Secondary amenorrhea

Definition

Secondary amenorrhea occurs when a woman who has been having normal menstrual cycles stops getting her periods for 6 or more months.

Women who are pregnant, breastfeeding, or in menopause are not considered to have secondary amenorrhea.

Alternative Names

Amenorrhea - secondary; No periods - secondary; Absent periods - secondary; Absent menses - secondary; Absence of periods - secondary

Causes, incidence, and risk factors

Women who are taking birth control pills or who receive hormone shots such as Depo-Provera may not have any monthly bleeding. When they stop taking these hormones, their periods may not return for more than 6 months.

You are more likely to have amenorrhea if you:

• Are obese
• Exercise too much and for long periods of time
• Have very low body fat (less than 15% - 17%)
• Have severe anxiety or emotional distress
• Lose a lot of weight suddenly (such as with strict or extreme diets or after gastric bypass surgery)

Other causes include:

• Brain (pituitary) tumors
• Chemotherapy drugs for cancer
• Drugs used to treat schizophrenia or psychosis
• Overactive thyroid gland
• Polycystic ovarian syndrome
• Reduced function of the ovaries

Also, procedures such as a dilation and curettage (D and C) can lead to scar tissue formation that may cause a woman to stop menstruating. This is called Asherman syndrome. Scarring may also be caused by some severe pelvic infections.

Symptoms

In addition to having no menstrual periods, other symptoms can include:

• Breast size changes
• Weight gain or weight loss
• Discharge from the breast (galactorrhea) or change in breast size
• Increased hair growth in a "male" pattern (hirsutism) and acne
• Vaginal dryness
• Voice changes

If amenorrhea is caused by a pituitary tumor, there may be other symptoms related to the tumor, such as vision loss and headache.

Signs and tests

A physical exam and pelvic exam must be done to check for pregnancy. A pregnancy test will be done.

Blood tests may be done to check hormone levels, including:

• Estradiol levels
• Follicle stimulating hormone (FSH level)
• Luteinizing hormone (LH level)
• Prolactin level
• Serum hormone levels such as testosterone levels
• Thyroid stimulating hormone (TSH)

Other tests that may be performed include:

• CT scan or MRI scan of the head to look for tumors
• Biopsy of the lining of the uterus
• Genetic testing 
• Ultrasound of the pelvis or hysterosonogram

Treatment

Treatment depends on the cause of the amenorrhea. Normal monthly periods usually return after the condition is treated.

A lack of menstrual period due to obesity, vigorous exercise, or weight loss may respond to a change in exercise routine or weight control.

Support Groups

Expectations (prognosis)

The outlook depends on the cause of amenorrhea. Many of the conditions that cause secondary amenorrhea will respond to treatment.

Complications

Calling your health care provider

Call for an appointment with your primary health care provider or women's health provider if you have missed more than one period so that you can get diagnosed and treated, if necessary.

Prevention

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References

Lobo RA. Primary and secondary amenorrhea and precocious puberty: etiology, diagnostic evaluation, management. In: Lentz GM, Lobo RA, Gershenson DM, Katz VL, eds. Comprehensive Gynecology. 6th ed. Philadelphia, PA: Mosby Elsevier; 2012:chap 38.

Bulun SE. The physiology and pathology of the female reproductive axis. In: Melmed S, Polonsky KS, Larsen PR, Kronenberg HM, eds. Williams Textbook of Endocrinology. 12th ed. Philadelphia, Pa: Saunders Elsevier; 2011:chap 17.