Absence of Menstrual Periods

November 07, 2009

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Absence of Menstrual Periods

by Marjorie Greenfield, M.D.
reviewed by Marjorie Greenfield, M.D.

Is it normal to not have a period? I get asked this question frequently, and yet it is still hard to answer, because so many factors are involved. One of the most important considerations is whether or not a girl has gone through puberty yet. A girl in the U.S. will get her period, on average, at age 12, and the majority will have started menstruating by age 14½, usually about two years after breast development begins.

If by age 13 a girl still shows no sign of puberty (breast development, growth of pubic and underarm hair), or if she has not yet started her period by age 15, it warrants evaluation by a healthcare professional.

Once a girl has had her first period--or menarche (pronounced MEN-ar-kee)--her periods may be irregular, but it is not normal for menstruation to cease altogether. Loss of the period for six months or more merits a trip to the doctor.

What causes delay of menarche?
Absent periods and delayed puberty can be caused by many things. The patient's work-up is done step by step. The first step in the evaluation is to check if the girl has begun to show other signs of puberty. Does she have some breast development? Has she undergone a growth spurt recently? Does she have armpit and pubic hair?

If no signs of puberty are present by age 13, the girl's doctor will probably refer her to a hormone specialist (endocrinologist) for evaluation. If, however, pubertal development has been otherwise normal, a pediatrician, gynecologist, family doctor, or pediatric endocrinologist can usually sort out the situation. (In different parts of the United States, different specialists have this expertise.) If your child's primary doctor isn't comfortable with doing the work-up, he can refer you to another physician.

The doctor who is doing the work-up will ask about eating habits, exercise, and growth pattern up until that point. Are there other family members who started puberty late? The physical examination will include measurements of height and weight, a check of the thyroid gland (in the neck) to see if it's enlarged, an abdominal exam, and an external genital exam. Any need for further testing will depend on the findings. Ultrasound may be useful in checking the internal anatomy--determining the presence and structure of the ovaries, uterus, and vagina.

In some instances, an anatomical cause for the absence of periods is found, and further evaluation and treatment will proceed based on those findings.

The progestin challenge
In girls who have started to show some signs of puberty and who seem to have normal anatomy, a progestin challenge is generally the next step in determining the cause of absent periods. In the progestin challenge, the girl takes a short course--5 to 12 days--of a medication similar to the hormone progesterone to see if it brings on a menstrual period.

Hormonal causes of absent periods

Cycling problems. Occasionally all parts of the system involved in menstruation--the ovary, the pituitary, and the hypothalamus--work well individually but do not coordinate their efforts properly. This leads to fairly normal levels of estrogen and menstrual bleeding after the progestin challenge, a situation called chronic anovulation. Many girls with this condition are overweight, and some start off having periods that then stop or become irregular.

The ovaries are not being told what to do. Excess exercise, low body weight, and eating disorders all disrupt the workings of the pituitary gland, so that it doesn't send proper signals to the ovary. Girls with these conditions have very low levels of estrogen, do not bleed in response to the progestin challenge, and do not release eggs. (This physiological response probably evolved because in times of great stress or starvation, it was better not to get pregnant.)

Some girls have low levels of estrogen, despite the absence of these three specific causes. Certain blood tests and a CT (computerized tomography) or MRI (magnetic resonance imaging) scan of the brain may be needed to ensure that a benign tumor of the pituitary gland is not responsible for the lack of periods.

The ovaries are not able to make hormones. Sometimes delayed puberty or delayed menarche is an indication that something is wrong with the ovaries, as releasing eggs and making hormones go hand in hand. One way of determining whether the ovaries are incapable of making eggs is to test for an elevated blood level of the pituitary hormone FSH. Ovarian problems are serious conditions that, if present, will need to be explained in more detail by the physician.
RELATED INFORMATION
Menstrual Cycle Basics
The Events of Ovulation
Menstrual Issues
Menstruation

Created July 24, 2001
Reviewed August 05, 2004

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