When a lack of menstruation exceeds a period of 3 months is called AMENORRHEA. Primary Amenorrhea is
the condition in which the patient has never been a spontaneous menstrual bleeding and Secondary Amenorrhea when absence of menstruation takes over after a period of spontaneous flows.
Excluding pregnancy, SECONDARY Amenorrhea’s (missed menstrual period) causes are especially endocrinological: among these the most frequent are the Polycystic Ovarian Syndrome (PCOS), Hyperprolactinaemia, the Ovary Deficiencies and Thyroid disorders.
Ovarian menstrual disorders usually arise during the adolescence; in these cases, postmenarcheal menstruation are rare and sometimes absent for long time. In Polycystic Ovarian Syndrome it is not uncommon to witness aspects of hyperandrogenism and hirsutism, obesity and overweight. In this cases treatment now relies on a metabolic approach with very effective results.
In adult life Amenorrhea may be dependent on Prolactin disorders (PRL) or on pharmacological treatments (i.e. gastro-protectants and antidepressant drugs) that increase the production of this small hormone of Pituitary Gland origin. In such cases, the therapy is based on removing the iatrogenic (medical) cause, and when this is not present must be found a possible Pituitary Gland Microadenoma.
During the evaluation of a patient with absent menstruation is important to always conduct a Follicle Stimulating Hormone (FSH) assay. FSH is an anterior Pituary Gland polypeptide hormone highly correlated with ovarian activity: its levels are inversely proportional to follicular count. In fact is due to its assessment that can be identified situations of early ovary insufficiency (POF).
Do not forget that a secondary Amenorrhea onset may be dependent on weight changes through signals they transmit to brain central nuclei. Even the psychological aspects, central nervous system diseases, can cause Amenorrhea.
Amenorrhea can also occur in presence of Ovarian Cysts and uterine cavity diseases such as synechiae formation (Asherman Syndrome) that destroying the normal endometrial tissue as a result of traumatic insults or chronic inflammation.
As we have seen, except for a pregnancy, causes of absent periods (Amenorrhea) are so many and must be sought starting from a medical specialist gynecological evaluation.
Along with the gynecological evaluation, pelvic ultrasound has undoubtedly a very important role, which becomes even more accurate when it is transvaginal: modern techniques linked to a vascular blood supply (Doppler), allow to evaluate with more accuracy both morphology and functional internal genitalia.
Other hormonal investigations are sometimes necessary for a differential diagnosis involving other endocrine organs such as the thyroid and the Adrenal Gland. Sometimes it can also be useful genetic (chromosomal) investigations. For Central Nervous System disorders is often required a Nuclear Magnetic Resonance that can give a good definition of the Diencephalon-Pituitary axis.
Hrmonal Stimulating Tests (of both ovaries and Pituitary Gland) are now rarely used.