Discover causes, symptoms, and treatments for Secondary Amenorrhea at Meri Sehat. It's the condition where menstruation stops for six months or more after regular cycles.

Secondary Amenorrhea

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ZAKA CLINIC GULBERG LAHORE

Saad Ullah Siddiqui

Overview

Secondary amenorrhea is the lack of menstruation for three months or more, in women with previously regular periods. In women with irregular periods, secondary amenorrhea is the absence of periods for 6 months or more. 
While it is normal for some women to experience irregular periods from time to time, the sudden absence of periods can be a sign of an underlying medical condition. Understanding the potential causes of secondary amenorrhea can help individuals seek appropriate medical treatment.

&nbsp;

Approximately 5-7% of women in the United States experience secondary amenorrhea<a href="#accordion">[6]</a>. A Pakistani study assessing the prevalence of menstrual disorders among adolescents found a prevalence of 12.2% for secondary amenorrhea<a href="#accordion">[7]</a>.

Menopause, pregnancy, and lactation are the most common physiological causes of secondary amenorrhea. While other causes, such as eating disorders, PCOS, stress, and thyroid disorders account for 2-5% of cases<a href="#accordion">[3]</a>. 
&nbsp;

Amenorrhea is defined as the lack of a menstrual period. It is not a disease, but rather a symptom of different conditions. Amenorrhea can be divided into primary and secondary.

According to the American College of Obstetricians and Gynecologists (ACOG), primary amenorrhea is when a girl does not menstruate by the age of 15 years. Whereas, secondary amenorrhea is the absence of periods for 3 months or more in a woman who already menstruates. 
&nbsp;

Primary amenorrhea can result from genetic disorders (e.g., Turner Syndrome), pituitary gland or hypothalamus dysfunction, and structural defects in the organs of the reproductive system. On the other hand, secondary amenorrhea can be due to various reasons e.g. oral contraceptives, weight changes, stress, and conditions, such as PCOS, pituitary tumors, and hypothyroidism. 
&nbsp;

There are no known types of secondary amenorrhea. 
&nbsp;

Signs and Symptoms

The absence of menstruation is the characteristic sign of amenorrhea. However, depending on the underlying cause, women can experience several other symptoms. These include:

<ul>
	<li>Vaginal dryness</li>
	<li>Hot flashes</li>
	<li><a href="https://merisehat.pk/disease/acne">Acne</a></li>
	<li>Hair loss</li>
	<li>Voice deepening</li>
	<li>Headache</li>
	<li>Unwanted or excessive hair growth on the face and body</li>
	<li>Vision changes</li>
	<li>Milky discharge from the nipples</li>
	<li>Pelvic pain 
	&nbsp;</li>
</ul>

Note: If your periods are missing for more than three cycles or if your symptoms seem to be worsening, contact a healthcare professional immediately<a href="#accordion">[1]</a>. 
&nbsp;

Causes

During a menstrual cycle, estrogen levels rise and cause the uterus lining to thicken for a potential pregnancy. If an egg is not fertilized, estrogen levels drop, and the uterus lining is shed during the menstrual period. However, various factors can cause disturbances in this process.

<ol>
	<li>Pregnancy - The most common cause of secondary amenorrhea is pregnancy, which is the absence of menstrual periods due to the growth and development of the fetus. 
	&nbsp;</li>
	<li>Polycystic Ovaries -&nbsp; Ovarian cyst growth can result from hormonal imbalances brought on by conditions like polycystic ovary syndrome (PCOS). Ovarian cysts are noncancerous, benign masses that form in the ovaries. 
	&nbsp;</li>
	<li>Thyroid Disorders - An overactive or underactive thyroid gland can interfere with the body&#39;s hormonal balance and disrupt the menstrual cycle. 
	&nbsp;</li>
	<li>Stress - Emotional stress is another potential factor contributing to secondary amenorrhea. Extreme stress may disturb the regular menstrual cycle. Management of the stress and anxiety will lead to the menstrual cycle resuming. 
	&nbsp;</li>
	<li>Rapid Weight Loss Or Gain - Significant weight loss or gain can disrupt the hormonal balance, cause irregular menstrual periods, and eventually, secondary amenorrhea. Weight has an impact on menstruation. Women who are overweight or have less than 15% body fat risk having irregular menstrual cycles. This is particularly true for athletes who train too hard or excessively. 
	&nbsp;</li>
	<li>Medications - Certain medications, such as hormonal contraceptives, can cause temporary secondary amenorrhea. 
	&nbsp;</li>
	<li>Pituitary Disorders - Excessive prolactin production and benign pituitary tumor are pituitary disorders that can cause secondary amenorrhea. 
	&nbsp;</li>
	<li>Hypothalamus Disorders - Disorders of the hypothalamus, such as functional hypothalamic amenorrhea (FHA), also known as hypothalamic amenorrhea (HA) can result in secondary amenorrhea. FHA occurs when amenorrhea is linked to stress or weight loss but isn&#39;t clearly brought on by a physical problem with a woman&#39;s body. 
	&nbsp;</li>
	<li>Premature Ovarian Failure - This occurs when the ovaries stop functioning before the age of 40, leading to hormonal imbalances and early menopause. There is a higher chance of having early menopause if it already runs in the family. 
	&nbsp;</li>
	<li>Breastfeeding - Lactating women have high levels of prolactin as the hormone helps produce milk. The hormone also plays a role in preventing ovulation. Thus, the periods are delayed. 
	&nbsp;</li>
	<li>Surgical Procedures -&nbsp; Menstruation can also be halted by scar tissue that develops after repeated dilatation and curettage (D &amp; C) surgeries or pelvic infections. In a similar manner, adhesions, or fibrous tissue in the uterus or cervix, can lead to Asherman syndrome and obstruct the menstrual flow4. During a D &amp; C, the cervix is dilated and the uterine lining is scraped with a tool called a curette. The uterus&#39; extra tissue is frequently removed using this surgical technique. 
	&nbsp;</li>
</ol>

There are no screening tests for secondary amenorrhea. 
&nbsp;

Diagnosis

Secondary amenorrhea results from several underlying conditions. For this reason, the diagnosis may require a series of tests to confirm the causative factor.

<ul>
	<li>Medical History: The doctor will ask about the woman&#39;s menstrual history, including the date of her last period and any changes in her menstrual pattern or symptoms. They will also inquire about any medical conditions or medications that could be affecting the menstrual cycle. 
	&nbsp;</li>
</ul>

<ul>
	<li>Physical Exam: A general physical exam will be done, including a pelvic exam to assess the reproductive organs and check for any abnormalities or signs of pregnancy. 
	&nbsp;</li>
	<li>Pregnancy Test: This helps doctors rule out pregnancy, the most common cause of secondary amenorrhea. 
	&nbsp;</li>
</ul>

<ul>
	<li>Blood Tests: Blood tests may be done to check hormone levels, such as thyroid-stimulating hormone (TSH), prolactin, follicle-stimulating hormone (FSH), luteinizing hormone (LH), and estradiol. These tests can help identify hormonal imbalances that may be contributing to amenorrhea. 
	&nbsp;</li>
</ul>

<ul>
	<li>Imaging Tests: Depending on the suspected cause, imaging tests such as an ultrasound, CT scan, or MRI may be done to look for abnormalities in the reproductive organs or pituitary gland. 
	&nbsp;</li>
	<li>Hysteroscopy: This involves passing a thin, lighted camera through the vagina and the cervix to the inside of the uterus. It is usually reserved for cases where no specific cause is found with other diagnostic tests. 
	&nbsp;</li>
	<li>Other Tests: In some cases, additional tests such as a test for sexually transmitted infections (STIs), or a biopsy of the uterine lining may be done. 
	&nbsp;</li>
</ul>

Treatment

The first step of treatment is to identify the underlying cause. Treating it can resolve amenorrhea and any associated symptoms.

<ul>
	<li><a href="https://merisehat.pk/disease/polycystic-ovary-syndrome-pcos">PCOS </a>can be treated with progesterone or combined oral contraceptive pills. Metformin may be given for insulin resistance.</li>
	<li><a href="https://merisehat.pk/disease/hypothyroidism">Hypothyroidism </a>can be treated with thyroid hormones (thyroxine replacement).</li>
	<li><a href="https://merisehat.pk/disease/hyperthyroidism">Hyperthyroidism </a>can be treated with ablation, thioamides, or surgery.</li>
	<li>Hyperprolactinemia can be treated with dopamine agonists or tumor removal.</li>
	<li>Ovarian failure may be treated with hormone replacement therapy.</li>
	<li>Cervical stenosis can be treated with cervical dilation.</li>
	<li>Asherman syndrome can be treated by hysteroscopy.</li>
	<li>Hypothalamic-pituitary dysfunction can be treated with hormone replacement therapy or lifestyle changes.</li>
	<li>Ovarian cysts may require surgical removal.</li>
	<li>Lifestyle changes such as regular exercise and a healthy diet can help treat amenorrhea due to obesity or excess weight.</li>
	<li>Stress management techniques can help relieve stress that can contribute to secondary amenorrhea.</li>
	<li>Psychological help for eating disorders. 
	&nbsp;</li>
</ul>

Additional treatments may also be prescribed to avoid any complications. These include:

<ul>
	<li><a href="https://merisehat.pk/disease/vitamin-d">Vitamin D</a> and calcium supplements to prevent the weakening of bones.</li>
	<li>Strength training to maintain muscle strength.</li>
	<li>Estrogen therapy to treat hot flashes and vaginal dryness. 
	&nbsp;</li>
</ul>

Amenorrhea poses no danger to life.&nbsp; However, depending on the underlying cause, it can lead to several complications. These include:

<ul>
	<li>A higher incidence of hip and wrist fractures</li>
	<li>Weakened bones</li>
	<li>Infertility</li>
	<li>Psychological stress</li>
	<li>Pelvic pain</li>
	<li>Cardiovascular disease, e.g., heart attack 
	&nbsp;</li>
</ul>

The following factors can increase the risk of secondary amenorrhea.

<ul>
	<li>Hormonal disorders</li>
	<li>Eating disorders</li>
	<li>Obesity or underweight</li>
	<li>Smoking</li>
	<li>Stress</li>
	<li>Excessive exercise</li>
	<li>Chronic disease</li>
	<li>Family history of amenorrhea or early menopause</li>
	<li>History of gynecologic procedures, such as dilation and curettage (D&amp;C) 
	&nbsp;</li>
</ul>

The following measures can help prevent secondary amenorrhea

<ul>
	<li>Maintaining a healthy weight</li>
	<li>A healthy diet</li>
	<li>Stress management</li>
	<li>Avoiding strenuous exercise</li>
	<li>Quitting smoking and alcohol</li>
	<li>Regular gynecological appointments and Pap smear</li>
	<li>Adequate sleep</li>
	<li>Treating underlying conditions, such as PCOS 
	&nbsp;</li>
</ul>

<ul>
	<li>A recent study evaluated the possible association between covid vaccination and changes in the menstrual cycle4. The team of researchers observed more than 3,000 premenopausal women in Canada and the United States. They collected information on COVID-19 vaccination status, history of positive SARS-CoV-2 test, vaccine type, and menstrual cycle characteristics. To assess the participants&rsquo; pre-COVID menstrual cycle characteristics, the researchers used data from between 2011 and 2016. Any post-COVID changes were collected with the help of surveys completed in 2020 and 2021. As per the results, vaccinated women were more at risk of increased menstrual cycle length. Thus, demonstrating that&nbsp; the COVID-19 vaccine may cause temporary changes in the menstrual cycle length, especially in women who had irregular cycles before vaccination. Therefore, it is essential to monitor menstrual health during vaccine clinical trials. Further research is needed to understand the possible biological causes of this effect. 
	&nbsp;</li>
	<li>The journal, Frontiers in Endocrinology recently published a case report of hypothalamic amenorrhea following COVID-19 in a 36-year-old woman5. Further research is needed to confirm this as a complication of SARS-CoV-2 infection, as it is difficult to detect the virus in hypothalamic tissue. The authors recommend that clinicians monitor patients for potential endocrine disorders following COVID-19, especially hypothalamic-pituitary dysfunction and female infertility, and provide appropriate diagnostic and therapeutic management for reproductive health. 
	&nbsp;</li>
</ul>

Key Points

<ul>
	<li>Secondary amenorrhea is the lack of menstruation for more than three months or irregular menstruation for more than six months in females&nbsp;with previously regular cycles.</li>
	<li>While it is normal for some women to experience irregular periods from time to time, the sudden absence of periods can be a sign of an underlying medical condition.</li>
	<li>You should contact your doctor if your periods are missing for more than three cycles or if your symptoms seem to be worsening.</li>
	<li>Secondary amenorrhea frequently results from physiologic factors such as pregnancy, lactation, and menopause. Between 2% and 5% of women get secondary amenorrhea for all other reasons.</li>
	<li>Secondary amenorrhea can be caused by many underlying conditions. For this reason, the diagnosis may require a series of tests to confirm the causative factor.</li>
	<li>Amenorrhea poses no danger to life. Amenorrhea must constantly be assessed because some reasons could eventually result in elevated risks.</li>
	<li>In some cases, additional tests such as a test for sexually transmitted infections, or a biopsy of the uterine lining may be done.</li>
	<li>The doctor will first rule out pregnancy which is the most common cause.</li>
	<li>Hypothalamic-pituitary dysfunction can be treated with hormone replacement therapy or lifestyle changes.</li>
</ul>

[1] Roth E. Secondary amenorrhea: Causes, symptoms, and diagnosis. Healthline.

[2] Amenorrhea & secondary amenorrhea: Causes, diagnosis & treatment. Cleveland Clinic.

[3] StatPearls. Secondary amenorrhea. StatPearls.

[4] Wang S, Mortazavi J, Hart JE, et al. A prospective study of the association between SARS-CoV-2 infection and COVID-19 vaccination with changes in usual menstrual cycle characteristics [published online ahead of print, 2022 Jul 13]. Am J Obstet Gynecol. 2022;227(5):739.e1-739.e11. doi:10.1016/j.ajog.2022.07.003

[5] Facondo P, Maltese V, Delbarba A, et al. Case Report: Hypothalamic Amenorrhea Following COVID-19 Infection and Review of Literatures. Front Endocrinol (Lausanne). 2022;13:840749. Published 2022 Jun 10. doi:10.3389/fendo.2022.840749

[6] Kristi A Tough DeSapri MD. Amenorrhea. Background, Pathophysiology, Etiology.

[7] Zafar M, Sadeeqa S, Latif S, Afzal H. PATTERN AND PREVALANCE OF MENSTRUAL DISOREDERS IN ADOLESCENTS. International Journal of Pharmaceutical Sciences and Research. 2018;9(5). doi:10.13040/ijpsr.0975-8232.9(5).2088-99