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Amenorrhea (absence of menses)
Medical expert of the article
Last reviewed: 04.07.2025
Primary amenorrhea can be very distressing for the patient. In many cases, it is due to delayed puberty (often hereditary). The patient should be reassured that there is no organic cause for the disorder. Other causes include those that cause secondary amenorrhea but occur before menarche. Only a few causes are hereditary or result from morphological abnormalities, so check the following.
- Does the patient have secondary sexual characteristics? If so, is the structure of the external genitalia normal?
- If development has been disrupted, examination and karyotyping may help identify Turner syndrome or testicular feminization. The goal of treatment is to help the patient appear as a normal woman, capable of normal sexual activity and, if possible, childbearing (if she wishes).
Causes of amenorrhea
- Causes associated with dysfunction of the hypothalamic-pituitary axis are quite common, so menstrual cycle disorders often occur as a result of emotional stress, exams, weight loss, excessive production of prolactin (30% of women suffer from galactorrhea), imbalance of other hormones and severe systemic diseases, such as renal failure. Tumor and necrosis (Sheehan's syndrome) are rarely the cause. Causes associated with ovarian pathology: polycystic ovary disease, tumors, ovarian failure (premature menopause) are rare.
- Uterine dysfunction: pregnancy complications, Asherman's syndrome (uterine adhesion after previous curettage). "Pill-induced amenorrhea" is a common oligomenorrhea masked by regular "cancellation" of bleeding.
Who to contact?
Diagnosis of amenorrhea
Serum LH (elevated in polycystic ovary syndrome), FSH (very high in premature menopause), prolactin (elevated in cipecce, prolactinomas, and after taking certain medications such as phenothiazines) and thyroid function tests are the most informative diagnostic tests. Up to 40% of patients with hyperprolactinemia have tumors, so skull X-rays and CT scans may be required.
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Treatment of amenorrhea
Treatment of amenorrhea is determined by the cause. In case of premature menopause, hormone replacement therapy should be prescribed, which requires control of symptoms of estrogen deficiency and protection against osteoporosis.
Dysfunction of the hypothalamic-pituitary axis
In moderate disturbances (e.g., stress, mild weight loss), it is possible to stimulate sufficient ovarian estrogen production to form the endometrium (which will be shed after discontinuing progesterone, e.g., norethisterone 5 mg every 8 hours for 7 days), but the temporal regulation is impaired, so cycles are not restored. In more severe disturbances, the axis stops functioning (e.g., severe weight loss). FSH and LH levels, and therefore estrogen, are low. It is advisable to have a proper discussion with the patient, prescribe therapeutic nutrition, relieve stress, and recommend that she see a psychiatrist. Advise her to use contraceptives, since ovulation can occur at any time. If the patient wishes to restore fertility immediately or needs the reassurance of the onset of menstruation, then clomiphene citrate can be prescribed for moderate disturbances, but stimulation with gonadotropin-releasing hormone is necessary to restore the axis.
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