Table of ContentsView AllTable of ContentsPrimary AmenorrheaSecondary AmenorrheaWhen to Seek CareDiagnosis
Table of ContentsView All
View All
Table of Contents
Primary Amenorrhea
Secondary Amenorrhea
When to Seek Care
Diagnosis
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A Note on Sex and Gender TerminologyVerywell Health acknowledges thatsex and genderare related concepts, but they are not the same. To accurately reflect our sources, this article uses terms like “female,” “male,” “women,” and “girl” as the sources use them.
A Note on Sex and Gender Terminology
Verywell Health acknowledges thatsex and genderare related concepts, but they are not the same. To accurately reflect our sources, this article uses terms like “female,” “male,” “women,” and “girl” as the sources use them.
The causes of primary amenorrhea are largely related to genetics, although the underlying cause in many cases may never be known.
Turner Syndrome
About 70% to 80% of females with Turner Syndrome experience delays in puberty, while 90% experience amenorrhea. Hormonal therapy is the mainstay of treatment, includinggrowth hormone (GH)during early childhood to achieve a more typical height andestrogen therapyaround age 12 to instigate puberty.
MRKH Syndrome
Mayer–Rokitansky–Küster–Hauser (MRKH) syndromeis a condition in which a female is born with normal external genitals but either has an underdevelopedvaginaanduterusor no vagina or uterus at all. Amenorrhea is characteristic of this condition.
Around one of every 5,000 female births results in MRKH syndrome. The cause is thought to be genetic, though no gene has yet been linked to the disorder. Around 15% of cases of primary amenorrhea are due to MRKH syndrome.
Surgery and other specialist procedures may be used in females with MRKH syndrome to create a functional vagina to enable sexual intercourse. Uterine transplants have been performed in a number of people, but it is highly experimental.
Intersex Syndromes
Intersexdescribes people who have genitals, reproductive organs, or sex characteristics that do not confer to the male/female binary.
Intersex individuals who have female reproductive organs may or may not experience amenorrhea. Those who do are typically diagnosed with conditions like:
The treatment varies based on how these disorders affect the reproductive tract, development, or fertility.
Constitutional Delay of Puberty
The cause of delayed puberty may be genetic as it tends to run in families. Even so, many cases areidiopathic(of unknown origin). The treatment can vary, with some girls requiring no treatment and others being given hormones to stimulate puberty.
Girls who are chronically underweight may also experience delayed puberty. Dietary and medical interventions, including therapy, may be needed to increase weight and help kickstart puberty.
Secondary amenorrheaoccurs when you have normal periods but suddenly stop having them. It refers to the prolonged cessation of menstruation outside of pregnancy or menopause.
By definition, secondary amenorrhea is diagnosed if you have normal periods but then suddenly stop for three months or more. If you have irregular periods (calledoligomenorrhea), it is diagnosed when you stop having periods for six months or longer.
Pregnancyshould be ruled out before proceeding with looking for further causes of secondary amenorrhea. Aside from pregnancy, it is largely related to conditions that disrupt the normal balance of hormones that regulate your menstrual cycle.
Functional Causes
Women who exercise strenuously and/or lose a lot of body fat can experience changes in hormone production, leading to amenorrhea. This is largely due to a part of the brain called thehypothalamusthat synchronizes your periods.
When you are too thin or lack nutrition, the hypothalamus secretes less of a hormone, called gonadotropin-releasing hormone (GnRH), which plays a central role in your cycle. This leads to what is called functional hypothalamic amenorrhea, the most common cause of secondary amenorrhea.
Common causes of hypothalamic amenorrhea include:
Lifestyle adjustments or stress reduction techniques may be all that is needed to set your periods right. Anorexia nervosa is treated with therapy and medications.
Thyroid Disease
Bothhyperthyroidism(overactive thyroid)andhypothyroidism(underactive thyroid) can lead to the cessation of periods.
Treating hyperthyroidism withthyroid-suppressing treatmentsand hypothyroidism withthyroid hormonescan help remedy amenorrhea.
Hypothalamus, Pituitary, and Ovary Problems
The hypothalamus-pituitary-ovarian (HPO) axis is a feedback system in which chemical messages are sent back and forth to the hypothalamus,pituitary gland, andovariesto maintain normal menstrual cycles.
Disruption of the HPO axis can lead to amenorrhea if hormones involved in the menstrual cycle, such as GnRH and prolactin, are increased or decreased. Any disease affecting the hypothalamus, pituitary gland, or ovaries can cause this, including:
Severe systemic or inflammatory diseases, such as cancer,inflammatory bowel disease (IBD), andlupus, can indirectly interrupt signaling in the HPO axis and also cause amenorrhea.
Medications
Amenorrhea can sometimes be drug-induced. Estrogen therapies are among the most common causes. There are also non-hormonal drugs that can cause suppression of the HPO axis or indirectly affect hormone production.
Some of the more common causes of drug-induced amenorrhea include:
Most cases of drug-induced amenorrhea are reversible once treatment is stopped or changed.
When to Call a Healthcare Provider
If you have had normal periods, you should see a gynecologist if you miss three cycles (or six if you have a history of irregular periods). Also see a healthcare provider for any of these symptoms, even with normal periods:
Your healthcare provider may recommend performing apelvic examto check for any concerns. If you haven’t started your period yet, your provider may also examine your breasts and genitals to look for the typical changes that occur during puberty.
Throughout the process, you should be given the opportunity to ask questions and let your provider know if you’re feeling uncomfortable at any time. Your comfort and consent are important, and you are in control of the exam.
Because there are so many possible causes for missed periods, more than one test may be needed. Some of the tests your healthcare provider will most likely suggest include:
Other tests may be considered depending on the presentation:
If other tests show no specific cause, your healthcare provider may want to do ahysteroscopy. During this exam, a thin, lighted camera passes through the vagina andcervixto look at the inside of your uterus.
Summary
There are manyreasons why you may have no periods(amenorrhea). In women and girls who have never had a period (referred to as primary amenorrhea), it may be due to genetic disorders like Turner syndrome or delayed puberty.
If you have periods and suddenly stop (called secondary amenorrhea), the most common cause is pregnancy, which should be ruled out before proceeding with further testing. Other causes include excessive exercise, low body weight, chronic stress, thyroid disease, pituitary adenomas, PCOS, primary ovary insufficiency, and drugs like hormonal contraceptives and antipsychotics.
A Word From VerywellThere are many benign reasons for not having a period for months. However, there are also a few serious causes of amenorrhea. If you’ve gone two to three months or more without your period, you should be evaluated to rule out any concerning issues.—CORDELIA NWANKWO, MD, MEDICAL EXPERT BOARD
A Word From Verywell
There are many benign reasons for not having a period for months. However, there are also a few serious causes of amenorrhea. If you’ve gone two to three months or more without your period, you should be evaluated to rule out any concerning issues.—CORDELIA NWANKWO, MD, MEDICAL EXPERT BOARD
There are many benign reasons for not having a period for months. However, there are also a few serious causes of amenorrhea. If you’ve gone two to three months or more without your period, you should be evaluated to rule out any concerning issues.
—CORDELIA NWANKWO, MD, MEDICAL EXPERT BOARD
16 SourcesVerywell Health uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles. Read oureditorial processto learn more about how we fact-check and keep our content accurate, reliable, and trustworthy.Klein DA, Paradise SL, Reeder RM.Amenorrhea: a systematic approach to diagnosis and management.Am Fam Physician. 2019;100(1):39-48.Samal R, Habeebullah S.Primary amenorrhea: A clinical review.Int J Reprod Contracept Obstet Gynecol. 2017;6(11):4748-53. doi:10.18203/2320-1770.ijrcog20174981Cui X, Cui Y, Shi L, Luan J, Zhou X, Han J.A basic understanding of Turner syndrome: Incidence, complications, diagnosis, and treatment.Intractable Rare Dis Res. 2018;7(4):223‐228. doi:10.5582/irdr.2017.01056Londra L, Chuong FS, Kolp L.Mayer-Rokitansky-Kuster-Hauser syndrome: a review.Int J Womens Health. 2015;7:865–870. doi:10.2147/IJWH.S75637American Academy of Pediatrics.Explaining disorders of sexual development and intersexuality.Naroji S, Gomez-Lobo V, Finlayson C.Primary amenorrhea and differences of sex development.Semin Reprod Med. 2022 Jun 30;40(1-02):16–22. doi: 10.1055/s-0042-1753551Butler G, Purusnothaman P.Delayed puberty.Minerva Pediatr. 2020 Dec;72(6):484-490. doi:10.23736/S0026-4946.20.05968-XRyterska K, Kordek A, Zaleska P.Has menstruation disappeared? Functional hypothalamic amenorrhea—what is this story about?Nutrients. 2021 Aug 17;13(8):2827. doi:10.3390/nu13082827Shrestha S, Neupane S, Gautam N, et al.Association of thyroid profile and prolactin level in patient with secondary amenorrhea.Malays J Med Sci.2016 Oct 5;23(5):51–56. doi:10.21315/mjms2016.23.5.7Mickael S, Punjala-Patel A, Gavrilova-Jordan L.Hypothalamic-pituitary-ovarian axis disorders impacting female fertility.Biomedicines. 2019 Jan 4;7(1):5. doi:10.3390/biomedicines7010005Lania A, Gianotti L, Gagliardi I, Bondanelli M, Vena W, Ambrosio MR.Functional hypothalamic and drug-induced amenorrhea: an overview.J Endocrinol Invest. 2019 Sep;42(9):1001-1010. doi:10.1007/s40618-019-01013-wYale Medicine.Amenorrhea.American Congress of Obstetricians and Gynecologists.Should my teen see an Ob-Gyn? Here’s what I tell parents.Office on Women’s Health.Polycystic ovary syndrome.De Leo S, Lee SY, Braverman LE.Hyperthyroidism.Lancet. 2016;388(10047):906–918. doi:10.1016/S0140-6736(16)00278-6American Society of Reproductive Medicine.Hyperprolactinemia (high prolactin levels).
16 Sources
Verywell Health uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles. Read oureditorial processto learn more about how we fact-check and keep our content accurate, reliable, and trustworthy.Klein DA, Paradise SL, Reeder RM.Amenorrhea: a systematic approach to diagnosis and management.Am Fam Physician. 2019;100(1):39-48.Samal R, Habeebullah S.Primary amenorrhea: A clinical review.Int J Reprod Contracept Obstet Gynecol. 2017;6(11):4748-53. doi:10.18203/2320-1770.ijrcog20174981Cui X, Cui Y, Shi L, Luan J, Zhou X, Han J.A basic understanding of Turner syndrome: Incidence, complications, diagnosis, and treatment.Intractable Rare Dis Res. 2018;7(4):223‐228. doi:10.5582/irdr.2017.01056Londra L, Chuong FS, Kolp L.Mayer-Rokitansky-Kuster-Hauser syndrome: a review.Int J Womens Health. 2015;7:865–870. doi:10.2147/IJWH.S75637American Academy of Pediatrics.Explaining disorders of sexual development and intersexuality.Naroji S, Gomez-Lobo V, Finlayson C.Primary amenorrhea and differences of sex development.Semin Reprod Med. 2022 Jun 30;40(1-02):16–22. doi: 10.1055/s-0042-1753551Butler G, Purusnothaman P.Delayed puberty.Minerva Pediatr. 2020 Dec;72(6):484-490. doi:10.23736/S0026-4946.20.05968-XRyterska K, Kordek A, Zaleska P.Has menstruation disappeared? Functional hypothalamic amenorrhea—what is this story about?Nutrients. 2021 Aug 17;13(8):2827. doi:10.3390/nu13082827Shrestha S, Neupane S, Gautam N, et al.Association of thyroid profile and prolactin level in patient with secondary amenorrhea.Malays J Med Sci.2016 Oct 5;23(5):51–56. doi:10.21315/mjms2016.23.5.7Mickael S, Punjala-Patel A, Gavrilova-Jordan L.Hypothalamic-pituitary-ovarian axis disorders impacting female fertility.Biomedicines. 2019 Jan 4;7(1):5. doi:10.3390/biomedicines7010005Lania A, Gianotti L, Gagliardi I, Bondanelli M, Vena W, Ambrosio MR.Functional hypothalamic and drug-induced amenorrhea: an overview.J Endocrinol Invest. 2019 Sep;42(9):1001-1010. doi:10.1007/s40618-019-01013-wYale Medicine.Amenorrhea.American Congress of Obstetricians and Gynecologists.Should my teen see an Ob-Gyn? Here’s what I tell parents.Office on Women’s Health.Polycystic ovary syndrome.De Leo S, Lee SY, Braverman LE.Hyperthyroidism.Lancet. 2016;388(10047):906–918. doi:10.1016/S0140-6736(16)00278-6American Society of Reproductive Medicine.Hyperprolactinemia (high prolactin levels).
Verywell Health uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles. Read oureditorial processto learn more about how we fact-check and keep our content accurate, reliable, and trustworthy.
Klein DA, Paradise SL, Reeder RM.Amenorrhea: a systematic approach to diagnosis and management.Am Fam Physician. 2019;100(1):39-48.Samal R, Habeebullah S.Primary amenorrhea: A clinical review.Int J Reprod Contracept Obstet Gynecol. 2017;6(11):4748-53. doi:10.18203/2320-1770.ijrcog20174981Cui X, Cui Y, Shi L, Luan J, Zhou X, Han J.A basic understanding of Turner syndrome: Incidence, complications, diagnosis, and treatment.Intractable Rare Dis Res. 2018;7(4):223‐228. doi:10.5582/irdr.2017.01056Londra L, Chuong FS, Kolp L.Mayer-Rokitansky-Kuster-Hauser syndrome: a review.Int J Womens Health. 2015;7:865–870. doi:10.2147/IJWH.S75637American Academy of Pediatrics.Explaining disorders of sexual development and intersexuality.Naroji S, Gomez-Lobo V, Finlayson C.Primary amenorrhea and differences of sex development.Semin Reprod Med. 2022 Jun 30;40(1-02):16–22. doi: 10.1055/s-0042-1753551Butler G, Purusnothaman P.Delayed puberty.Minerva Pediatr. 2020 Dec;72(6):484-490. doi:10.23736/S0026-4946.20.05968-XRyterska K, Kordek A, Zaleska P.Has menstruation disappeared? Functional hypothalamic amenorrhea—what is this story about?Nutrients. 2021 Aug 17;13(8):2827. doi:10.3390/nu13082827Shrestha S, Neupane S, Gautam N, et al.Association of thyroid profile and prolactin level in patient with secondary amenorrhea.Malays J Med Sci.2016 Oct 5;23(5):51–56. doi:10.21315/mjms2016.23.5.7Mickael S, Punjala-Patel A, Gavrilova-Jordan L.Hypothalamic-pituitary-ovarian axis disorders impacting female fertility.Biomedicines. 2019 Jan 4;7(1):5. doi:10.3390/biomedicines7010005Lania A, Gianotti L, Gagliardi I, Bondanelli M, Vena W, Ambrosio MR.Functional hypothalamic and drug-induced amenorrhea: an overview.J Endocrinol Invest. 2019 Sep;42(9):1001-1010. doi:10.1007/s40618-019-01013-wYale Medicine.Amenorrhea.American Congress of Obstetricians and Gynecologists.Should my teen see an Ob-Gyn? Here’s what I tell parents.Office on Women’s Health.Polycystic ovary syndrome.De Leo S, Lee SY, Braverman LE.Hyperthyroidism.Lancet. 2016;388(10047):906–918. doi:10.1016/S0140-6736(16)00278-6American Society of Reproductive Medicine.Hyperprolactinemia (high prolactin levels).
Klein DA, Paradise SL, Reeder RM.Amenorrhea: a systematic approach to diagnosis and management.Am Fam Physician. 2019;100(1):39-48.
Samal R, Habeebullah S.Primary amenorrhea: A clinical review.Int J Reprod Contracept Obstet Gynecol. 2017;6(11):4748-53. doi:10.18203/2320-1770.ijrcog20174981
Cui X, Cui Y, Shi L, Luan J, Zhou X, Han J.A basic understanding of Turner syndrome: Incidence, complications, diagnosis, and treatment.Intractable Rare Dis Res. 2018;7(4):223‐228. doi:10.5582/irdr.2017.01056
Londra L, Chuong FS, Kolp L.Mayer-Rokitansky-Kuster-Hauser syndrome: a review.Int J Womens Health. 2015;7:865–870. doi:10.2147/IJWH.S75637
American Academy of Pediatrics.Explaining disorders of sexual development and intersexuality.
Naroji S, Gomez-Lobo V, Finlayson C.Primary amenorrhea and differences of sex development.Semin Reprod Med. 2022 Jun 30;40(1-02):16–22. doi: 10.1055/s-0042-1753551
Butler G, Purusnothaman P.Delayed puberty.Minerva Pediatr. 2020 Dec;72(6):484-490. doi:10.23736/S0026-4946.20.05968-X
Ryterska K, Kordek A, Zaleska P.Has menstruation disappeared? Functional hypothalamic amenorrhea—what is this story about?Nutrients. 2021 Aug 17;13(8):2827. doi:10.3390/nu13082827
Shrestha S, Neupane S, Gautam N, et al.Association of thyroid profile and prolactin level in patient with secondary amenorrhea.Malays J Med Sci.2016 Oct 5;23(5):51–56. doi:10.21315/mjms2016.23.5.7
Mickael S, Punjala-Patel A, Gavrilova-Jordan L.Hypothalamic-pituitary-ovarian axis disorders impacting female fertility.Biomedicines. 2019 Jan 4;7(1):5. doi:10.3390/biomedicines7010005
Lania A, Gianotti L, Gagliardi I, Bondanelli M, Vena W, Ambrosio MR.Functional hypothalamic and drug-induced amenorrhea: an overview.J Endocrinol Invest. 2019 Sep;42(9):1001-1010. doi:10.1007/s40618-019-01013-w
Yale Medicine.Amenorrhea.
American Congress of Obstetricians and Gynecologists.Should my teen see an Ob-Gyn? Here’s what I tell parents.
Office on Women’s Health.Polycystic ovary syndrome.
De Leo S, Lee SY, Braverman LE.Hyperthyroidism.Lancet. 2016;388(10047):906–918. doi:10.1016/S0140-6736(16)00278-6
American Society of Reproductive Medicine.Hyperprolactinemia (high prolactin levels).
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