Amenorrhea

Amenorrhea (pronounced "a-men-or-RE-ah") means simply the absence of menstrual periods. There are two types of amenorrhea — primary and secondary:

• Primary amenorrhea means that a teen girl hasn’t had a period by age 15 or three years after starting breast development.
• Secondary amenorrhea means that she has had a period before but stops having them.

On their own, neither of these types of amenorrhea is a disease. However, they may be caused by a hormone imbalance, excessive weight loss or exercise, pregnancy, medications, stress, and a myriad of other problems. This is why it’s important for a teen girl to see a health care professional if she’s stopped getting her periods or is late in starting them.

Amenorrhea is a symptom — missing periods. Depending on what’s causing your daughter’s amenorrhea, she may have other symptoms, too, including excess hair growth, acne, headaches, and pain.

Amenorrhea can have many different causes — that’s why it’s so important that a teen girl with amenorrhea be checked out by an expert. Some of the causes of primary and secondary amenorrhea overlap, and some are completely different. Some common causes include:

• Weight loss or gain and stress
• Strenuous exercise (“athletic amenorrhea”)
• Polycystic ovary syndrome (PCOS)
• Endocrine problems, such as too much or too little thyroid hormone
• Pregnancy
• Chronic illness, such as Crohn's disease, cystic fibrosis, sickle cell disease, lupus, diabetes, and celiac disease
• Ovary problems
• Congenital anomalies of the reproductive tract
• Birth control pills or other contraceptives
• Medications

• A teen girl may be fine and just a little late with regulating her periods.
• She may have a hormone imbalance called polycystic ovary syndrome and needs to be checked for high cholesterol and diabetes.
• She may have an ovary or thyroid problem and need hormones.
• She may have low estrogen levels from excessive exercise or low weight, and she may be at risk for low bone mass.

Without enough estrogen, not only do menstrual cycles stop, but the body does not absorb enough calcium to build strong bones. This can result in low bone mass. Since very little bone mass is added after women are 20 years old, the teen years are very important for building the right amount of bone for a lifetime.

Everyone, teen girls especially, needs the right balance of exercise, body weight, calcium intake, vitamin D, and estrogen levels to have healthy bones.

The first step in treating amenorrhea is to determine what’s causing it, so a complete and accurate diagnosis is extremely important. If your daughter hasn’t had her first menstrual cycle by 15, or if more than three years have passed since she started developing breasts, she should see a physician.

The health care provider will start by taking her medical history and asking questions about other health issues, weight loss, weight gain, concerns about eating disorders, medications she’s taking, excess hair growth and acne, sexual activity, and family history of problems with menstrual cycles. These questions might include:

• When did you start to go through puberty and develop breasts?
• Have you ever had any vaginal bleeding?
• When was your last menstrual period?
• Has your weight changed?
• Are you under stress or depressed?
• Has anyone thought you might have an eating disorder?
• How hard do you work to keep your weight where you want it to be?
• How much do you exercise?
• Do you have excessive hair growth or gain weight easily?
• Have you ever had sexual intercourse? Do you use contraception?
• Do you take any medications? Which ones?

The health care provider may also ask about any other physical symptoms she’s experiencing, such as headaches. Every teen is different and may require a general physical exam or external genital check. In some cases, girls might have a pelvic exam or an ultrasound. Her health care provider may also perform blood tests to check her hormone levels and a pregnancy test, so that they can consider all the possible causes of amenorrhea.

Treatment for amenorrhea will depend on what's causing it, but most conditions that cause amenorrhea can be treated with medication and lifestyle changes. What's important is that you and your daughter understand the options and decide what type of treatment is best for her.

Depending on your daughter’s age and test results for primary amenorrhea, the health care provider may suggest watchful waiting to see if her menstrual cycle is possibly delayed. Some common medical treatments for secondary amenorrhea may help restart the menstrual cycle or treat symptoms caused by an underlying condition. They include:

• Hormonal medication like birth control
• Hormone replacement therapy
• Medications to treat the symptoms of polycystic ovary syndrome (PCOS)

In some cases of primary or secondary amenorrhea, your daughter’s health care provider may recommend surgery. Though not common, surgery may be recommended for congenital anomalies, endocrine issues, or other conditions.

The Division of Gynecology and the Reproductive Endocrinology and Polycystic Ovary Syndrome (PCOS) Program at Boston Children’s Hospital recognize the special needs of adolescents, and we create a place where they can receive expert care for amenorrhea.