenorrhea is the absence of menstruation in a woman of reproductive age. The term "amenorrhea" is derived from the Greek for loss, men for months and rhein to flow.
2% to 5% of women would be affected by amenorrhea. This is a symptom of which it is important to know the cause. The absence of rules is quite natural when, for example, the woman is pregnant, breastfeeding or menopause approaches. But outside of these situations, it can be a telltale sign of chronic stress or a health problem such as anorexia or disorder of the thyroid gland.
Types
Primary amenorrhea: when at the age of 16, the rules have not yet been triggered. Secondary sex characteristics (breast development, pubic hair in the armpits and fat distribution and hips, buttocks and thighs) may still be present.
Secondary amenorrhea: when a woman has been menstruating and ceases to be for one reason or another, over a period equivalent to at least three intervals of previous menstrual cycles or 6 months without menstruation.
When to see?
Often, the fact of not knowing why we suffer from amenorrhea is worrying. The following people should consult a doctor:
- Women with primary or secondary amenorrhea;
- In the case of post-contraceptive amenorrhea, a medical evaluation is necessary if amenorrhea persists for more than six months in women who have been on birth control pills, having worn a hormonal IUD Mirena, or more than 12 months after the last injection Depo-Provera.
Important. Sexually active women who are not taking hormonal contraceptive should take a pregnancy test if their period is delayed for more than eight days, even when they are "certain" not to be pregnant. Note that the bleeding that occur under hormonal contraceptive (especially false rules generated by the pill) are not evidence of absence of pregnancy.
Diagnosis
In most cases, physical examination, a pregnancy test and sometimes an ultrasound sexual organs are sufficient to guide the diagnosis.
A radiograph of the wrist (to assess pubertal development), hormonal measurements or research of chromosomal sex are produced in rare cases of primary amenorrhea.
Causes
The causes of amenorrhea are numerous. Here are the most frequent in descending order.
Pregnancy. Most common cause of secondary amenorrhea, it must be the first suspected in a sexually active woman. Surprisingly, it often happens that this case be dismissed without prior verification, which is not without risk. Some treatments indicated for treating amenorrhea are cons-indicated during pregnancy. And with the tests commercially available, diagnosis is straightforward.
Delayed puberty without gravity. It's the most common causes of primary amenorrhea. The age of puberty is normally between 11 and 13 years, but can vary greatly depending on ethnicity, geographic location, food, and health.
In developed countries, delayed puberty is common among young women who are very thin or athletic. It seems that these young women do not have enough body fat to enable the production of estrogen hormones. Estrogens allow thickening of the uterine wall, and menstruation subsequently if the egg has been fertilized by a sperm. In a way, the bodies of these young women naturally protects and noted that their fitness is inadequate to support a pregnancy.
If their secondary sexual characteristics are present (appearance of breasts, pubic hair and armpits), there is no need to worry before the age of 16 or 17 years. If signs of sexual maturation are still absent at the age of 14 years, suspect a chromosomal problem (only one X sex chromosome instead of two, a disease which is called Turner syndrome), a problem development of the reproductive system or a hormonal problem.
Breastfeeding. Often breastfeeding women do not menstruate. However, note that they can still have an ovulation during this period, and thus a new pregnancy. Breastfeeding suspends ovulation and protects against pregnancy (99%) only if:
- The baby is exclusively breast;
- The baby is less than six months.
The arrival of menopause. Menopause is the natural cessation of menstrual cycles occurring in women aged 45 years to 55 years. The production of estrogen decreases gradually, so that menstruation become irregular and then completely disappear. It can occur sporadically ovulations during the 2 years following the cessation of menstruation.
Taking hormonal contraception. The "rules" that occur between two pill packs are not rules related to ovulatory cycle, but bleeding "deprivation" stopped tablets. Some of these pills decrease bleeding that sometimes after a few months or years outlet, can no longer occur. The intrauterine device (IUD), hormonal Mirena, the injectable Depo-Provera, birth control pills continuously, Implanon and Norplant implants can cause amenorrhea. It has no gravity and demonstrates contraceptive effectiveness: the user is often found in "pregnancy hormone" and does not ovulate. It therefore has no cycle, no rules.
The decision of taking a contraceptive (birth control pills, Depo-Provera, hormonal IUD Mirena) after months or years of use. There may be a delay of a few months is necessary before normal ovulation and menstruation cycle recovers. It's called post-contraceptive amenorrhea. Indeed, methods of hormonal contraception reproduce the hormonal state of pregnancy, and can suspend the rules. These may therefore take some time to return after stopping the method, as after pregnancy. This is especially true in women who had a very long cycle (over 35 days) and unpredictable before taking the contraceptive. The post-contraceptive amenorrhea is not a problem and does not affect subsequent fertility. Women who discover they have fertility problems after the birth had before, but because of their birth, they did not have "tested" their fertility.
The practice of a discipline or a demanding sport such as marathon running, bodybuilding, gymnastics or ballet career. The "athletic amenorrhea" is attributable to the lack of fat tissue and the stress to which the body is subjected. A lack of estrogen can be observed in these women. It can also be for the body not to waste energy unnecessarily because often undergoes a diet low in calories. Amenorrhea is 4-20 times more frequent among athletes than in générale1 population.
Stress or psychological shock. The so-called psychogenic amenorrhea result of psychological stress (death in the family, divorce, job loss) or any other type of major stress (travel, major changes in lifestyle, etc.). These states can temporarily impair the function of the hypothalamus and cause a cessation of menstruation as long as the source of stress persists.
A rapid weight loss or pathological eating behavior. Too low body weight can lead to decreased estrogen production and a cessation of menstruation. In the majority of women who suffer from anorexia or bulimia, menstruation stops.
Excessive prolactin secretion by the pituitary. Prolactin is a hormone that promotes the growth of the mammary gland and lactation. An excess of prolactin secretion by the pituitary gland may be caused by a small tumor (which is always benign) or by certain drugs (antidepressants, in particular). In this case, treatment is simple: rules reappear a few weeks after stopping the medication.
Obesity or overweight.
Taking certain medications such as oral corticosteroids, antidepressants, antipsychotics or chemotherapy. Substance abuse can also cause amenorrhea.
Uterine scarring. Following a procedure to treat uterine fibroids, resection of the endometrium or sometimes a cesarean section, there may be a significant reduction of the rules or a temporary or permanent amenorrhea.
The following causes are much less frequent.
Abnormal development of the sexual organs of non-genetic origin. The androgen insensitivity syndrome is the presence, in an XY subject (genetically male), sexual organs of female aspect by absence of cell sensitivity to male hormones. These people "intersex" with a feminine aspect to consult puberty for primary amenorrhea. The clinical and ultrasound examination allows diagnosis: they do not have a uterus, and gonads (testes) are located in the abdomen.
Chronic or endocrine diseases. A tumor of the ovary, polycystic ovary syndrome, hyperthyroidism, hypothyroidism, etc. Chronic diseases which are accompanied by a significant weight loss (TB, cancer, rheumatoid arthritis or other systemic inflammatory disease, etc.).
Medical treatments. For example, surgical removal of the uterus or ovaries; chemotherapy and radiotherapy of cancers.
An anatomical abnormality of the sexual organs. If the hymen is not perforated (imperforate), this may be accompanied by a painful amenorrhoea in the girl reached puberty: the first rules remain trapped in the vaginal cavity.
Evolution and possible complications
The duration of amenorrhea depends on the underlying cause. In most cases, amenorrhea is reversible and is easily treated (except, of course, of amenorrhea associated with genetic defects, non-operable malformations, menopause or ablation uterus and ovaries). However, when a long amenorrhea is not treated, the cause may eventually reach the mechanisms of reproduction.
Furthermore, amenorrhea associated with a lack of estrogen (amenorrhea caused by demanding sports or eating disorder) makes them more at risk of long-term osteoporosis - so fractures, instability of the vertebrae and lordosis - since estrogens play an essential role in preserving the bone structure. It is now well known that athletes who suffer from amenorrhea women have lower bone density than normal, which is why they are more prone to fractures1. If the practice of moderate exercise helps to prevent osteoporosis, excessive exercise, meanwhile, has rather the opposite effect if it is not balanced by a higher caloric intake.
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