Amenorrhea (Inability to see menstruation)


Inability to see menstruation can occur in two ways. If the woman has never had menstruation from the very beginning, this situation is called “primary amenorrhea” and if she has had regular menstruation, then it is called “secondary amenorrhea”.

In the definition of amenorrhea there are different definitions depending on several different situations:

* If secondary sex characters have never occurred until the age of 14 (armpit and genital area hair growth and breast enlargement)

* If secondary sex characters occur but there is no one until the age of 16

* If a woman has normal periods, she is referred to as amenorrhea if her periods are interrupted for 3 months.

The causes of amenorrhea may actually be caused by the hypothalamus and pituitary that stimulate the central nervous system, as well as from ovaries (ovaries) or uterus (uterus) or vagina.


Originating from the uterus and vagina;

If hormonal stimulation comes healthy from the central nervous system and the ovaries (ovaries) respond well to this stimulation, the next process is related to the uterus response. If there is no uterus, it will not be possible to see menstruation. In cases where there is no congenital uterus and cervix and the upper part of the vagina called Müllerian agenesis, a blind vagina is found and the woman cannot see menstruation.

Likewise, in individuals who are genetically male but cannot develop male genital organs due to insensitivity to the male hormone testosterone, the external genital structure will develop in the form of women, and a blind vagina will be found, but the uterus and ovaries will not be found (androgen insensitivity syndrome).

Again, in cases where the hymen is congenitally closed (imperforated hymen), the menstrual bleeding that occurs inside the uterus cannot be emptied because the outflow path is closed. In this case, menstrual blood that does not empty out will accumulate backwards in time and will fill the uterus and cause the condition characterized by the severe pain called “hematomata”.

Even if there is adhesion in endometrial tissue due to previous abortion operation, the woman may not have menstruation (Asherman syndrome).


Ovarian origin:

In order to have normal menstruation, the hormone estrogen and progesterone must be released. This is possible with ovulation (ovulation) flour. There are about 2 million egg cells in the baby girl at birth and this number decreases to 400.000 in adolescence. This amount is used throughout the woman’s fertile life and the menopause process begins upon completion.

Sometimes, congenital ovaries may not have developed at all, or congenital diseases such as Turner Syndrome have very few eggs, and eggs are depleted until birth.


Amenorrhea may also occur in cases such as polycystic ovaries where ovulation is absent or infrequent.

Sometimes there are enough egg cells in the ovaries, but they may not respond to hormones from the pituitary gland (resistant ovarian syndrome).


Pituitary originated:

The central source of amenorrhea may be due to insufficient secretion of FSH and LH hormone (gonadotropins) from the pituitary gland. In this woman, it may be related to the problems arising from the chromosome structure or in the pituitary adenomas secreting excessive prolactin, FSH and LH may not be secreted and therefore the ovaries may not be stimulated. In the pituitary, which develops after severe postpartum haemorrhage, Sheehan Syndrome may occur due to low blood supply and ischemia, and ovarian and uterine production will cease when the central stimulus does not come to the wool.


Hypothalamic origin:

The secretion of gonadotropins called FSH and LH provides the highest centre in the hormone axis of the brain tissue, which is called the hypothalamus. The reasons why the gonadotropin-releasing hormone cannot be released can be some genetic anomalies, as well as excessive exercise, sadness, stress, sudden weight loss (such as anorexia nervosa) and even air exchange.


Diagnosis and treatment of amenorrhea:

In primary amenorrhea, hormone tests, a detailed ultrasonography and if necessary MR or CT tests, genetic diagnosis tests are performed and the cause is tried to be determined. The treatment will be arranged purely for the cause.

In secondary amenorrhea, pregnancy should be considered first and ultrasonography should be performed with a pregnancy test. If there is no pregnancy, hormone tests should be done. Secondary amenorrhea can be detected in thyroid and prolactin hormone abnormalities. When thyroid and prolactin hormone levels are returned to normal, the menstrual pattern will be normalized. If FSH and LH levels are high in the hormone profile, the probability of decreasing the ovarian reserve or going further to menopause can be determined. “Progesterone challenge test” has an important place in testing secondary amenorrhea. If the woman has menstruation after progesterone treatment; estrogen level is sufficient, there are uterus and ovaries. However, since there is no ovulation (ovulation), progesterone cannot be released and the woman cannot have menstruation. If she does not have menstruation despite progesterone treatment, either estrogen is not secreted enough or there is a lack of uterus and vagina. Then estrogen and progesterone are given together. If bleeding occurs, the uterus and vagina are normal. Then the possibility of hypothalamic pituitary insufficiency will be raised. The very low FSH and LH levels will support this diagnosis.

Treatment should be determined entirely by cause. In the meantime, women should be consulted about whether they can have children according to the cause of amenorrhea and, if possible, the ways of this process. From time to time, an approach to amenorrhea may require a multidisciplinary approach, including an endocrinologist, nutritionist and geneticist. Combination of estrogen and progesterone in hypothalamic and pituitary insufficiencies will provide menstrual order. In the case of anovulation, using only progesterone is sufficient to ensure menstrual order. If the patient wants a child, the path will be continued with the options for ensuring ovulation in both cases.

In congenital anomalies such as imperforate hymen, a simple surgical procedure will solve the problem very easily and the flow path of menstrual bleeding will be relieved.

The surgical option will also be a solution for the treatment of Asherman’s syndrome.

When genetic anomaly is determined, genetic counselling should be given with genetic experts and treatment should be taken by considering the clinical features brought by the anomaly.