Causes of Primary and Secondary Amenorrhea

Amenorrhea is the medical term for absent menses (no period). Amenorrhea can be classified as :

1. Primary amenorrhea which occurs in young girls who have not reached menarche (the onset of menses). Amenorrhea is diagnosed in these cases if a girl has not had her periods by the age of 16 or if she is showing the signs of puberty for more than 2 years without having a period.
2. Secondary amenorrhea occurs in girls or women who were previously menstruating but this has now stopped. In these cases, missed periods can only be considered as amenorrhea if there is no sign of a period for 6 consecutive months.

Causes of Amenorrhea

Since menstruation is controlled by a cyclic play of hormones involving multiple structures in the body, any dysfunction or abnormality in any of these organs may be the cause of amenorrhea. The organs involved in ovulation and menstruation are the hypothalamus, pituitary gland, ovaries, uterus and the vagina.

Hypothalamus

The hypothalamus secretes gonadotropin-releasing hormone (GnRH), which then acts on the pituitary gland, triggering the release of follicle-stimulating hormone (FSH) and luteinizing hormone (LH).

Some of the causes for a deficiency or lack of gonadotropin-releasing hormone (GnRH) include :

• Genetic disorders.
• Starvation or malnutrition.
• Eating disorders like anorexia or bulimia.
• Excessive dieting and exercise.
• Trauma to the brain.
• Tumors of the hypothalamus.
• Irradiation of the hypothalamus, either accidental or induced due to radiation therapy.
• Narcotic use and alcohol abuse.
• Certain drugs, especially psychoactive drugs.
• Infections like tuberculosis and HIV/AIDS.
• Other chronic diseases – many chronic disorders of vital organs in the body may affect the hypothalamus.
• Psychological or psychiatric conditions like depression and schizophrenia.
• Mental and/or emotional stress.

Pituitary Gland

The pituitary gland is stimulated by gonadotropin-releasing hormone (GnRH) from the hypothalamus. Follicle-stimulating hormone (FSH) and luteinizing hormone (LH) from the pituitary gland then act on the ovaries, triggering ovulation and estrogen production.

Some of causes of amenorrhea due to pituitary dysfunction include :

• High levels of prolactin (hyperprolocatinemia).
• Trauma to the brain.
• Tumors of the pituitary gland and surrounding brain tissue.
• Infections like TB.
• Degeneration of the pituitary gland.

Breastfeeding stimulates the production and secretion of prolactin. This may contribute to amenorrhea in breastfeeding mothers.

Ovaries

The ovaries are stimulated by follicle-stimulating hormone (FSH) and luteinizing hormone (LH) to mature and release an egg cell (ovum). It also secretes estrogen and progesterone to facilitate implantation of the embryo in the event of conception.

In most cases of amenorrhea, ovulation does not occur (anovulation). This is known as anovulatory amenorrhea. However at times, ovulation may occur although menstruation is absent and this is referred to as ovulatory amenorrhea.

Some ovarian causes of amenorrhea include :

• Genetic disorders.
• Polycystic ovary syndrome (PCOS).
• Autoimmune diseases like Hashimoto’s thyroiditis.
• Infections like mumps and complications of untreated bacterial vaginosis.
• Irradiation of the pelvis, either accidental or due to radiation therapy.
• Drugs like chemotherapy and hormone contraceptives.
• Chronic conditions like diabetes.

Uterus & Vagina

If pregnancy does not occur after ovulation , the endometrial lining of the uterus will slough off and menstruation will commence. The menses is then passed out through the vagina. In uterine causes of amenorrhea, ovulation is usually not affected and amenorrhea in this instance is often considered as ovulatory amenorrhea.

Some uterine and vaginal causes of amenorrhea include :

• Uterine fibroids and polyps causing an obstruction.
• Infections of the uterus like TB.
• Incomplete growth and development of vagina and/or uterus (aplasia).
• Vaginal septum.
• Hymen that does not perforate.
• True or pseudo-hermaphroditism (hermaphrodite).
• Use of an intra-uterine device (IUD).
• Fertility, abortion and miscarriage surgical procedures like a dilation and curettage (d&c)

Many of the uterine and vaginal causes of amenorrhea are congenital, meaning that it is present from birth (birth defect).

Systemic and Other Causes

Apart from the chronic and systemic causes mentioned above, other conditions that may contribute to amenorrhea include :

• Thyroid disorders – hyper- or hypothyroidism.
• Obesity or if severely underweight.
• High levels of androgens (male sex hormones) due to tumors.
• Tumors producing high level of estrogen or HCG (human chorionic gonadotropin).
• Cushing’s syndrome.
• Sarcoidosis.

It is important to bear in mind that the most common cause of secondary amenorrhea is pregnancy. Menopause or early menopause (premature ovarian failure) is another common cause. These conditions must be excluded before considering further diagnostic investigation to identify the cause of primary or secondary amenorrhea.