Amenorrhea

Menstruation occurs when the lining of the uterine cavity sheds along with blood and tissue through the vaginal canal. The regular menstrual cycle is a complex process controlled by the hypothalamus and pituitary gland in the brain. The hypothalamus regulates the pituitary gland, which, in turn, controls ovulation and the release of hormones like estrogen and progesterone from the ovaries. These hormones prompt the thickening of the uterine lining, preparing it for embryo implantation and pregnancy.

Amenorrhea is the absence of menstruation, typically lasting 3-6 months. Approximately 1 in 4 women experience amenorrhea at least once in their lifetime.

Types of amenorrhea include:

• Primary amenorrhea occurs when a person reaches age 15 without experiencing their first menstrual period or after entering puberty for at least five years and still does not have regular periods. It can be due to genetic factors or other acquired causes.
• Secondary amenorrhea is when a person who previously had regular menstrual cycles experiences the absence of periods for 3-6 months or longer. It can result from pregnancy, breastfeeding, stress, or chronic medical conditions.

Symptoms

The main symptom is the absence of menstrual periods. However, other symptoms may occur depending on the underlying cause, including:  

• Menopausal symptoms include hot flashes, increased body hair growth (hirsutism), and vaginal dryness.
• Galactorrhea.
• Acne.
• Headache.
• Vision change.

Causes

• Natural amenorrhea due to pregnancy, breastfeeding, or menopause 
• Medications, such as contraceptives, allergy and blood pressure drugs, antipsychotics, antidepressants, and chemotherapy
• Lifestyle factors such as excessive exercise, high energy expenditure, low body fat, being underweight or 10% less than regular weight, common in athletes or ballet dancers, and eating disorders such as bulimia or anorexia nervosa can disrupt menstrual cycle. Psychological stress can impact hormone levels and menstruation. 
• Hormonal imbalance from health conditions, such as polycystic ovary syndrome (PCOS) that always keeps your hormone levels high, abnormal thyroid hormone secretions such as hyperthyroidism or hypothyroidism causing menstrual irregularities, pituitary tumors, and premature menopause.
• Structural problems of reproductive organs
  
  • Intrauterine adhesions (Asherman's Syndrome) can develop after cesarean section, surgery for uterine adhesion, or dilation and curettage.  
  • Congenital absence of reproductive organs such as the uterus, cervix, or vagina
  • Constricted or obstructed vagina can obstruct menstrual flow.
    Risk factors

The risk factors for amenorrhea include:

Stress, excessive intense exercise, being overweight or underweight, nutritional imbalances, eating disorders, chronic illness, family history of early menopause or amenorrhea, or genetic health conditions that affect the female reproductive system.

Complications

Amenorrhea, or the absence of menstrual periods, can lead to various complications and health risks, especially when it persists over an extended period. Here are some potential complications associated with amenorrhea:

• You may have infertility if you do not ovulate regularly.
• You are at higher risk of miscarriage if your amenorrhea is due to hormone imbalance.
• You are at risk of osteoporosis and cardiovascular disease due to insufficient estrogen levels. 
• You may have pelvic pain if amenorrhea is secondary to an anatomical problem.
• You may develop psychological stress from missing periods.

Diagnosis

• History taking and physical examination.
  The doctor will inquire about the menstrual history and perform a pelvic examination. Keeping a record of menstrual history can aid in diagnosis.
• Pregnancy test
• Blood tests
• Genetic testing to assess if you have primary ovarian insufficiency, especially if you are younger than 40.
• Imaging tests, including pelvic ultrasound to assess the ovaries and uterus and MRI to check your hypothalamus and pituitary gland.

Treatment

Natural causes of amenorrhea, such as pregnancy or breastfeeding, require no treatment. However, if amenorrhea is due to other issues, lifestyle adjustments can be helpful. Start by adopting a healthy diet and regular exercise like weightlifting or muscle-strengthening activities and managing stress. Some individuals may require hormone therapy with substances like estrogen, calcium, or vitamin D. In structural abnormalities, surgery may be performed for uterine adhesion, pituitary tumor, vaginal septum, or imperforate hymen.

Prevention

• Consume a balanced diet that includes all five food groups.
• Engage in regular physical exercise.
• Ensure adequate and quality sleep and relaxation.
• Manage stress effectively.
• Schedule regular check-ups with a gynecologist for pelvic examinations and Pap smears. 
• Keep a record of your menstrual cycles to track the onset and duration of your periods and identify any missed periods.

Preparing for Your Doctor's Appointment

• Ask family members if anyone has experienced amenorrhea.
• Keep a record of your symptoms, including the date and duration of your periods, medications and supplements you're taking, any emotional stressors you're facing, and questions you have for the doctor, such as:
  
  • What could be causing amenorrhea?
  • Do I need further examinations?
  • What are the treatment options? 

Be prepared to answer common questions the doctor may ask, such as:

• When was your last period?
• Are you sexually active?
• Are you using contraception?
• Are you currently experiencing any stress?
• Have you noticed any changes in your weight?
• Do you engage in regular exercise?
• Are you dealing with any other health issues?