Amenorrhea Q&A

Your “period” is the bleeding at the end of one cycle that overlaps with the beginning of your next. And even though they overlap, the reality is that the bleeding of your period has nothing to do with your next cycle; instead, it is the debris of tissue that had built up the previous cycle and then disintegrated as menstrual debris when pregnancy didn’t happen. This results in what you see as your “period,” whose timing is actually during the beginning of your next cycle.

Without pregnancy, therefore, the end of the cycle happens simultaneously with the beginning of your next one. Since menstruation (the menstrual “period”) is the only outward indication of this whole process (a process designed for pregnancy), its first day of bleeding has been traditionally called “Day 1” of the new cycle, even though it’s based on the bleeding that is the outcome of the previous cycle.

Loss of this tissue (endometrium, or the innermost lining of your uterus where implantation occurs), seen as bloody menstrual tissue, happens because your hormones stopped at the end of the previous cycle and the tissue was no longer nourished hormonally.

Nevertheless, that is the traditional way things are labeled and it is why most consider their period as the end of the last cycle, which it is, but not the time of the beginning of the next, which it also is. In other words, by the time you’re bleeding with your period from your last cycle, you’re already building up your hormones in the following cycle. Of course, all you see is the period.

There are many medical words that refer to conditions associated with your period:

• Oligomenorrhea (periods not coming every month, but taking longer; or scant periods)
• Hypermenorrhea (heavy periods)
• Menorrhagia (heavy and/or prolonged periods)
• Hypomenorrhea (scant periods from low progesterone, due to an inadequate corpus luteum)
• Dysmenorrhea (painful periods, indicating possible endometriosis)
• Polymenorrhagia (periods too frequent, that is, less than every 21-28 days)and
• Amenorrhea (no periods at all, the subject of this article)

What is amenorrhea?

The word is a combination of 3 parts:

1. A-, meaning “without”
2. meno, meaning “monthly”
3. Rrhea, meaning “flow”

Simply, when there isn’t your “monthly flow,” or period.

Having your period, whether you find it bothersome or not, is reassuring that everything in your menstrual cycle is working fine. Certainly there are normal circumstances in which natural amenorrhea occurs, such as before puberty, during pregnancy or breastfeeding, after menopause, or taking birth control pills in such a way that you get to skip your periods.

But if you’ve gone through puberty, are not being hormonally manipulated with birth control pills, are too young for menopause, and are not pregnant or breastfeeding, you should definitely see your monthly reassurance that all is well with an expected period each month. The normal range is every 21 to 35 days, but every 28-29 is the most frequent interval for most. 

What causes amenorrhea?

Your cycle has a first half, where estrogen dominates and builds up the innermost lining of your uterus (womb), thickening it for the possibility of implantation. After ovulation, progesterone is added to your system to mature that lining so that it will be hospitable for an implanted fertilized egg (at that point, a “blastocyst,” developed from a growing zygote). This is the second half of your cycle, divided from the first by ovulation. This “hospitable” environment allows for the blood supply of the tissue to support the growing pregnancy.

In the absence of fertilization, that egg, along with the lining which loses its hormonal stimulation and support, exits your body via your vagina onto a napkin or tampon to the outside world for discarding. You have your period. You are reassured.

What if my period doesn’t happen?

As above, this constitutes amenorrhea. The average age of menopause in the USA is 52, so if you’re considerably younger and you experience amenorrhea, something is wrong somewhere.

After pregnancy, the next most-common cause of amenorrhea is being stuck in the first half (the estrogen-dominant half) of your cycle because you have an ovarian cyst. If that cyst is just an exaggerated follicle, it will delay ovulation, lengthening the first half of your cycle, until you ovulate. Of course, this means a delay in the second half and a late period. Or none at all, if the hormonal dysfunction wasn’t able to muster enough stimulation to create enough tissue to slough away as a period.

Although such amenorrhea isn’t technically abnormal, because it’s the result of dysfunction in an otherwise normal process, a return to normal (function) is all that is needed. This is also true for the time it takes after taking birth control pills for things to get back running again or for resumption of your cycles during or after breastfeeding.

What if it’s abnormal amenorrhea?

If that ovarian cyst is not just a delayed follicle, it can be abnormal tissue, either benign or malignant. Such cysts can range from harmless to life-threatening, so that identifying such a structure is necessary and is best done by a specialist in ovarian cysts, such as Dr. Ulas Bozdogan of NJEndometriosis. A cyst from endometriosis, called a “chocolate cyst,” can also delay your periods. If it ends up being something that must be removed, Dr. Bozdogan uses state-of-the-art minimally-invasive robotic (same-day) surgery that is cosmetic in its tiny incisions and has a fast recovery and minimum of discomfort. If it is a chocolate cyst, Dr. Bozdogan is also an endometriosis specialist, who is necessary since the cyst isn’t the only problem associated with endometriosis.

Since things like stress can act on your brain to delay your period, you are best served with a specialist like Dr. Bozdogan, for you don’t want a rush to needless surgery for something as innocent as stress. The same goes for other things for which surgery would be the wrong treatment, such as thyroid problems or the side effects of medications.

Rarely, a fibroid can block the menstrual flow. Dr. Bozdogan is also a fibroid specialist, which is the expertise you would want in treating it, often with the same minimally-invasive robotic techniques he uses. You want to leave the operating room with as much reproductive tissue as you went in with.

How obese is too obese?

If your fat cells are making their own estrogen, which they do, then too much fat tissue can make too much estrogen, which then competes with your normal cycles, resulting in either irregular bleeding or no periods at all. This can also be a cause for infertility.

Is amenorrhea the same thing as menopause?

Although the average age of menopause is 52, the approach to menopause can begin as early as 15 years before this. However, this won’t reflect as the absence of your periods, but a change in them, perhaps becoming lighter and/or coming longer than every 28-20 days. Longer than every 35 days, though, is abnormal. If your hormones stop cycling before menopause, this is called “premature menopause,” and is usually genetic—and a tragedy if pregnancy is desired. So amenorrhea, from many causes, is not menopause, although menopause is amenorrhea.

Can amenorrhea make me infertile?

Yes, and it usually means just this, because the “period” results as a process initiated by ovulation: if you don’t have a period, you’re not ovulating. And if you’re not ovulating, you’re not going to get pregnant.

Amenorrhea = mandatory evaluation

So, there are many reasons to see an amenorrhea specialist like Dr. Bozdogan at NJEndometriosis:

• Rule out pregnancy
• Rule out an ovarian cyst
• Rule out a tumor of the ovary, pituitary gland, or elsewhere
• Identify medications that should be changed because of side effects
• Rule out premature menopause
• Rule out other causes (obesity or medical illnesses)

Besides his expertise, experience, and training, Dr. Bozdogan will have a keen eye on all of these related issues, seeing the big picture as it applies to you. This is considered the practice of complete medicine, and you deserve nothing less than this.