Pregnancy Isn't the Only Cause of Absent Periods
Pregnant until proved otherwise
One of the most used lines in medical schools all over the world is this: ‘Any woman who walks into your consultation room is pregnant until proved otherwise’. It is a piece of dry humour that may offend some people but actually carries a very serious message. One of the gravest errors that a doctor can make is to miss a pregnancy. That kind of error can lead to extremely serious consequences and finding out about possible pregnancy is, in most cases, asking the simple question: When was your last period? It does not matter whether the person is presenting with a seemingly unrelated ailment, let’s say, pain in the shoulder (you may want to order an x ray), just establish the status, even if she walks in in a nun’s garb. The other side of this coin is the question of missed periods.
Amenorrhoea: Many Causes
There are several other causes of missed periods other than pregnancy. Amenorrhoea is the medical term for absent periods. Primary amenorrhoea is where a girl/woman has never had periods at all. This will be a subject of a separate hub. In this hub, we are going to look at secondary amenorrhoea whereby periods which had hitherto been normal, cease. On many occasions I have seen questions, even here on Hubpages, about missed periods and pregnancy tests that have been repeatedly negative with a bewildered air of ‘what is going on?’. Here are some of the possible explanations:
Polycystic Ovarian Syndrome (PCOS):
This is a fairly common condition, affecting many women to varying degrees of severity. The commonest manifestations of PCOS are being overweight/obese, increased body hair (hirsutism) and erratic periods. In a typical case of PCOS, the affected woman may find that her periods are unpredictable sometimes going several months without one. This particular feature tends to be masked by the use of the combined contraceptive pill. With the pill, the periods will arrive on time like clockwork. It is when the woman decides to come off the pill, usually because she wants to conceive, that this particular feature will be manifest. She may, in fact, believe she has conceived but a pregnancy test will show she is not pregnant. Were she to pursue this further, a hormone profile blood test and a pelvic ultrasound scan will clinch the diagnosis. Absent or erratic periods in polycystic ovarian syndrome (PCOS) are caused by the abnormal hormone environment that underlies this condition. In the majority of cases, a successful reduction of body weight to a normal body mass index (BMI) will lead to a resumption of normal regular periods.
This is not a common cause of missed periods but its importance lies in the fact that thyroid disease affects the functioning of many vital organs hence the need to be aware of the possibility of this being the underlying cause. Bothunder- and over-active thyroid disease can cause absent or erratic periods.
In underactive thyroid, the thyroid hormone is produced in insufficient quantities leading to a feeling of lethargy, cold even in warm weather, weight gain, dry and brittle hair and nails, low mood and, yes, erratic periods.
Excessive production of thyroid hormone tends to be characterised by, in the main, the opposite symptoms except for the issue with the periods. A sufferer will experience a sense of restlessness and even hyperactivity, palpitations, feeling warm and poor tolerability of heat, weight loss even though there may be increased appetite, occasionally hair loss, sweatiness and, yes, there may be erratic or absent menstrual periods in this case as well. A condition called Graves’ disease is the main cause of excessive thyroid hormone production.
In both under- and over-active thyroid, correcting the thyroid hormone problem leads to resumption of regular periods and resolution of the other symptoms.
Up to a half of long distant runners and around 4 in 10 of professional ballet dancers will experience secondary amenorrhoea. Excessive exercises will tend to lead to the shutting down of the process in the part of the brain called the hypothalamus which control the menstrual periods. It is one of the ways that the body deals with the excessive energy expenditure that it is being put through. In the case of ballet dancers, the situation is enhanced by the fact that they tend to maintain a restricted calorie intake. Once the athlete cuts down on her training or exercising, the periods will resume
The tiny gland in the brain called the ‘Pituitary’ is responsible for production of a variety of vital hormones. One of the hormones is called Prolactin. Prolactin hormone is responsible for milk production. Sometimes a hormone producing tumour, usually small in size will develop in the pituitary and start producing prolactin hormone in ever increasing quantities. This will have the effect of suppressing periods and like a pregnant or breast-feeding woman, a person with this type of tumour will experience absent periods. Prolactin producing tumours are overwhelmingly benign and treatment involves taking medication that suppress the production of the hormone. This is usually effective and periods will resume once the prolactin levels have dropped back to normal. A condition where there is excessive prolactin is generally called hyperprolactinaemia.
This is an entirely different disease from the one described above. Another hormone produced in the pituitary gland is known as ACTH. When ACTH is produced in excessive amounts it, in turn, leads to excessive production of the steroid cortisol. This leads to the condition known as Cushing’s disease. The presentation of Cushing’s disease is rather dramatic with rapid weight gain, thinning of skin usually with easy bruising; stretch marks may appear on the abdomen and thighs and periods tend to stop. Cushing’s disease is part of the wide spectrum of what is known as Cushing’s syndrome, the common factor in all these being excessive cortisol in the body. This brings us to another cause of absent periods due to problems in the adrenal glands (below).
Adrenal gland problems
Adrenal glands which are perched on top of kidneys are vital for production of various hormones and other chemicals. These include the steroid cortisol. Sometimes cortisol producing tumours develop leading to the condition discussed above i.e. Cushing’s syndrome. Among other things, Cushing’s syndrome will be characterised by cessation of periods (until the excessive cortisol situation is brought under control)
Another cause of Cushing’s syndrome is when the systemic steroids are prescribed to treat other diseases such as severe asthma or some types of arthritis.
Medications and drugs
Apart from steroids mentioned above, prolonged use of other drugs can lead to temporary cessation of periods. Phenothiazines are drugs that are employed mainly as anti-psychotics in schizophrenia. Some are used in heart conditions and weaker ones are used for controlling nausea and vomiting. They include such drugs as Chlorpromazine, Thioridazine, Prochlorperazine etc. They are available in an array of different brand names. Long-term use of these drugs can lead to cessation of menstrual periods.
Metoclopromide is used mainly as an antiemetic (to control nausea and vomiting). It is therefore unusual for this to be taken for a prolonged duration and, in any case, it should never be used for more than three months. Side effects are rare but Metoclopromide can also cause temporary cessation of periods. Metoclopromide is more popularly known by the brand names Maxolon, Reglan or Pramin.
Cocaine is an illicit drug with many potential side-effects one of which could be absent menstrual periods. The problem tends to resolve spontaneously within a few weeks of the person coming off the drug.
Stress of the emotional kind can and does often cause missed periods. Events such as bereavement, exams, marital difficulties or even severe sustained stress at work could cause a woman to miss her periods, sometimes for several months at a stretch.
Anorexia nervosa, a serious psychiatric condition the hallmark of which is being severely underweight is almost always accompanied by absent periods.
Excessive weight loss starting from normal weight not associated with this anorexia can also lead to missed periods especially if the weight is lost rapidly over a relatively short period of time.
Obliterated uterine cavity
Menstruation is a result of breakdown of the lining of the womb. Sometimes, especially following the procedure dilatation and curettage (D&C), adhesions form within the uterine cavity effectively obliterating it. As a result, the woman may find that she does not get any more periods after undergoing this. The condition is known as Asherman’s syndrome. In some cases, it is possible to reverse this through surgery.
Premature ovarian failure
This can also be called premature menopause. It is estimated that up to 1% of women go into menopause before the age of 40. It is not clearly known why ovaries stop functioning at such an early age. Premature ovarian failure has been known to happen to girls in their late teens and early twenties. Often, the most notable symptom is disappearance of periods without any obvious explanation. A hormone profile blood test will usually clinch the diagnosis. Premature ovarian failure is usually irreversible.
Damaged pituitary gland
We discussed this little gland with regard to over-production of the hormones Prolactin and ACTH. There is another way that the Pituitary gland can come into the picture when a woman is experiencing absent periods. There is a condition known as Sheehan’s syndrome. This describes a situation where the Pituitary gland has been damaged by disease, trauma, radiotherapy or, in some cases, prolonged deficiency of blood supply to the gland as can happen when there is undue delay in correcting severe blood loss for any reason as can happen following childbirth (postpartum haemorrhage).
Some women, after using the contraceptive pill for a prolonged duration will find that, when they come off, the periods do not resume, at least not for a few months. This is known as post-pill amenorrhoea. This can also happen after using other forms of contraception especially the injection ‘Depo-Provera’.
The final Word...
Now, this may appear like a long list. The main message for clinician is to always be diligent in taking the woman’s history when she presents with unexplained absent periods. The answer is often clinched there. For the affected woman, it is really to highlight the fact that there are many and varied causes of absent periods. For somebody who is sexually active, it is perfectly legitimate to rule out (or in) the possibility of pregnancy. When the pregnancy test is negative, it is prudent to get to see a doctor to establish what is going on especially because some of the underlying conditions require early intervention. Pregnancy isn’t the only cause of absent periods.
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