Amenorrhea means not menstruating or having a period. There are two types of amenorrhea: primary and secondary. When a girl reaches age 16 and has not had a period, she may have primary amenorrhea. When a woman who has been having periods misses three in a row, she is considered to have secondary amenorrhea. Amenorrhea is expected in certain circumstances, including during pregnancy, lactation, and menopause. Secondary amenorrhea is more common than primary amenorrhea.

Amenorrhea is a sign of another condition, not a disease itself. Many things can cause it, including low body weight, hormonal imbalances, stress, and problems with the pituitary gland. Usually, the underlying condition is not serious.

Symptoms of primary amenorrhea may include:

• Headaches
• Abnormal blood pressure
• Vision problems
• Acne
• Unwanted hair growth

Symptoms of secondary amenorrhea may include:

• Nausea
• Swollen breasts
• Headaches
• Vision problems
• Being very thirsty
• Goiter (an enlarged thyroid gland)
• Darkening skin

Hot flashes, mood changes, depression, and vaginal dryness are common with estrogen deficiency.

Both primary and secondary amenorrhea can have several causes.

Primary amenorrhea

• Lack of reproductive organs, such as uterus, cervix, or vagina
• Problems with the pituitary gland
• Anorexia
• Stress
• Too much exercise
• Abnormal chromosones
• Malnutrition

Secondary amenorrhea

• Pregnancy or breastfeeding
• Polycystic ovaries
• Using some types of birth control
• Taking some types of medicines, such as corticosteroids
• Hormone imbalance
• Low body weight
• Too much exercise
• Thyroid problems
• Pituitary gland tumor
• Stress
• Premature menopause (menopause before age 40)
• Malnutrition
• Autoimmune diseases

Your doctor may ask you to take a pregnancy test, then do a physical exam, which will include an internal pelvic exam. Your doctor may also order lab tests to check your hormone levels and to learn how well your thyroid is working. Other tests may include computerized tomography (CT) scan, magnetic resonance imaging (MRI), or ultrasound.

Your doctor will determine which treatment is right for you based on the cause of your amenorrhea. Treatments include hormone therapy, psychological counseling and support, and surgery, among others.

Drug Therapies

Your health care provider may suggest the following:

• Birth control pills or hormones to help you start menstruating.
• Estrogen replacement for low levels of estrogen caused by ovarian problems, hysterectomy, or menopause. Women with an intact uterus should get estrogen plus progesterone. Estrogen, or hormone replacement therapy (HRT), has both benefits and risks. Post-menopausal women who take HRT have higher risk of breast cancer, stroke, heart disease, and blood clots in the lungs. However, for some younger women, the benefits may outweigh the risks. Talk to your doctor to decide what is best for you.
• Progesterone to treat ovarian cysts and some problems with the uterus.
• Metformin to treat cysts in the ovaries and support ovulation.

Complementary and Alternative Therapies

Maintaining a healthy weight and exercising regularly can keep your body healthy. Other alternative therapies may help your body make and use hormones properly.

Nutrition and Supplements

Be sure to eat a healthy diet. Limit processed foods, and eat foods with heart-healthy fats (unsaturated fats) rather than saturated fats. Avoid caffeine and alcohol. Eat more whole grains, vegetables, and omega-3 fatty acids found in cold-water fish, nuts, and seeds. Diets that are very low in fat can raise your risk of amenorrhea. In addition, these supplements may help:

• Calcium, magnesium, vitamin D, vitamin K, and boron. Women who do not have periods are at higher risk of osteoporosis, and these vitamins and minerals may help keep bones strong. Vitamin K can interact with blood-thinning medications such as warfarin (Coumadin) and clopidogrel (Plavix).
• B6 may reduce high prolactin levels. Prolactin is a hormone released by the pituitary gland, and women with amenorrhea often have higher levels of prolactin.
• Essential fatty acids: Evening primrose or borage oil. These fatty acids may increase the risk of bleeding, especially if you take blood thinners such as clopidogrel (Plavix) or warfarin (Coumadin).

Progesterone is sometimes available as an over-the-counter oral supplement. However, you should never take progesterone without your doctor's supervision.

Herbs

The use of herbs is a time-honored approach to strengthening the body and treating disease. Herbs, however, can trigger side effects and can interact with other herbs, supplements, or medications. For these reasons, take herbs only under the supervision of a provider.

Most of the herbs listed below have not been studied specifically for treatment of amenorrhea, but they have been used traditionally. Many act like the hormone estrogen in the body. Talk to your doctor before taking them, and avoid these herbs if you have a history or family history of cancers associated with estrogen, including breast, cervical, uterine, and ovarian cancer.

• Chaste tree: For high prolactin levels, chaste tree (Vitex agnus-castus) may help the pituitary gland function normally and may reduce prolactin levels, but it must be taken for 12 to 18 months. One very small study found that 10 of 15 women with amenorrhea started having periods after taking chaste tree for 6 months. If you already use hormone therapy, do not use chaste tree except under your doctor's supervision. Chaste tree may interact with a number of medications, including chlorpromazine (Thorazine), haloperidol (Haldol), levodopa, metoclopramide, olanzapine (Zyprexa), prochlorperazine (Compazine), quetiapine (Seroquel), ropinirole (Requip), and risperidone (Risperdal). It also may make birth control pills less effective.

The following herbs have estrogen-like effects and are sometimes used to treat menopausal symptoms, although there are no clinical trials that show whether they work or are safe. People with a history of hormone-related cancers should consult a physician before using these herbs:

• Black cohosh (Cimicifuga racemosa), licorice (Glycyrrhiza glabra), and squaw vine (Mitchella repens): Black cohosh may interact with a number of medications processed by the liver, including acetaminophen (Tylenol), atorvastatin (Lipitor), carbamazepine (Tegretol), isoniazid (INH), methotrexate (Rheumatrex), and others. Licorice interacts with many prescription and over-the-counter medications, and can potentially cause a variety of side effects, so ask your doctor before taking it. DO NOT take licorice if you have high blood pressure or heart failure.
• Lady's mantle (Alchemilla vulgaris) and vervain (Verbena officinalis): These are other herbs that may help stimulate menstrual flow. DO NOT take these herbs without your doctor's supervision. Your doctor should monitor your liver function if you take lady's mantle.
• Kelp (Laminaria hyperborea), oatstraw (Avena sativa), and horsetail (Equisetum arvense): These three are rich in minerals that may help promote thyroid function. Avoid horsetail if you have diabetes, take lithium, or take a diuretic (water pill), such as hydrochlorothiazide or furosemide (Lasix).
• Wild yam: Some people believe wild yam is a natural source of progesterone, but that is not true. Although it was once used to make progesterone in the laboratory, the body cannot make progesterone from wild yam.

DO NOT take the herb blue cohosh (Caulophyllum thalictroides). This toxic herb should not be used without strict medical supervision.

Homeopathy

Few studies have examined the effectiveness of specific homeopathic remedies. Professional homeopaths, however, may recommend treatments for amenorrhea based on their knowledge and clinical experience. Before prescribing a remedy, homeopaths take into account a person's constitutional type, which is your physical, emotional, and intellectual makeup.

• Pulsatilla: For most menstrual problems, especially in women who have poor appetite and do not favor exertion; they may faint easily. They may be aggravated by heat and feel worse in the evening. They may like to be in the open air.
• Sepia: For women with late or irregular menstruation. They may have a sallow complexion and experience frequent headaches, toothaches, and pain when bearing down. They may feel cold and want to be alone.
• Graphites: For women with late or light menstruation. They may have a sallow complexion and experience a feeling of fullness or constipation and headaches. They often have a fair complexion.

Physical Medicine

The following help increase circulation and relieve pain from pelvic congestion:

• Castor oil pack: Apply oil to a soft, clean cloth, place on abdomen, and cover with plastic wrap. Place a hot water bottle or heating pad over the pack and let sit on your abdomen for 30 to 60 minutes. You can safely use this treatment for 3 days, although it may be beneficial to use for longer. Talk to your provider to determine how long to use it.
• Contrast sitz baths: Use two basins that you can comfortably sit in. Sit in hot water for 3 minutes, then in cold water for 1 minute. Repeat this 3 times to complete one "set." Do 1 to 2 sets per day, 3 to 4 days per week.

Acupuncture

Acupuncture may improve hormonal imbalances that can go along with amenorrhea and related conditions, such as polycystic ovary syndrome (PCOS). A few small studies of women with fertility problems, which are sometimes connected with amenorrhea, suggest that acupuncture may help promote ovulation.

Acupuncturists treat people with amenorrhea based on an individualized assessment of the excesses and deficiencies of qi located in various meridians. Acupuncturists believe that amenorrhea is often associated with liver and kidney deficiencies, and treatment often focuses on strengthening function in these areas.

Becoming pregnant may be difficult or impossible. Amenorrhea also may cause pregnancy complications.

Amenorrhea can also raise the risk of developing osteoporosis.

Bope ET, Kellerman RD, eds. Conn's Current Therapy 2013. 1st ed. Philadelphia, PA: Elsevier Saunders; 2012.

Böhnert KJ. The use of Vitex agnus castus for hyperprolactinemia. Quart Rev Nat Med. 1997;Spring:19-21.

Bruni V, Dei M, MOrelli C, Schettino MT, Balzi D, Nuvolone D. Body composition variables and leptin levels in functional hypothalamic amenorrhea and amenorrhea related to eating disorders. J Pediatr Adolesc Gynecol. 2011;24(6):347-52.

Cardigno P. Homeopathy for the treatment of menstrual irregularities: a case series. Homeopathy. 2009 Apr;98(2):97-106.

Carr AC, Frei B. Toward a new recommended dietary allowance for vitamin C based on antioxidant and health effects in humans. Am J Clin Nutr. 1999;69(6):1086-107.

Chen B-Y. Acupuncture normalizes dysfunction of hypothalamic-pituitary-ovarian axis. Acupunct Electro-Therapeut Res. 1997;22:97-108.

Feldmann JM, Belsha JP, Elissa MA, Middleman AB. Female adolescent athletes' awareness of the connection between menstrual status and bone health. J Pediatr Adolesc Gynecol. 2011;24(5):311-4.

Frederick CE, Edelman A, Carlson NE, Rosenberg KD, Jensen JT. Extended-use oral contraceptives and medically induced amenorrhea: attitudes, knowledge and prescribing habits of physicians. Contraception. 2011;84(4):384-9.

Gabel KA. Special nutritional concerns for the female athlete. Curr Sports Med Rep. 2006 Jun;5(4):187-91. Review.

Heiss G, Wallace R, Anderson GL, Aragaki A, Beresford SA, Brzyski R, et al; WHI Investigators. Health risks and benefits 3 years after stopping randomized treatment with estrogen and progestin. JAMA. 2008 Mar 5;299(9):1036-45.

Hutchins AM, Martini MC, Olson BA, et al. Flaxseed consumption influences endogenous hormone concentrations in post-menopausal women. Nutr Cancer. 2001;39:58-65.

Johnston CS. Recommendations for vitamin C intake. JAMA. 1999;282(22):2118-9.

Levine M, Rumsey SC, Daruwala R, Park JB, Wang Y. Criteria and recommendations for vitamin C intake. JAMA. 1999;281(15):1415-53.

Mowrey DB. The Scientific Validation of Herbal Medicine. New Canaan, CT: Keats Publishing; 1988.

Palomba S, Meterazzo C, Falbo A, Orio F, La Sala GB, Sultan C. Metformin, oral contraceptives or both to manage oligo-amenorrhea in adolescents with polycystic ovary syndrome? A clinical review. Gynecol Endocrinol. 2014; 30(5):335-40.

Rakel. Textbook of Family Medicine. 8th ed. Philadelphia, PA: Elsevier Saunders; 2011.

Sourgens H, Winterhoff H, Gumbinger HG, et al. Antihormonal effects of plant extracts; TSH- and prolactin-supressing properties of Lithospermum officianale and other plants. Planta Med. 1982;45:78-86.

Stener-Victorin E, Waldenstrom U, Andersson SA, Wikland M. Reduction of blood flow impedance in the uterine arteries of infertile women with electro-acupuncture. Hum Reprod. 1996;11(6):1314-7.

Stener-Victorin E, Waldenstrom U, Tagnfors U, Lundeberg T, Lindstedt G, Janson PO. Effects of electro-acupuncture on anovulation in women with polycystic ovary syndrome. Acta Obstet Gyneol Scand. 2000;79:180-8.

Tyler VE. Herbs of Choice: The Therapeutic Use of Phytomedicinals. Binghamton, NY: Pharmaceutical Products Press; 1994.

West S, Vahasarja M, Bloigu A, et al. The impact of self-reported oligoamenorrhea and hirsutism on fertility and lifetime reproductive success: results from the Northern Finland Birth Cohort 1966. Hum Reprod. 2014;29(3):628-33.

Xiaoming M, Ding L, Yunxing P, Guifang X, Xiuzhen L, Zhimin F. Clinical studies on the mechanism for acupuncture stimulation of ovulation. J Tradit Chin Med. 1993;13(2):115-9.