Menstruation: Absent Periods (Amenorrhea)

Description

Alternative Names

Diagnosis

A pregnancy test is, of course, the first test performed when a woman with normal sexual development experiences a cessation of her period. A physician will perform a pelvic examination to check for pregnancy or any structural problems. Thinning or dryness of the vaginal tissue would suggest low estrogen levels. The physician will check for excess hair growth or enlarged clitoris, which may be signs of polycystic ovaries.

Medical and Personal History. The physician needs to have a complete history of any medical or personal conditions that might be causing amenorrhea. Some experts believe that with a good history, a physician can determine the cause in 85% of cases:

• History of pregnancy, abortion, or miscarriage.
• Any family history of amenorrhea.
• Any other unusual symptoms or the presence or history of any conditions that might indicate a medical cause of amenorrhea.
• The pattern of menstruation.
• Any occurrence of milky discharge from the breast.
• Any symptoms such as hot flashes, a reduction in sexual drive, reduction in breast tissue (which would suggest premature ovarian failure).
• Regular use of any medications.
• History of contraceptive use, including discontinuation. (Some women do not regain regular periods for several months after stopping.)
• Any mental or stressful events.
• Any history of extreme exercise, extreme weight changes, or both.
• History of uterine surgery.

Reproductive Hormonal Tests

Hormonal tests are often administered, such as the following:

Progestational Challenge Test. The progestational challenge test uses oral or injected progesterone to test for a functional uterine lining (endometrium):

• Bleeding that occurs up to three weeks after the progesterone dose suggests that the woman has normal estrogen levels but is not ovulating, particularly if thyroid and prolactin levels are normal. In such cases, the physician should be sure to check for stress, recent weight loss, and any medications. Such results could also suggest polycystic ovaries or stress.
• A failure to bleed could indicate an abnormal uterus that prevents outflow or insufficient estrogen. In such cases, the next step may be to administer estrogen followed by progestin. If bleeding occurs after that, then the cause of amenorrhea is related to low estrogen levels. The physician will then check for ovarian failure, anorexia, or other causes of low estrogen. If bleeding does not occur, then the physician would check for obstructions that are preventing outflow of menstruation.

Tests for Male Hormones. Tests that measure androgen (male hormone) levels are useful if the patient shows male characteristics (acne or increased hair growth) and the physician suspects polycystic ovaries.

Prolactin Levels. Prolactin levels may be measured. High levels could suggest a pituitary tumor or hypothyroidism.

Hormonal Tests for Perimenopause. Physicians may sometimes measure follicle-stimulating hormone (FSH) or estrogen levels for changes that might help determine impending menopause. They are not very accurate, however. In general, the best gauges for perimenopause are a woman's age and the pattern of amenorrhea or skipped periods.

Tests for Underlying Nonhormonal Medical Conditions

Depending on other symptoms or history of other conditions, the physician may perform tests for underlying disorders. Examples include the following:

• Blood tests for anemia.
• Thyroid function tests are important for detecting hypothyroidism.
• Stress hormone tests for Cushing's disease or other disorders associated with low stress hormones.
• Tests for autoantibodies.

Imaging Techniques

Imaging technique may sometimes be used to detect certain conditions that may be causing menstrual disorders. For example, computed tomography (CT) scans may be used if prolactin levels are elevated and the physician suspects a pituitary tumor as their cause. In some cases, imaging techniques may be used to detect obstructions in the uterus or genital tract if these are suspected.

CT stands for computerized tomography. In this procedure, a thin X-ray beam is rotated around the area of the body to be visualized. Using very complicated mathematical processes called algorithms, the computer is able to generate a 3-D image of a section through the body. CT scans are very detailed and provide excellent information for the physician.

Invasive Techniques

Laparoscopy and hysteroscopy are minimally invasive operative procedures that may be used for detecting obstructions that may be preventing menstrual outflow. They employ fiberoptic tubes containing tiny surgical instruments and microcameras that allow a view of the inside of the pelvis and abdomen (laparoscopy) or uterus (hysteroscopy). [For more information on these diagnostic techniques, see Well-Connected Report Fibroids: Uterine.]