By Dr. Shawna Darou, ND
Amenorrhea means absent periods, and I find that this is a condition where there is a lot of misdiagnosis, and often insufficient lab testing. There are many possible causes of missing periods, and with correct lab tests matched with symptoms we can navigate your best treatment options.
What are the possible causes of amenorrhea?
The most common conditions that lead to absent periods or amenorrhea include:
- Hypothalamic amenorrhea: periods lost due to stress, weight loss, restrictive dieting, or excessive exercise.
- Post-pill amenorrhea: absent periods for an extended time after stopping hormonal contraception.
- Polycystic ovarian syndrome (PCOS): one common symptom of PCOS is absent or irregular periods.
- Premature ovarian insufficiency (POI): this condition is quite rare, and results in a hormonal shift into menopause at a younger age (under age 45).
- Perimenopause / Menopause: periods become irregular and absent with true menopause, and can become very irregular in the years leading up to it.
Lab testing is essential:
An accurate diagnosis can be found when we match age + health history + lab testing. It’s extremely important not to jump to conclusions based on age alone or body weight. For example, a thin athletic woman may have PCOS and not hypothalamic amenorrhea; and a woman in her 40’s may have hypothalamic amenorrhea due to high stress and not be in perimenopause.
Most important tests:
- Estradiol
- LH
- FSH
Other extremely useful tests:
- AMH (anti-Mullerian hormone)
- DHEA
- Fasting glucose and insulin
- Thyroid hormones, including free T3
Summary Table:
| Lab test | Hypothalamic | Post-pill amenorrhea | Premature Ovarian Insufficiency (POI) | Polycystic Ovarian Syndrome (PCOS) | Perimenopause | Menopause |
|---|---|---|---|---|---|---|
| Estradiol | Low | Low or normal | Low | Normal | Low, Normal or high | Low |
| LH | Low | High or normal | High | High | Normal or high | High |
| FSH | Low | Normal | High | Normal | Normal or high | High |
| DHEA | Normal | Normal | Normal | Often high | Normal | Normal |
| AMH* | Normal | Normal | Very low | Higher than expected for age | Low | Very low |
| Other tests | Free T3 (excellent marker for under-eating or over-exercising) | Insulin resistance (fasting glucose & insulin) | ||||
| Additional notes: | History of high stress, weight loss, dietary restriction, over-exercise. | No period since coming off hormonal birth control. | Often family history of early menopause. Night sweats, hot flashes may be present. | Often carry weight central abdomen, signs of high androgens: acne, hair loss, hirsutism.** | Age > 42years, and change in menstrual cycle. Symptoms usually come and go. | Age > 45years, hot flashes, night sweats, mood swings, insomnia. |
*AMH = Anti-Mullerian Hormone, a marker of ovarian reserve.
**PCOS can present in many different ways – not all women struggle with weight Irregular periods, high LH, normal Estradiol, and some sign of high androgens would confirm a diagnosis.
Treatment Options:
Once a diagnosis is made, we move on to treatment which becomes much simpler to navigate with clarity. A very brief summary of Naturopathic treatment options is shown below, but please remember that individualized care is key!
Hypothalamic amenorrhea:
The most important consideration is to address the stress, weight loss or over-exercise (or combination of all three) that caused the period to stop. Ensuring balanced nutrition, sufficient body fat levels, and looking at life stress is key. There are supplements that can be considered, including adrenal support, acetyl-l-carnitine, Vitex, Maca, and especially acupuncture treatments.
Post-pill amenorrhea:
This condition may present very much like PCOS, but without a high AMH level or insulin resistance. Absent periods, acne, and ovarian cysts on ultrasound after coming off hormonal birth control may all be present temporarily. Treatment that may be considered includes Peony and Licorice supplement, Vitex (if LH level is not high), stress support and acupuncture treatment.
Polycystic ovarian syndrome (PCOS):
This article is too short to get into the various ways PCOS can present, but some common themes in treatment include: supporting regular ovulation with a low-glycemic nutrition plan, supplements such as Peony and Licorice, Inositol, Reseveratrol and Vitamin D, and the addition of regular exercise.
Premature ovarian insufficiency (POI):
BHRT (Bioidentical hormone replacement therapy) may be strongly recommended if the ovaries are no longer active at too young an age. Hormones can protect bone density, cognitive function and cardiovascular health, and are generally continued until the average age of menopause around 50 years.
Perimenopause:
The goal during perimenopause is to encourage regular ovulation and hormone balance for as long as possible. Depending on the estrogen state (may be low or high), we support estrogen metabolism, and use herbs such as Maca, Vitex, Dong Quai to create stability. Bioidentical progesterone cream can also be useful for cycle regulation and reduction in premenstrual symptoms.
Menopause:
Again, this article is too short to discuss all of the options to treat menopause symptoms, and this is ideally a comprehensive plan including nutrition, regular exercise, herbs and possibly bioidentical hormone therapy.
What’s Next?
I hope this article has given you insight into the many causes of amenorrhea, or missing periods and the information to request correct testing to understand the cause. Women’s hormonal systems affect every part of our lives – mood, energy, stress resilience, weight, sleep quality and more. It is so important to support and balance hormones well for your overall health and wellbeing.
Book an appointment with Dr. Darou online.
Contact us: 416.214.9251, admin@drdarou.com
www.darouwellness.com