Amenorrhea

Yes, even absence of menstruation is a problem.

Amenorrhea is of 2 types, primary and secondary. Primary is when the menstruation never occurs in the first place, and secondary is when it had occurred in the past but then it stops. Gestational amenorrhea is the normal absence of menstruation during pregnancy. Lactational amenorrhea is the absence of menstruation during the period a mother continues to breastfeed her child, which is again, perfectly normal. We will explain the possible causes of primary amenorrhea and secondary excluding gestational and lactational.

Primary amenorrhea

Primary amenorrhea is absence of menstruation. This may be accompanied with presence or absence of secondary sexual characteristics like breast development or body hair.

If your daughter is 14 with normal secondary sexual characteristics, she might just be a late bloomer and you can wait for a year or two. However, if there is no menarche by the time she is 16, you need to see a gynecologist. Similarly, if your daughter does not show any secondary sexual characteristics, then you need to see a gynecologist once she is 14, if there is still no menstruation. The causes are multifactorial, but quite often due to developmental problems.

The causes of the amenorrhea are mainly due to a problem in any one of the following three areas:

1. Hypothalamus
2. Pituitary
3. Ovaries

Together they form a functional endocrine axis, known as the HPO axis.

1. A. Hypothalamic reasons of primary amenorrhea:

As we have explained earlier, a very important hormone called GnRH is secreted by the hypothalamus. This GnrH stimulates gonadotropins in the pituitary gland which then stimulate the release of FSH and LH from ovaries, ultimately causing menstruation and ovulation. A decrease in GnRH release or its absence will never let the menstrual cycle occur.  When the decreased GnrH level is congenital, it is known as Kallman Syndrome.

Functional hypothalamic amenorrhea snubs GnrH levels, directly cutting LH levels and LH surge. The reasons may be over-eating, under-eating, excessive exercising, mental stress, depression, physical stress, etc.

1. B. Pituitary reasons of primary amenorrhea:

When the Pituitary gland fails to release gonadotropins in response to GnRH release by the hypothalamus, the cause clearly lies in this part of the axis. Pituitary tumors are the most common cause. Other examples in which pituitary gland causes are etiological are:

1. Cushing disease
2. hypothalamic tumors
3. Craniopharyngioma
4. Germinoma
5. Brain injury
6. Cranial irradiation
7. Empty sella syndrome
8. Pituitary infarct
9. Hemachromatoses
10. Sarcoidosis

1. C. Then we have another axis for amenorrhea; the ovarian cause:

This is usually due to defective or absent ovarian function. Deformation of gonads is called gonadal dysgenesis. Some causes are:

1. Turner X syndrome
2. Premature ovarian failure
3. Fragile X pre-mutation
4. Swyer Syndrome
5. Polycystic Ovarian disease( more known for secondary amenorrhea)

1. D. There are a few other causes as well that do not fall in either of the categories. They are:
2. Hypothyroidism
3. Hyperthyroidism
4. Sarcoidosis
5. Galactosemia

The ovarian cycle and the uterine cycle

The ovarian cycle and the uterine cycle are two different things happening together and dependent on one another. The ovarian cycle is happening in the ovaries and the uterine cycle in the uterus. The blood flow is due to the effects of the menstrual cycle on the uterine cycle, resulting in a uterine blood flow.

It all begins with the birth of a female child. When a female child is born, she has 100,000 primary oocytes in her ovaries, waiting for puberty when they will become secondary oocytes. After that, with each menstrual cycle they take the form of ova. An ovum is a potential egg that gets fertilizes by a sperm.

100,000 oocytes mean potentially 100,000 menstrual cycles. However, that does not happen. A normal healthful female reproductive life consists of 34-35 years that can be approximately 400 normal menstrual cycles, using only 400 oocytes.

What is menarche?

The beginning of the menstruation with the first menstrual cycle is called menarche.  This is the onset of puberty and is marked by the following changes in the female body:

1.    Change in body shape
2.    Widening of pelvis
3.    Typical fat distribution
4.    Response of ovaries to the pituitary hormones with secretion of estrogen
5.    Growth of the breasts, body hair, and uterus

What is thelarche then?

Thelarche is a term referred to the 2 years preceding menarche. It primarily is characterized by development of the breasts.

Can you tell me about menstruation before we move on the menstrual irregularities?

Estrogen released by the ovary is more specifically released by a mature ovarian follicle. The follicle will cause the release of GnRH from the Hypothalamus in the brain, which will cause the secretion of FSH and LH from the brain’s pituitary gland. These hormones will induce ovulation. Once an ovum is released from a mature follicle in the ovary, it is ready to form a zygote with a sperm. If the sperm can get to the ovum through a normal fallopian tube (one that has either never been ligated or one that has undergone a tubal reversal), there is a chance of fertilization. Fertilization results in a zygote. The follicle left behind will become a Corpus Luteum and begin to secrete progesterone. This is the ovarian part of the cycle.
Now the progesterone will be preparing the uterus to receive a freshly conceived zygote. However, if that does not happen, the follicle finally dies and the uterine tissue starts disintegrating, resulting in blood flow, completing the uterine cycle.

So when do the irregularities occur?

This was a very brief summary of what happens in the cycle. There are a lot of places where things could go wrong, ultimately resulting in menstrual irregularities. We are trying to explain here what happens normally and how many processes need to happen correctly in order to ensure proper menstruation. There may be a hormonal imbalance, a born deformity in the reproductive system, absence of ovulation, or perhaps many other problems that may affect the normal menstrual cycle.

Wait, wait, absence of ovulation? If I am having menses, doesn’t that mean I am ovulating as well?

No, you may or may not be ovulating. Menstrual abnormalities, as noted above, have many causes.

I don’t understand this?

You will.
Continue patiently with the rest of the articles in the menstrual irregularities series.

The first question that brings you to us, or any physician, regarding your reproductive system is (usually) a menstrual irregularity. There might be many questions on your mind pertaining to the seriousness of the issue.

• Is my menstrual cycle telling me something about my body?
• Is an irregularity telling me something about my body?
• Do I have to be concerned about this irregularity?
• Do I need to see a doctor for this irregularity?

We will be answering all of these queries, but not right now. For that you will have to follow our series on Menstruation.

Like always, we will first begin with the basics, the menstrual cycle.

Understanding a normal menstrual cycle

What goes on in a normal menstrual cycle?

Until a few years back, one was constrained in terms of acquiring knowledge and information, sometimes irrelevant, but often very germane. Today, the internet has fulfilled this basic motive of universal access to knowledge. Educating oneself was never so easy.

This means fewer people lack knowledge about a normal menstrual cycle. However, a lot of bad information is available as well. Often there is no check on the quality of content. We believe strongly in the credibility of content, and so we will address both relevant and irrelevant questions about the menstrual cycle. You may often come across questions like “will a tubal reversal restore my normal menstrual cycle” or “will my uterus fall out after menopause.” The accuracy of some of this information, as well as the kind of information available, is not always correct.

Your menstrual cycle will not be affected by a tubal reversal (until you get pregnant after your tubal reversal). A tubal reversal does not affect your ovarian function or your uterine lining, so your menstrual cycles will remain the same.

Your uterus will not fall out after menopause… unless you have pelvic support issues. These will be addressed in another series on our blog. Uterine prolapse is an issue related to the support structures of the pelvic floor, and these are more commonly affected by genetic factors and childbirth trauma.

A menstrual cycle is a perfectly normal physiological occurrence that is supposed to happen after a female has reached puberty. More than just the cycle of monthly bleeding, menstrual cycles bring about some very essential hormonal changes which alter the appearance of a female body as well.

Only humans and some of our Darwin relatives (i.e. chimpanzees) have been blessed with the menstrual cycle. Although the rest of the mammals do have a uterus, their reproductive cycles differ and are called estrous cycles.

The main difference between a menstrual cycle and an estrous one is the show of blood. A menstrual cycle is completed with blood flow out of the body where as in an estrous cycle the bleeding is inside the body where the blood mostly stays inside the body. We hope you will not wonder about the menstrual cycles of your pet animals anymore now.

A menstrual cycle is an essential cycle required for a female before she can reproduce. Inability of a menstrual cycle to occur is read as a definitive issue with the reproductive system. We will discuss more of that and the normal physiological changes in menstruation in the next article.

Simply put, the brain produces a hormone that is transported in the blood to the ovaries. This hormone causes the ovary to produce a follicle. Inside of the follicle, an egg is developed. Ovulation is induced by another hormone from the brain sent down through the blood. Once this occurs, ovulation causes the follicle to break open and release the egg that has developed inside. The ruptured follicle (called the Corpus Luteum) will then begin to produce yet another hormone that makes the uterus a better place for the implantation of the fertilized egg (if it gets fertilized by a sperm). If the egg does not get fertilized (for example, a tubal ligation would prevent this) then the uterine lining is shed and released into the vagina. This is referred to as your menstrual cycle.