Irregular Periods (Amenorrhea): Causes and Treatment

Irregular periods or absence of periods (amenorrhea) are irregularities in the cycles of time from the first day of bleeding to the start of the next menstrual period. Normally, about one year after the first period, a woman’s usual menstrual pattern settles into vaginal bleeding that occurs every 28 days, lasts 1–8 days and is not excessively heavy or clotted.

Absence of periods is known as AMENORRHEA. This type of menstrual irregularity, which we can describe as not having periods, can be examined in two groups: primary amenorrhea and secondary amenorrhea, which develops later.

What Is Never Having a Period (Primary Amenorrhea)?

It is when periods never start. In most girls, menstrual periods begin between the ages of 9 and 18, with an average age of 12.

• If an adolescent girl has never had a period even though breast development and pubic and underarm hair have begun,
• If she is over 15 years of age,

this is referred to as "primary amenorrhea" .

Causes of Primary Amenorrhea

It can be seen when the genital and pelvic organs are congenitally absent or defective.

For example;

• Severe narrowing or complete closure of the cervix, which forms the lower part of the uterus
• An imperforate (closed) hymen
• Absence of the uterus and/or vagina
• Formation of a vaginal septum
• Hormonal causes: secretory or physical problems in the hormonal system involving the brain, thyroid and ovaries
• Anorexia
• Chronic diseases (cystic fibrosis, heart diseases)
• Genetic disorders
• Infections
• Poor nutrition
• Tumors
• Other congenital defects

Apart from the explanatory causes listed above, no definite cause can be identified in most cases.

Diagnosis and Diagnostic Methods for Primary Amenorrhea

• Physical and genital examination findings: These are evaluated together with your medical history, such as the medications and other supplements you use, your exercise and eating habits and whether you are pregnant, as well as your family history. A diagnosis is sought through other investigations.
• Laboratory tests: In addition to a pregnancy test, other hormone tests are performed.
• Chromosomal or genetic tests.
• Brain CT or MRI scan.
• Pelvic ultrasonography.

Treatment Approaches for Primary Amenorrhea

Treatment is planned according to the underlying cause.

• For absent periods due to congenital defects, hormonal treatment, surgery or both may be considered.
• If the absence of periods is due to a brain tumor, the tumor may need to be surgically removed after being shrunk with certain medications, and in some cases radiotherapy may need to be added after surgery.
• In cases of amenorrhea due to chronic systemic diseases and eating disorders, resolving the medical problem may bring on menstruation.
• In cases of amenorrhea that cannot be treated, achieving development consistent with female anatomy through hormonal treatment is important both for the patient to feel better and to protect the bones.

If a young girl has not started her period by the age of 14 despite showing other signs of puberty, or if she has passed the age of 15 without signs of puberty or the onset of menstruation, be sure to consult an obstetrician-gynecologist.

What Is Menstrual Irregularity (Secondary Amenorrhea)?

The absence of menstruation for 3 consecutive months, other than during menopause, breastfeeding or pregnancy, is called secondary amenorrhea. The most common cause of this menstrual irregularity is pregnancy; other causes are related to the reproductive organs and hormonal regulation.

Signs and Symptoms of Secondary Amenorrhea

In addition to irregular periods or absence of periods, the following signs may be present depending on the underlying cause:

• Milky discharge from the nipple
• Hair loss
• Headache
• Vision problems
• Pelvic pain
• Facial hair growth

Causes of Secondary Amenorrhea

Natural causes:

• Pregnancy
• Breastfeeding
• Menopause

Contraceptives:

• Use of birth control medications: some oral or injectable birth control medications can cause an absence of periods over a long period. A return to normal is expected after the method is stopped.

Medications:

• Antidepressant and antipsychotic medications, cancer chemotherapy drugs, blood pressure medications, medications used to treat allergies

Lifestyle;

• Very low body weight
• Excessive exercise: may be seen in athletes and ballet dancers.
• Stress

Hormonal Disorders:

• Polycystic ovary syndrome
• Thyroid disorder
• Pituitary tumors
• Early menopause

Structural problems:

• Adhesions in the uterine cavity (Asherman syndrome)
• These may develop after curettage, cesarean section or fibroid surgery.

Complications of Amenorrhea

• Infertility
• Osteoporosis, weakening of the bones

Diagnosis and Diagnostic Methods for Secondary Amenorrhea

Gynecological and general systemic examination:

• In addition to breast and genital examinations in particular, a detailed neurological examination may be needed for hormonal disorders originating from brain tissue.

Laboratory tests:

• Pregnancy test
• Thyroid function tests (TSH, T3, T4)
• Ovarian function tests (FSH)
• Prolactin test
• Androgenic hormones: testosterone.

Imaging methods:

• Ultrasound
• Computed tomography
• MRI, especially pituitary MRI.

Treatment Approach for Secondary Amenorrhea

Treatment approaches targeting the underlying disease are applied. If there are tumors or structural problems, a surgical approach may be needed. In conditions caused by lifestyle, behavioral changes are recommended regarding the patient’s weight, stress and contraception.