Introduction:

Amenorrhea means not menstruating or having a period. There are two types of amenorrhea: primary and secondary. When a girl reaches age 16 and has not had a period, she may have primary amenorrhea. When a woman who has been having periods misses three in a row, she is considered to have secondary amenorrhea. Secondary amenorrhea is more common than primary amenorrhea.

Amenorrhea is a sign of another condition, not a disease itself. Many things can cause it, from low body weight to hormonal imbalances to problems with the pituitary gland. Usually the underlying condition is not serious.

Signs and Symptoms:

Symptoms of primary amenorrhea may include:

• Headaches
• Abnormal blood pressure
• Vision problems
• Acne
• Unwanted hair growth

Symptoms of secondary amenorrhea may include:

• Nausea
• Swollen breasts
• Headaches
• Vision problems
• Being very thirsty
• Goiter, an enlarged thyroid gland
• Darkening skin

Hot flashes, mood changes, depression, and vaginal dryness are common with estrogen deficiency.

What Causes It?:

Both primary and secondary amenorrhea can have several causes.

Primary amenorrhea

• Lack of reproductive organs, such as uterus, cervix, or vagina
• Problems with the pituitary gland
• Anorexia
• Stress
• Too much exercise
• Abnormal chromosones

Secondary amenorrhea

• Pregnancy or breastfeeding
• Using some kinds of birth control
• Taking some types of medication, such as corticosteroids
• Hormone imbalance
• Low body weight
• Too much exercise
• Thyroid problems
• Pituitary tumor
• Stress
• Premature menopause (menopause before age 40)

What to Expect at Your Provider's Office:

Your doctor may ask you to take a pregnancy test, then do a physical exam, which will include an internal pelvic exam. Your doctor may also order lab tests to check your hormone levels and see how your thyroid is working. Other tests may include computerized tomography (CT) scan, magnetic resonance imaging (MRI), or ultrasound.

Treatment Options:

Your doctor will see which treatment is right for you based on what's causing the problem. Treatments include hormone therapy, psychological counseling and support, and surgery, among others.

Drug Therapies

Your health care provider may suggest the following:

• Birth control pills or hormones to cause you to start menstruating.
• Estrogen replacement for low levels of estrogen caused by ovarian problems, hysterectomy, or menopause. Women with an intact uterus should get estrogen plus progesterone. Estrogen or hormone replacement therapy (HRT) has both benefits and risks. Post-menopausal women who take HRT have higher risk of breast cancer, stroke, heart disease, and blood clots in the lungs. However, for some younger women the benefits may outweigh the risks. Talk to your doctor to decide what's best for you.
• Progesterone to treat ovarian cysts and some problems with the uterus.

Complementary and Alternative Therapies

Staying at a proper weight and exercising the right amount can keep your body healthy. Other alternative therapies may help your body make and use hormones properly.

Nutrition and Supplements

Be sure to eat a healthy diet: Eat fewer processed foods, and eat foods with heart-healthy fats (unsaturated fats) rather than saturated fats. Avoid caffeine and alcohol. Eat more whole grains, vegetables, and omega-3 fatty acids found in cold-water fish, nuts, and seeds. Diets that are very low in fat can raise your risk of amenorrhea. In addition, these supplements may help:

• Calcium (1,000 mg per day), magnesium, vitamin D (200 - 400 IU per day), vitamin K (1 mg per day), and boron (1 to 3 mg per day). Women who don' t have periods are at higher risk of osteoporosis, and these vitamins and minerals may help keep bones strong. Vitamin K can interact with blood thinning medications such as warfarin (Coumadin) and clopidogrel (Plavix).
• B6 (200 mg per day) may reduce high prolactin levels. Prolactin is a hormone released by the pituitary gland, and women with amenorrhea often have higher levels of prolactin.
• Essential fatty acids: Evening primrose or borage oil (1,000 - 1,500 mg one to two times per day). These fatty acids may increase the risk of bleeding, especially if you take blood-thinners such as clopidogrel (Plavix) or warfarin (Coumadin).

Progesterone is sometimes available as an over-the-counter oral supplement. However, this is a hormone that should never be taken without your doctor's supervision.

Herbs

The use of herbs is a time-honored approach to strengthening the body and treating disease. Herbs, however, can trigger side effects and can interact with other herbs, supplements, or medications. For these reasons, take herbs only under the supervision of a health care provider.

Most of the herbs listed below have not been studied specifically for amenorrhea, but have been used traditionally. Many act like the hormone estrogen in the body. Talk to your doctor before taking them, and avoid these herbs if you have a history or family history of cancers associated with estrogen. That includes breast, cervical, uterine and ovarian cancer.

• For high prolactin levels: Chaste tree (Vitex agnus-castus) may help the pituitary gland function normally and may reduce prolactin levels, but it must be taken for 12 - 18 months. One very small study found that 10 of 15 women with amenorrhea started having periods after taking chaste tree for 6 months. If you already use hormone therapy, do not use chaste tree except under your doctor's supervision. Chaste tree may interact with a number of medications, cinluding chlorpromazine (Thorazine), haloperidol (Haldol), levodopa, metoclopramide, olanzapine (Zyprexa), prochlorperazine (Compazine), quetiapine (Seroquel), ropinirole (Requip), risperidone (Risperdal). It also may make birth control pills less effective.
• These herbs have estrogen-like effects and are sometimes used to treat menopausal symptoms, although there are no clinical trials that show whether they work or are safe: Black cohosh (Cimicifuga racemosa), licorice, (Glycyrrhiza glabra), and squaw vine (Mitchella repens). Black cohosh may interact with a number of medications processed by the liver, including acetaminophen (Tylenol), atorvastatin (Lipitor), carbamazepine (Tegretol), isoniazid (INH), methotrexate (Rheumatrex), and others. Licorice interacts with many prescription and over-the-counter medications, so ask your doctor before taking it. Do not take licorice if you have high blood pressure or heart failure.
• Other herbs that may help stimulate menstrual flow include lady's mantle (Alchemilla vulgaris) and vervain (Verbena officinalis). Do not take these herbs without your doctor' s supervision. Your doctor should monitor your liver function if you take lady's mantle.
• Kelp (Laminaria hyperborea), oatstraw (Avena sativa), and horsetail (Equisetum arvense) are rich in minerals that may help promote thyroid function. Avoid horsetail if you have diabetes, take lithium, or take a diuretic (water pill) such as hydrochlorothiazide or furosemide (Lasix).

Wild yam is sometimes said to be a natural source of progesterone, but that is not true. Although it was once used to make progesterone in the laboratory, the body cannot make progesterone from wild yam.

Avoid blue cohosh (Caulophyllum thalictroides). This toxic herb should not be used without strict medical supervision.

Homeopathy

There have been few studies examining the effectiveness of specific homeopathic remedies. Professional homeopaths, however, may recommend treatments for amenorrhea based on their knowledge and clinical experience. Before prescribing a remedy, homeopaths take into account a person' s constitutional type -- your physical, emotional, and intellectual makeup.

• Pulsatilla -- For most menstrual problems, especially in women who have poor appetite and do not favor exertion; they may faint easily. They may be aggravated by heat and feel worse in the evening. They may like to be in the open air.
• Sepia -- For women with late or irregular menstruation. They may have a sallow complexion and experience frequent headaches, toothaches, and pain when bearing down. They may feel cold and want to be alone.
• Graphites -- For women with late or light menstruation. They may have a sallow complexion and experience a feeling of fullness or constipation and headaches. They often have a fair complexion.

Physical Medicine

The following help increase circulation and relieve pain from pelvic congestion:

• Castor oil pack. Apply oil to a soft, clean cloth, place on abdomen, and cover with plastic wrap. Place a hot water bottle or heating pad over the pack and let sit on your abdomen for 30 - 60 minutes. You can safely use this treatment for 3 days, although it may be beneficial to use for longer. Talk to your health care provider to determine how long to use it.
• Contrast sitz baths. Use two basins that you can comfortably sit in. Sit in hot water for 3 minutes, then in cold water for 1 minute. Repeat this three times to complete one "set." Do one to two sets per day, 3 - 4 days per week.

Acupuncture

Acupuncture is believed to improve hormonal imbalances that can go along with amenorrhea and related conditions, such as polycystic ovary syndrome (PCOS). A few small studies of women with fertility problems, which are sometimes connected with amenorrhea, suggest that acupuncture may help promote ovulation.

Acupuncturists treat people with amenorrhea based on an individualized assessment of the excesses and deficiencies of qi located in various meridians. Acupuncturists believe that amenorrhea is often associated with liver and kidney deficiencies, and treatment often focuses on strengthening function in these areas.

Special Considerations:

Becoming pregnant may be difficult or impossible. Amenorrhea also may cause pregnancy complications.

Amenorrhea can also raise the risk of developing osteoporosis.

Alternative Names:

Menstruation - absence of