Secondary Amenorrhea (2)

Absence of menstruation for more than 3 months: what are the causes?

Dr. Claude Allouche, gynecologist Amenorrhee2 english
Ahuza Clinic, Raanana
058 726 02 64

Apart from pregnancy, breastfeeding, and menopause, an absence of menstruation for more than three months (amenorrhea) requires investigation to determine the cause.

ABSENCE OF MENSTRUATION: THREE "NORMAL" SITUATIONS IN A WOMAN'S GYNECOLOGICAL LIFE

1/ Pregnancy

Amenorrhea (absence of menstruation) is the first sign of pregnancy.
Initially, you can take a pregnancy test available at pharmacies or general stores.
If the test is positive, or if you have doubts even after a negative test, consult your doctor. In some cases, your doctor may request a blood test to measure Beta HCG levels.

2/ Breastfeeding

Breastfeeding triggers the production of a hormone in the mother called prolactin. This hormone blocks ovulation and is responsible for amenorrhea.

3/ Menopause

Menopause is the period in a woman’s life when menstruation stops permanently.
It usually occurs between the ages of 45 and 55, typically around age 50, when the ovaries stop producing hormones and eggs.
Menopause is considered complete when menstruation has been absent for one year.

Mechanism of Menopause

Menopause is a natural event in the aging process of a woman. It marks the end of the menstrual cycle and a woman’s ability to conceive.
During a woman’s fertile years, hormones such as estrogen and progesterone fluctuate in a continuous cycle to prepare the body for menstruation, conception, and pregnancy.
When the repeated release of these hormones decreases, menopause begins. Menopause typically occurs around age 50, or earlier if following the removal of the ovaries.

Symptoms vary from woman to woman. Some experience very few, if any, while others have a range of symptoms with varying severity. Menopausal symptoms include the absence of monthly periods, vaginal dryness, hot flashes, and mood swings.
Due to decreased estrogen levels, postmenopausal women are at increased risk for osteoporosis and heart disease. Patients and their doctors should discuss the risks and benefits of hormone replacement therapy.

ANATOMICAL CAUSES OF SECONDARY AMENORRHEA

1/ Cervical stenosis

The cervix becomes closed, preventing menstrual flow. This abnormal closure can occur after electrocauterization of cervical lesions or a cone biopsy performed when abnormal cervical lesions are detected.
Amenorrhea is accompanied by menstrual pain due to blood retention in the uterine cavity.
The treatment is surgical.

2/ Adhesion of the uterine mucosal walls (uterine synechiae)

The uterine mucosal walls adhere to each other. This complication can occur after an instrumental abortion, uterine curettage, or uterine revision after a hemorrhagic childbirth.
Hysteroscopy can confirm the diagnosis and provide treatment simultaneously.

PREMATURE MENOPAUSE OR PREMATURE OVARIAN FAILURE

Every woman is born with a finite ovarian reserve, which is the predetermined number of eggs formed during fetal development. This is known as the ovarian reserve.
From birth to menopause, the ovarian reserve gradually diminishes.
In cases of premature menopause, the ovarian reserve is depleted before the age of 40. The cessation of menstruation is often accompanied by symptoms similar to menopause: hot flashes, sweating, etc.

In some cases, premature ovarian failure may follow:

  • The removal of ovaries;
  • Pelvic radiotherapy;
  • Chemotherapy for cancer;
  • An autoimmune disease (such as Hashimoto's thyroiditis or autoimmune diabetes);
  • A genetic abnormality like Fragile X syndrome, caused by a defect in a gene on the X chromosome.

Hormonal replacement therapy allows for the return of “withdrawal bleeding” and prevents the onset of osteoporosis.

TEMPORARY ANOMALIES IN HYPOTHALAMIC-PITUITARY HORMONAL SECRETION

In the following situations, the pituitary gland and hypothalamus, which regulate ovarian function, are intact but are temporarily put to rest by the body.
These anomalies are reversible but may require medical care.

1/ Amenorrhea linked to a traumatic event

Menstruation may cease following a traumatic event, such as the death of a loved one, divorce, conflict, or sexual assault.
Menstruation returns when the psychological state improves.

2/ Amenorrhea in anorexia nervosa

Anorexia nervosa is diagnosed when a young woman exhibits several symptoms, including restricted food intake, weight loss, hyperactivity, and cessation of menstruation.
Amenorrhea often lasts for several months or even years, depending on the progression of the eating disorder and weight gain.
Treating anorexia and regaining weight allows the return of menstruation.
If amenorrhea persists, there is a risk of osteoporosis, and hormonal replacement therapy (estrogen-progestogen) may be prescribed.

3/ Amenorrhea in high-level athletes or women with intense physical activity

In young women who are highly athletic, nutritional intake, particularly of fats, is often insufficient compared to energy expenditure. Amenorrhea sets in when the body’s fat mass decreases significantly.
Amenorrhea is more common in endurance sports, aesthetic sports (figure skating, gymnastics), and weight-class sports (judo, boxing, etc.).

4/ Post-pill amenorrhea

After stopping hormonal contraception, it’s normal for menstruation to take several weeks to return. However, if amenorrhea persists for more than three months, further investigation is needed.

ANOMALIES IN THE HYPOTHALAMO-PITUITARY AXIS

These causes are much rarer.

1/ Abnormal prolactin secretion by the pituitary gland

Prolactin is the hormone responsible for lactation. Elevated secretion can cause discharge from the nipples without breastfeeding.
The abnormal secretion of prolactin may be caused by a pituitary adenoma (benign tumor).
Treatment with bromocriptine, a derivative of ergot, brings prolactin levels back to normal. Cycles with ovulation and the possibility of pregnancy signal recovery.
Surgery may also be considered.

2/ Rare causes of amenorrhea

Other rare causes of amenorrhea may be revealed during examinations, including:

  • A cancerous tumor (glioma);
  • After cranial irradiation for cancer treatment;
  • A genetic abnormality;
  • Autoimmune damage to the pituitary gland.

AMENORRHEA WITH VIRILIZATION OF SECONDARY SEXUAL CHARACTERISTICS

Amenorrhea may be accompanied by signs of virilization caused by androgen secretion, particularly testosterone:

  • Excessive hair growth (hirsutism) on the face (upper lip, chin), chest, back, and buttocks;
  • Oily skin and acne that persists into adulthood;
  • Hair loss (alopecia) on the top of the head and around the forehead.

These symptoms guide doctors in investigating the cause of the absence of menstruation.

POLYCYSTIC OVARY SYNDROME (PCOS)

This syndrome is common, affecting 5 to 10% of women of childbearing age.
It is associated with virilization symptoms and irregular menstrual cycles that last more than 35 to 40 days, or even a complete absence of periods (amenorrhea).
Women with PCOS often experience weight gain and difficulty losing weight.

You can learn more by visiting my website at https://claude-allouche.com.

Source: https://www.ameli.fr