Amenorrhea is the absence of menstruation (not 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. Secondary amenorrhea is more common than primary amenorrhea. Amenorrhea is a sign of another condition, not a disease itself. Many things can cause it, from low body weight to hormonal imbalances to 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
• Excessive 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

Secondary amenorrhea

• Pregnancy or breast-feeding
• Using some kinds of birth control
• Taking some types of medication (such as corticosteroids)
• Hormone imbalance
• Low body weight
• Too much exercise
• Thyroid problems
• Pituitary tumor
• Stress
• Premature menopause (menopause before age 40)

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 see how your thyroid is functioning. 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 underlying cause. Treatments include hormone therapy, psychological counseling and support, and surgery, among others.

Drug Therapies

Your health care provider may suggest the following:

• Oral contraceptives (birth control pills) or hormones to cause you to start menstruating.
• Estrogen replacement for low levels of estrogen caused by ovarian disorders, hysterectomy, or menopause. Women with an intact uterus should receive 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's best for you.
• Progesterone to treat ovarian cysts and some problems with the uterus.

Complementary and Alternative Therapies

Maintaining a proper weight and exercising the right amount can keep your body healthy. Other alternative therapies may help your body produce and use hormones properly.

Nutrition and Supplements

Be sure to eat a healthy diet: Eat fewer processed foods, and eat foods that are higher in unsaturated fat (but low in saturated fat). Avoid caffeine and alcohol. Eat more whole grains, vegetables, and omega-3 fatty acids (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 (1,000 mg per day), magnesium (600 mg per day), vitamin D (200 - 400 IU per day), vitamin K (1 mg per day), and boron (1 to 3 mg per day). Women who don’t have periods are at higher risk of osteoporosis, and these vitamins and minerals may help keep bones strong.
• B6 (200 mg per day) 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 (1,000 - 1,500 mg one to two times per day).

Progesterone is sometimes available as an over-the-counter oral supplement. However, this is a hormone that should never be taken 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 health care provider.

Most of the herbs listed below have not been studied specifically for amenorrhea, but have been used traditionally. Many have an effect in the body that’s similar to the hormone estrogen. Talk to your doctor before taking them, and avoid these herbs if you have a history or family history of cancers associated with estrogen. That includes breast, cervical, uterine and ovarian cancer.

• 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 - 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.
• These 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: Black cohosh (Cimicifuga racemosa), licorice, (Glycyrrhiza glabra), and squaw vine (Mitchella repens). Do not take licorice if you have high blood pressure or heart failure.
• Other herbs that may help stimulate menstrual flow include lady's mantle (Alchemilla vulgaris) and vervain (Verbena officinalis). 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) are rich in minerals that may help promote thyroid function.

Wild yam is sometimes said to be a natural source of progesterone, but that is not true. Although it was once used to produce the hormone in the laboratory, the body cannot make progesterone from wild yam.

Avoid blue cohosh (Caulophyllum thalictroides). This toxic herb should not be used without strict medical supervision.

Homeopathy

There have been few studies examining 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 -- 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 - 60 minutes. You can safely use this treatment for 3 days, although it may be beneficial to use for longer; talk to your health care 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 three times to complete one "set." Do one to two sets per day, 3 - 4 days per week.

Acupuncture

Acupuncture is believed to 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.

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

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):1086-1107.

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

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):2118-2119.

Levine M, Rumsey SC, Daruwala R, Park JB, Wang Y. Criteria and recommendations for vitamin C intake. JAMA. 1999;281(15):1415-1453.

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

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): 1314-1317.

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;79:180-188.

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

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):115-119.