Definition

Secondary amenorrhoea is the absence of menstruation for three or more consecutive menstrual cycles in a woman who has previously experienced menstruation.

Causes

Some cases of secondary amenorrhoea are considered natural, such as during pregnancy, lactation, or menopause. However, some cases of amenorrhoea might be due to medication side effects or signify an underlying medical condition. Causes of secondary amenorrhoea include:

• Contraception. Contraceptive tablets can induce amenorrhoea in certain individuals. After discontinuing contraceptive tablets, it will take a while for the menstrual cycle to normalize. Injectable birth control, implant birth control, and IUDs can lead to amenorrhoea.
• Medications. These medicines induce amenorrhoea:
  • Antipsychotic
  • Chemotherapy for cancer
  • Antidepressant
  • Antihypertensive
  • Antihistamine
• Lifestyle factors. Lifestyle can have an impact on the menstrual cycle. Examples include:
  • Low body mass index. Anaemia (10% below the recommended body weight) has the potential to disrupt hormonal processes, including ovulation. Women afflicted with eating disorders, including anorexia or bulimia, frequently encounter disturbances in their menstrual cycles as a result of hormonal fluctuations.
  • Excessive amount of exercise. Individuals who engage in physically demanding activities, such as ballet or athletics, may be susceptible to developing menstrual cycle disorders. Athletes are susceptible to secondary amenorrhoea due to fatigue, high energy expenditure, and low body fat mass.
  • Stress. Psychological stress has the potential to disrupt the function of the hypothalamus, the brain region responsible for regulating hormones and the menstrual cycle. As a result, ovulation and menstruation may stop.
• Hormonal imbalance. Numerous medical conditions can cause hormonal imbalances, including:
  • Polycystic ovary syndrome (PCOS). PCOS is characterised by persistently elevated levels of reproductive hormones in comparison to healthy individuals.
  • Thyroid dysfunctions. Insomnia or hypothyroidism has the potential to induce menstrual cycle irregularities, such as amenorrhoea.
  • A pituitary tumor. Pituitary gland benign (noncancerous) tumors have the potential to disrupt the regulation of menstrual hormones.
  • Early menopause. Menopause typically commences around the age of fifty. However, menstruation ceases and the number of ovarian cells decreases in some women before the age of 40.
• Tissue changes. Additionally, reproductive organ dysfunction can result in amenorrhoea. Scar tissue on the uterus is an example. Asherman's syndrome is a pathological state characterised by the development of scar tissue on the inner uterine lining. It can manifest after uterine tumor therapy, curettage, or cesarean section. The formation of scar tissue on the uterus inhibits the natural processes of uterine wall thickening and discharge that take place during menstruation.

Risk factor

The following variables may increase the risk of developing amenorrhoea:

• Hereditary history of amenorrhoea.
• Eating disorders. Individuals with an eating disorder, including anorexia or bulimia, are more susceptible to developing amenorrhoea.
• Athletic practice. An intense training schedule may elevate the susceptibility to amenorrhoea.
• A prior uterine surgical procedure or procedure, including curettage, may elevate your risk of developing amenorrhoea.

Symptoms

Some indications and symptoms are associated with the underlying cause. In addition to discontinuation of menstruation, patients may also have the following symptoms:

• Milky discharge from the nipple
• Hair loss
• Headache
• Visual impairment
• Excessive facial hair
• Pelvic pain
• Acne

Diagnosis

The doctor will perform a medical interview with the patient to diagnose amenorrhoea. Following the medical interview, the doctor will proceed with a physical examination.

A physical examination involves inspecting the pelvis to detect any irregularities in the patient's reproductive organs. The absence of menstruation can indicate a more intricate hormonal issue. Identifying the reason will be time-consuming and may necessitate multiple supportive examinations.

The following examinations are being performed:

• Blood tests

• • Pregnancy test. This may be the initial checkup suggested by a doctor to either exclude or verify the potential for pregnancy.
  • Thyroid function assessment. Assessing the level of thyroid stimulating hormone (TSH) in the blood helps determine the appropriate functioning of the thyroid gland.
  • Assessment of ovarian activity. Assessing the level of follicle-stimulating hormone (FSH) in the bloodstream can indicate any issues with the ovaries.
  • Prolactin test. Reduced prolactin levels may indicate the presence of a pituitary gland tumor.
  • Testosterone hormone analysis. If the patient experiences heightened facial hair growth or a deeper voice, the doctor may assess their testosterone hormone levels.
• Hormone trial testing. During this test, the patient will be required to take hormonal medication for 7 to 10 days to induce menstruation. This test will determine if menstruation has stopped as a result of estrogen deficiency.
• Radiological examination.
  • The doctor may suggest ultrasonography (USG) based on the signs, symptoms, and blood test findings. This test is used to detect any irregularities in the reproductive organs.
  • MRI scan to detect the existence of a pituitary tumor.
• If additional tests are inconclusive, the doctor might suggest hysteroscopy, a procedure where a slender, flexible tube with a camera is placed via the vagina and cervix to examine the anatomy of the uterus.

Management

Treatment for secondary amenorrhoea varies based on the underlying etiology. Contraceptive pills or hormone therapy can sometimes induce the resumption of the menstrual cycle.

Thyroid and pituitary gland abnormalities causing amenorrhoea can be addressed with medication. If secondary amenorrhoea is due to a tumor or uterine tissue changes, surgery is a viable treatment option.

Complications

The causes of amenorrhoea might lead to other complications as well.

• Infertility and Complications During Pregnancy
• Osteoporosis and cardiovascular disease
• Dyspareunia

Prevention

Certain lifestyle factors, such as excessive exercise or inadequate dietary intake, can cause amenorrhoea. Strive to achieve equilibrium between work, exercise, leisure, and relaxation. Solicit assistance from family, friends, or a medical professional if you are unable to manage stress independently. Effective stress management can help avoid amenorrhoea.

When to see a doctor?

If you miss your period three consecutive times, you should seek advice from a doctor.

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