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Amenorrhea | | Description |
Amenorrhea is the absence of menstrual cycles. Amenorrhea is called
primary when a woman has not started to menstruate by the age of 16 years,
while secondary amenorrhea refers to the abnormal cessation of
menstruation in a woman who previously has had menstrual cycles. In
amenorrheic women, the levels of female reproductive hormones are not
sufficient to stimulate menstruation. This condition is sometimes
associated with malnutrition, such as that which occurs in anorexia
nervosa, or with extreme exercise, which puts excessive nutritional and
other demands on the body. An association between stress and amenorrhea
has also been demonstrated. Amenorrhea may also result from potentially
serious disorders of the ovaries, the hypothalamus, or the pituitary
gland; therefore, a physician should always evaluate chronic absence of
menstrual cycles. Prolonged amenorrhea can result in early bone loss and
increased risk of osteoporosis. Amenorrhea occurs naturally in women who
are breast-feeding, but in these circumstances it does not put the bones
at risk.
What are the symptoms of amenorrhea? Women with amenorrhea
may have symptoms of absent periods, increased facial hair, decreased
pubic and armpit hair, deeper voice, decreased breast size, and secretions
from the breast.
Conventional treatment options: Conventional
treatments for amenorrhea include oral birth control pills, clomiphene
citrate, or gonadotropin-releasing hormone (GnRH) therapy.
Dietary
changes that might be helpful: It has long been known that extreme dietary
restriction can cause amenorrhea. When such restriction is due to eating
disorders, such as anorexia and bulimia, professional treatment is
necessary. Athletic amenorrheic women may have low intakes of calories and
other nutrients, and there are reports of some athletes resuming
menstruation after adding to their diet a daily nutritional beverage
containing additional calories, protein, carbohydrate, fat, vitamins, and
minerals. However, these women also decreased their exercise intensity,
which likely contributed to normalization of their menstrual
function.
When compared with women who menstruate regularly, women
who menstruate infrequently or not at all often have lower dietary intakes
of fat (especially saturated fat), protein, and total calories, as well as
a greater proportion of carbohydrate and fiber in their diet. In
preliminary studies of normal-weight women with no obvious eating
disorders, women who experienced amenorrhea had diets described as "close
to normal" but significantly low in fat. These women had lower percentages
of body fat as well. In one of these studies, regular menstruation
returned in women who increased their fat intake and percentage of body
fat to normal over four months.
Specific diets may be associated
with increased risk of amenorrhea. A strict raw foods diet was found in
one preliminary study to be strongly associated with weight loss and
amenorrhea. Vegetarians have been studied for their susceptibility to
amenorrhea, but the results so far have been inconsistent. Vegetarian
diets tend to be rich in the antioxidant nutrients known as carotenes.
Women with excessive carotene levels in their blood appear to be at higher
risk of amenorrhea than women with normal levels, and, while research has
not shown high carotene levels to directly cause amenorrhea, they may
constitute a contributing factor. In one preliminary study, women with
high levels of both carotenes and amenorrhea had predominantly vegetarian
diets, and reducing dietary intake of carotenes led to lower carotene
levels and improvement in their amenorrhea. Women vegetarians often rely
heavily on soy foods as sources of protein, and a number of studies have
found that increasing dietary intake of soy reduces levels of estrogen and
progesterone in premenopausal women, although some studies have not found
these changes. Changes in menstrual cycles were not consistent in these
studies, and none found an increase in missed menses with high-soy diets.
The only well-controlled comparison study found that the number of cases
of amenorrhea among healthy, stable-weight vegetarian women was not
different from that of healthy, stable-weight non vegetarian women. The
authors of this study speculated that, after reviewing all of the
evidence, a vegetarian diet is likely not to contribute to
amenorrhea.
Lifestyle changes that may be helpful: Moderate
exercise has many benefits to the overall health of premenopausal women,
but intensive or excessive exercise can contribute to amenorrhea and
increase the risk of early bone loss due to detrimental effects on hormone
balance. Exercise typically increases bone density, but a study of dancers
with amenorrhea found that bone density measurements remained below normal
for the entire two-year duration of the study. The demands placed upon
women performers and athletes are believed to contribute to the high
incidence of eating disorders among them. This, along with the increased
physical and nutritional demands of intensive exercise, can lead to
nutrient deficiencies and lowered body-fat percentages that may contribute
to amenorrhea and bone loss in women athletes. Running and ballet dancing
are among the activities most closely associated with amenorrhea, with as
many as 66% of women long-distance runners and ballet dancers experiencing
amenorrhea.40 Among women bodybuilders in one study, 81% experienced
amenorrhea, and many had nutritionally deficient diets. While some
amenorrheic athletes have been reported to resume menstruation after
adding one day of rest per week and consuming a daily nutritional beverage
containing additional calories, protein, carbohydrate, fat, vitamins, and
minerals, no controlled trials have investigated this
approach.
Hormonal changes associated with breast-feeding prevent
menstruation in healthy women. The duration of this interruption in
menstruation, known as lactational or postpartum amenorrhea, depends on
many factors, including the nutritional health of the mother. Poor
maternal nutritional status has been associated with longer periods of
lactational amenorrhea in developing countries as well as in Great Britain
among poor nursing women. Better maternal nutritional status was found to
be associated with shorter lactational amenorrhea in well-nourished
nursing mothers in the United States. When malnourished nursing mothers
are given food supplements, the length of lactational amenorrhea can be
shortened, according to preliminary studies. However, one controlled trial
found dietary supplementation with skim milk did not shorten the duration
of amenorrhea in well-nourished nursing mothers. Although prolonged
lactational amenorrhea prevents another pregnancy, it has not been shown
to result in permanent bone loss.
Excessive stress causes the body
to produce increased amounts of the adrenal hormone cortisol, and several
studies have linked high cortisol levels to low levels of reproductive
hormones and to amenorrhea. In one study, amenorrheic women showed a
greater increase in cortisol in response to stress than did women with
normal menstrual cycles. No research has been done to evaluate stress
reduction interventions for the treatment of amenorrhea.
Smoking
may contribute to amenorrhea. A survey study found that young women
smoking one pack or more per day were more likely to be amenorrheic than
other women. However, whether smoking cessation will normalize menstrual
function in amenorrheic women is unknown.
Nutritional supplements
that may be helpful: Oral, micronized progesterone (200 to 300 mg per day)
has been shown in at least one double-blind trial to successfully induce
normal menstrual bleeding in women with secondary amenorrhea. Use of this
natural hormone should always be supervised by a doctor.
A
preliminary trial showed that bone loss occurred over a one-year period in
amenorrheic exercising women despite daily supplementation with 1,200 mg
of calcium and 400 IU of vitamin D. In a controlled study of amenorrheic
nursing women, who ordinarily experience brief bone loss that reverses
when menstruation returns, bone loss was not prevented by a multivitamin
supplement providing 400 IU of vitamin D along with 500 mg twice daily of
calcium or placebo. Despite the lack of evidence that calcium and vitamin
D supplements alone are helpful to amenorrheic women, they are still
generally recommended to prevent the added burden of calcium and vitamin D
deficiency from further contributing to bone loss. Amounts typically
recommended are 1,200 to 1,500 mg calcium and 400 to 800 IU vitamin D
daily.
Acetyl-L-carnitine is an amino acid that may have effects on
brain chemicals and hormones that control female reproductive hormones. In
a preliminary trial, 2 grams daily of acetyl-L-carnitine was given to
amenorrheic women who had either low or normal blood levels of female
hormones. Hormone levels improved in the women with low initial levels,
and half of all the women resumed menstruating within three to six months
after beginning supplementation. Controlled trials are needed to confirm
these promising results.
Vitamin C alone, at 400 mg daily, had no
effect on amenorrhea in one preliminary trial, although it was associated
with the return of ovulation in some women who were menstruating regularly
but not ovulating. In a second phase of the trial, the same amount of
vitamin C was combined with a drug that affects female hormone levels, and
this combination was associated with return of ovulation in almost half of
amenorrheic women who had not benefited from the drug alone. More studies
of the effect of vitamin C on amenorrhea are needed.
Prolactin is a
hormone that may be elevated in some cases of amenorrhea. A preliminary
trial of 200 to 600 mg daily of vitamin B6 restored menstruation and
normalized prolactin levels in three amenorrheic women with high initial
prolactin levels; however, 600 mg daily of vitamin B6 had no effect on
amenorrheic women who did not have high prolactin levels. A number of
other small, preliminary trials have not demonstrated an effect of either
oral or injected vitamin B6 on prolactin levels, and they also have
reported inconsistent effects on restoring menstruation. Larger,
controlled trials are needed to better determine the usefulness of vitamin
B6 in amenorrhea.
While zinc is known to be important for many
aspects of reproductive function, little research has investigated its
role in amenorrhea. In a controlled study of intense exercisers, zinc
deficiency was equally common between amenorrheic and menstruating
exercisers. More research is needed.
Are there any side effects or
interactions? Refer to the individual supplement for information about any
side effects or interactions.
Herbs that may be helpful: Blue
cohosh is a traditional remedy for lack of menstruation. It is considered
an emmenagogue (agent that stimulates menstrual blood flow) and a uterine
tonic. No clinical trials have validated this traditional
use.
Other herbal emmenagogues traditionally regarded as
stimulating absent or diminished menses are motherwort, rue, partridge
berry, and yarrow. None of these herbs has undergone modern clinical
trials to determine their efficacy. All emmenagogues should be avoided in
pregnancy, as they may possibly cause a spontaneous abortion.
In
herbal medicine, Vitex agnus-castus (chaste tree) is sometimes used to
treat female infertility and amenorrhea. Elevation of prolactin can be a
cause of amenorrhea, and vitex has been shown in animals to reduce
elevated prolactin levels. In a controlled trial, prolactin production was
normalized in women with high prolactin levels after three months of
treatment with vitex. Vitex has also been found to raise levels of
luteinizing hormone and subsequent progesterone levels in women with
luteal phase defect-a condition that can also lead to menstrual cycle
abnormalities, including amenorrhea. To date, only one small preliminary
trial has studied the effects of vitex on amenorrhea. This study found
that ten of fifteen women with amenorrhea began having a normal period
after taking 40 drops of a liquid vitex preparation once daily for six
months. Further research is needed to determine what role vitex may play
in the management of amenorrhea.
Are there any side effects or
interactions? Refer to the individual herb for information about any side
effects or interactions.
Other integrative approaches that may be
helpful: In a number of preliminary trials, acupuncture has been shown to
induce ovulation in women with disorders involving lack of ovulation.
Preliminary studies show that levels of estrogen and progesterone, as well
as levels of the related hormones LH (luteinizing hormone) and FSH
(follicle-stimulating hormone), may all be affected by acupuncture. Few
studies have looked at the use of acupuncture for treatment of amenorrhea,
but one preliminary trial found it helpful for women who have widely
separated menstrual cycles. In one controlled trial, amenorrheic women
showed a trend toward normalizing hormone levels following acupuncture.
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