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Amenorrhoe
First the test, then the control: load, thyroid, prolactin, PCOS, the pill, the transition years.
Also known as: missed period · no period · amenorrhoea · absent menstruation
Open in the tool — with search and all the links →This compilation is for information and replaces neither medical diagnosis nor treatment. If you have symptoms, see a doctor.
When a period does not come, the first step is always the same: a pregnancy test, even if it seems unlikely. After that, look at the control system. The cycle is sensitive and responds to load — marked underweight, a lot of sport, low energy over a longer period, a serious illness or ongoing stress can shut it down; this is not an ovarian disorder but a brake applied from above. Polycystic ovary syndrome is common too, with long, irregular cycles. A thyroid outside the normal range disturbs the cycle, as does a raised prolactin, which sometimes also produces milk flow and can be caused by medication. After stopping the pill it can take months for one’s own rhythm to return. And in the years before menopause, skipped cycles become normal. An absence of more than three months without explanation should be assessed — not out of worry, but because most reasons can be named and treated well.
Infrequent or absent cycles together with increased body hair, acne or thin scalp hair are the commonest picture of PMOS — the condition called PCOS until 2026. Before the diagnosis, thyroid and prolactin are clarified.
Date of the last bleed, length of recent cycles — the basis of every consultation.
It is not the training that is the problem, but the gap between output and intake.
Some drugs raise prolactin — the timing is the key.
Without an explanation this is the usual threshold — sooner if other signs appear.
A period counts as absent after three months without bleeding in an otherwise regular cycle, or six months in an irregular one. A normal cycle lasts twenty-four to thirty-eight days. The most common reason is pregnancy, then PCOS, stress, underweight, sport, thyroid and a raised prolactin. Below about seventeen per cent body fat the cycle often stops — that is an adaptation and not a disorder in the strict sense.
The pill produces a withdrawal bleed — it does not restore the cycle, it replaces it, and while on it you cannot see whether the cycle would come back by itself. In PCOS, metformin brings ovulation back in some; letrozole is used when trying to conceive. In a cycle stopped by underweight or sport, no drug helps — there the cycle returns with weight and energy, usually over three to twelve months.
Before any further thought — a test costs little and clarifies a lot.
The body saves on the cycle first. This is reversible when the cause is addressed.
With increased body hair or acne, the PCOS pattern.
Points to raised prolactin — easily measured and usually well treatable.
Every bleed costs iron. With heavy or long periods the store empties faster than it fills — ferritin shows this earlier than the haemoglobin.
Often used for cramps of the womb muscle. The studies are small and inconsistent; it is well tolerated, and the belly shows the upper limit.
Acts on ovary and womb lining. Low values are common; correcting them is worthwhile for bone and muscle regardless of the cycle.
Often named for complaints before the period and defensible in a moderate dose. At a high dose over months it harms the nerves — that is the limit that counts.
Best studied in PCOS: 2 g myo-inositol twice a day over 3–6 months; in studies the cycle returned for some of the women. With low weight or hard training it is the wrong point to press.
With PCOS a low level is common; whether the missing period is connected is open. Measured and replaced by finding.
Whatever the reason: anyone who could become pregnant takes 400 µg a day — the benefit lies in the first weeks, often before the missed period is noticed.
Clearly effective with proven deficiency, useless without. Take only with a documented deficiency — excess is harmful.
Effective when deficient; effects on sleep and stress plausible but moderate. Too much causes loose stool.
A raised value slows the control of the ovaries and stops the bleeding. Causes are stress, breastfeeding, several commonly prescribed medicines and a benign growth of the pituitary gland.
These two separate the causes: if they are high it lies with the ovaries; if they are low or normal with a low oestradiol it lies with the control in the brain — through being underweight, much sport or strain.
If it stays low for long, the bone lacks its most important protection. That is why bleeding that stays away for months is no side finding.
Both an overactive and an underactive thyroid throw the cycle out. The value belongs in the same blood draw as the prolactin.
The signal from fatty tissue tells the brain whether there is enough reserve. If it falls below a threshold, the control switches the cycle off — that is the road with being underweight and hard training.
When periods stop without pregnancy, too low an energy intake is one of the most common causes — especially with a lot of sport. The body puts reproduction on hold before sacrificing anything else.
Both marked underweight and heavy overweight bring the cycle to a halt — by different routes. In both cases it usually returns within 3–6 months after a change.
Too low an energy intake over a longer time is one of the most common causes, especially with a lot of sport. The body puts reproduction on hold before sacrificing anything else — after a change the cycle usually returns within 3–6 months.
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