Lack of Periods

It is common for women who have just delivered to ‘miss’ their monthly periods. A lot of confusion and questions arise as a result, with many wondering whether that means they are incapable of conception under these circumstances. Others are anxious and nervous about not being able to resume their cycle; while some get worried that they might be having a medical problem.

Understanding the term ‘amenorrhea’

In general, many women get to know that as long as one is exclusively and regularly breastfeeding her newborn, she may not menstruate or conceive. This can last, on average, up to six months. Why this is the case, most parents do not know.

Return of menstruation after delivery varies widely from one woman to another.  Amenorrhea is the absence of menstrual flow in a woman of reproductive age. Lactational amenorrhea, which occurs after delivery, refers to the normal lack of menstruation over the first several weeks, typically up to six months.

There are certain conditions that must be fulfilled for lactational amenorrhea to take effect. These include exclusive and regular breast-feeding. Once the condition is present, ovulation does not happen and therefore birth control becomes guaranteed.

In the post-pregnancy period, the process that causes preparation of breast milk leads to the release of a hormone called prolactin from the pituitary gland—a tiny roundish organ at the bottom of the brain. Prolactin stimulates and sustains production and release of breast milk.

The hormone that stimulates the origination of the egg during ovulation, known as the ‘follicle stimulating hormone’ or FSH. is also produced by the pituitary gland. During breastfeeding, a baby’s suckling sends signals, to the brain, that interfere with FSH release. Low levels of FSH results in irregular or nil ovulation and stoppage of periods.

As time progresses and the mother starts weaning (giving sclids to) the baby, the intensity of breastfeeding will go down, enabling more FSH to be produced and thereby increasing regularity of ovulation and monthly periods.

Lack of periods without pregnancy or baby
In the absence of pregnancy and contraceptives, a woman is said to be suffering from amenorrhea if she fails to achieve a period for three consecutive months—In the case of a woman known to have a history of regular periods—or six months if hers are irregular periods.

The condition is referred to as ‘primary amenorrhea’ if a woman who has exhausted her childhood fails to achieve commencement of menstrual flow—meaning she has never had a period. It is known as ‘secondary amenorrhea’ if periods have been present and established but have ceased without pregnancy or menopause.

Primary amenorrhoea may be the result of various problems, including congenital lack of a uterus or delayed development during puberty.

Secondary amenorrhoea commonly results from problems which may include hormonal imbalances or premature menopause (permanent end of menstruation, normally after child-bearing age).

Besides the three to six month period, mentioned earlier, the lack of a menstrual flow, without pregnancy, for a period equivalent to three times the duration of a normal cycle, is diagnosed as amenorrhea—for instance, if one’s cycle is 28 days and 84 days go by without having a flow.

If the duration is shorter than this and one does not have a history that would raise an infertility concern or inability to conceive, doctors would not normally take such a person through the process of investigation.

How does a period occur?
Your menstrual cycle can be divided into two steps or phases: the first step (known as the ‘follicular phase’) is the preovulatory phase during hormones cause the uterine lining (endometrium) to grow. The next step (known as the ‘Luteal phase’) during which the uterine lining thickens further and prepares for possible implantation of a fertilised egg.

This layer or blanket converts into the placenta once an egg implants onto the lining of the uterus.

If fertilisation of the egg does not happen, the level of hormones responsible for the thickening of the inner lining of the uterus falls, causing the shedding of the lining. Subsequent expulsion of this lining, accompanied by blood and mucous, makes up the menstrual flow referred to commonly as a period.

What causes amenorrhea?
Situations that lead to amenorrhea include ovulation abnormality, pregnancy, thyroid disorder, birth defect (or other physical abnormality), strenuous or excessive exercise (‘athletic’ amenorrhoea), eating disorder and obesity.

Normal and abnormal situations that cause lack of periods arise at the brain, the ovary, and the uterus. The pituitary gland controls ovulation and has a direct effect on ovulation and the growth of the eggs. Without growth and maturity of the eggs, one cannot have a menstrual flow.

It is important to understand that the menstrual cycle is basically a result of intricate coordination of hormones between three parts of the body: the brain, the ovaries and the uterus.

A woman with amenorrhea is normally tested for pregnancy first before assessing other possible causes such as the tumours.

At the brain
Tumours within the brain in the pituitary gland can result in the release of excessive levels of prolactin. Women with such tumours will lactate (produce milk) even when they are not pregnant or breastfeeding. Excessive prolactin prevents the development of eggs within the ovary.

Environmental changes can also influence the cascade of events that leads to the maturation of the eggs. For instance, women who have lost a lot of weight may sometimes present amenorrhea which is meditated through the brain. Stress can also present ‘hypothalamic’ amenorrhea. One can also have what is referred to us premature menopause, before the age of 35 years.

At the ovaries
One of the common causes of amenorrhea is ovaries that are larger than usual which produce hormones, specifically oestrogen, in extraordinarily large amounts. This condition is commonly referred to as polycystic ovary syndrome. This hormone influences the thickening of the inner wall of the uterus, and affects the onset of shedding of the endometrium (inner lining of the uterus). Surgical removal of the ovaries due to medical disorder can cause amenorrhea.

Women who have been treated with chemotherapy for management of certain types of cancer could also experience destruction of eggs in the ovary and that could render them amaenorrheic.

At the uterus
An overdone D&C can result into permanent amenorrhea. D&C is a procedure whereby dilation (opening of the cervix) and curettage (surgical removal of tissue from inside the uterus) is undertaken, for instance to ‘dean’ the uterus in the event of an abortion or miscarriage. A metal rod called a ‘curette’ with a sharp loop, is inserted into the uterus through the dilated cervix, and used to gently scrape the lining of the uterus to remove unwanted tissue.

Diseases such as tuberculosis of the uterus can also cause amenorhea because of destruction of the inner lining of the uterus.

Another common uterine cause of amenorrhea is the use of certain family planning injections, which result in lack of periods for several months, for example Depo-Provera and in some cases Norplant.

Hereditary and congenital disorders
Some women are born with incomplete genital system. There are those who are born without functional ovaries or without uterus.

What is the treatment?
Management will depend on the cause, ones medical history, age. tolerance to specific drug or supplement interventions, and the seriousness of the condition. Interventions may include hormone regulation, surgery, fertility drugs, anti-TB therapy etc.

Where ovulation is found to have occurred but periods have failed, menstruation will be induced, to reduce the risk of uterine cancer which can be caused by the cummulative thickening of the uterine lining.

END:PG12/58-59