Written by Dr.M.D.Mazumdar, MD
Amenorrhoea (loss of periods) can be
- Physiological (i.e. in the normal course of life)
- Pathological (i.e. due to some abnormalities).
Physiological Amenorrhea (Loss of Periods)
Amenorrhea may be normal at certain periods in a woman's life, for example, during pregnancy, during breastfeeding, before attaining puberty and after the menopause.
Pathological Amenorrhea (Loss of Periods)
Pathological Amenorrhoea or loss of periods is amenorrhea that occurs as a symptom of an underlying disease. It is not a disease process in itself. There are two types of pathological amenorrhea.
When a girl has never experienced menarche and menses, she is said to be suffering from primary amenorrhoea or primary lack of menses. The cause is usually congenital, i.e. from birth, and can be due to genetic or chromosomal abnormalities or due to a defect in the development of the reproductive tract. Treatment of this condition is very difficult.
When the patient has had at least one episode of spontaneous menses before the loss of her periods, she is said to suffer from secondary amenorrhoea. This is the commonest form of amenorrhoea. The problem may lie in the hypothalamus and the pituitary, or the uterus or the ovary. Other endocrine glands like the thyroid, the pancreas and the adrenal cortex also have a role to play in causing amenorrhoea. There are many causes of secondary amenorrhea:
A. Diseases in the Midbrain
Conditions like encephalitis or meningitis cause inflammaiton in the brain tissue or brain membranes. Tumours can press on the surrounding tissue causing loss of periods.
B. Influences from the Cerebral Cortex
Psychoses like depressive mental disorders often cause loss of menses. It can also be caused by electric convulsion therapy given as treatment for some types of mental disorders.
Emotional upsets like the death of a close friend or a relative, change of work or residence, traveling and marriage can temporarily cause amenorrhoea.
Pseudocyesis or false pregnancy is a condition in which a woman believes that she is pregnant and subconsciously suppresses her menstruation. She can also develop other signs of pregnancy like nausea and vomiting, an increase in body weight, breast changes and swelling of the abdomen. Read more...
Anorexia Nervosa is a syndrome resulting from a girl's skewed image of her own body image. The girl refuses to eat, causing severe weight loss and amenorrhea besides a number of other symptoms. Read more...
Post pill Amenorrhea: Oral Contraceptive pills can also suppress the hypothalamic-pituitary system to cause loss of periods. Read more...
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C. Pituitary Amenorrhoea
Lack of menses/periods due to a cause in the pituitary gland is very rare. But some of them are:
Tumours in or near the pituitary gland - Tumours which stimulate excessive production of the Prolactin hormone can cause amenorrhoea. Tumours near the pituitary gland can also suppress pituitary function and cause amenorrhoea.
Diseases of the anterior pituitary gland - destruction or necrosis of the anterior pituitary gland can affect almost all the glands dependent on it for stimulation. The ovaries, the thyroid, the adrenal cortex may all be affected.
Sheehan's Syndrome is a condition in which there is necrosis of the anterior pituitary, secondary to severe haemorrhage or bleeding during childbirth. The pituitary thus fails to release hormones necessary to maintain the menstrual cycle and this leads to amenorrhea. Read more...
D. Ovarian Amenorrhoea
The causes of amenorrhea in most cases lie in the ovaries.
Decreased Production of estrogens and progesterones : Surgical removal of the ovaries or exposure to radiation (e.g. exposure to X-rays) can decrease the level of these hormones in the body. Less production of estrogen and progesterone can also be due to abnormal sex chromosomes like 47XXX, 46XX/XO.
Continuous production of ostrogens and progesterones : This can occur in the presence of certain hormone producing tumours of the ovary, like thecal cell tumours.
Production of male hormones : Certain ovarian tumours can produce male hormones and can cause amenorrhoea.
Polycystic Ovarian Syndrome: Also called the Stein-Leventhal Syndrome, the chief complaint of the patient in this condition may be absent or irregular periods or very decreased flow of blood during her periods. Infertility or subfertility may also be the presenting complaint. Failure of ovulation because of the thick cortex of the ovary is believed to be the main cause of loss or irregularity of periods. Read more...
E. Uterine Causes
Congenital absence of uterus
Surgical removal of the uterus.
Damage after radiotherapy.
Asherman's Syndrome: Too heavy curettage after D&C or abortion can cause the two walls of the uterus to get damaged with formation of scar tissue. Growth of the endometrium is thus prevented, causng loss of periods or amenorrhea. Read more...
F. Other Causes
Thyroid : Both hypofunction and hyperfunction of the thyroid can cause loss of periods.
Pancreas : Diabetes mellitus can cause amenorrhoea, especially if the disease starts in childhood.
Adrenal Cortex : Tumours or hyperplasia of the adrenal cortex can cause amenorrhoea.
Chronic diseases : Most chronic diseases can cause amenorrhoea.
Of these, tuberculosis is the most important as the tuberculous toxins appear to have a special affinity for the ovary and the uterine endometrium.
Nutritional Causes : Severe starvation as seen in malabsorption syndromes and during war and famine can cause loss of periods. On the other hand, severe obesity due to overeating or any other cause can also cause amenorrhoea.
Environment : Sudden change in the environment as in change of residence or in occupation can cause amenorrhoea. Stress during examination can also cause loss of menses.
Severe exercise : as in long distance running can cause amenorrhoea.
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