Between ages 12 and 49, women typically experience uterine bleeding every 28-30 days. This happens when the hormones signal the absence of pregnancy and the uterine lining, which was thickening in preparation for potential pregnancy, is shed.

However, there are certain times when this naturally ceases. This process can also be interrupted by other medical conditions. In addition, there are some instances in which it does not begin in the typical time frame.

If someone is expecting to menstruate but is not, it is important to investigate why and to support hormonal balance and overall health. This is true even if someone is not looking to conceive soon or at all, as the menstrual cycle can be seen as a vital sign, providing valuable insight into the health of the body.

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What is Amenorrhea?

When a woman is expecting to have a monthly menstrual cycle is not, this is called amenorrhea. Amenorrhea is not a disease per se and occurs naturally during certain times of the reproductive life, such as pregnancy, postpartum, and while breastfeeding. There are two major categories of amenorrhea: Primary and Secondary amenorrhea.

Primary amenorrhea: is when menstruation does not start by the expected age. If a female has been growing and developing typically yet does not have menses by age 15, this is considered primary amenorrhea. If someone reaches 13 and has no signs of breast development, this should also trigger an investigation for primary amenorrhea. It is also possible for a young woman to be experiencing cyclic pain but no bleeding before age 15, which might indicate a possible anatomical blockage.

Secondary amenorrhea: is when someone has been menstruating, even if irregularly, and stops. For someone with a regular, predictable cycle roughly every 28-30 days, secondary amenorrhea would be defined as starting after three months of no bleeding. Amenorrhea would technically begin after six months without a period for someone who has been bleeding but irregularly.

The causes of each are somewhat different. We will primarily focus on secondary amenorrhea in this article.

What is Secondary Amenorrhea?

Let's say you have been menstruating for either a short time or perhaps many years. It is common to miss one period during particular physical or mental stress or other major adaptations. Some people will consistently have irregularities in the interval between periods, which is a different concern. But if one has missed three cycles or gone six months with no menses, this is technically secondary amenorrhea.  

Often missing just one period is enough to trigger a sexually active woman to wonder about the possibility of pregnancy. In this case, testing for pregnancy is a good idea, as it is the most common (and completely normal) reason for the temporary cessation of periods.

It isn't the only reason, though, and any secondary amenorrhea with negative pregnancy tests should be taken seriously.

What Causes Amenorrhea?

As most women know, when they wonder why they might have missed or been late for a period, pregnancy is the most common cause of secondary amenorrhea. It is also perfectly normal to experience amenorrhea while breastfeeding. Another natural time to experience amenorrhea is when menopause happens at the end of a woman's reproductive years. If this occurs earlier than expected, as in earlier than 40 years of age, it is known as primary ovarian insufficiency and may be confused with other causes.

While pregnancy, breastfeeding, and natural menopause are natural causes of amenorrhea, there are also causes that occur because of imbalances. By far, the most common clustering of issues leading to secondary amenorrhea falls into the category of Functional Hypothalamic Amenorrhea (FHA). This is primarily caused by stress, excessive exercise, decreased caloric intake, or some combination of these factors.  

Particularly at risk are young female athletes in sports with high energy demands and the perceived benefit of extremely low body fat levels for either performance or aesthetics, such as endurance running or dancing. This particular combination is also sometimes referred to as relative energy deficiency in sports (RED-S) (previously "the female athlete triad"). Depression and desire for thinness have also been identified as leading psychological factors leading to Functional Hypothalamic Amenorrhea.

In FHA, the hormones that regulate menstruation are disrupted by the physiologic effects of stress.

Other causes of secondary amenorrhea include:

• Using certain progesterone-based birth control such as depo-provera or hormonal IUDs
• Inadequate nutrition or nutritional deficiencies
• Hormonal problems (Hypothyroid, adrenal issues, increased prolactin, or Polycystic Ovarian Syndrome (PCOS))
• Chronic illness
• Tumors (ovaries or brain)
• Cancer treatments (chemo or radiation)
• Scarring or removal of the uterus and/or ovaries
• Some prescription drugs (antidepressants, antipsychotics, blood pressure, and allergy medicines)

Functional Medicine Labs to Test for Root Cause of Amenorrhea

If a woman has stopped menstruating, the first testing should be for pregnancy, as it is a common reason, and one would want to know as soon as possible to initiate prenatal care.

The next set of tests to consider would be the female hormones involved in the signaling from the brain through to the ovaries (HPO axis). These can help determine if an imbalance in this hormonal system is driving the lack of menses.

Thyroid function is also a likely suspect for causing loss of menses and should be tested. This should include markers for autoimmune thyroiditis as well as the hormones themselves.

A Micronutrients Panel is warranted, especially for vegetarians/vegans or athletes who may unknowingly be low in certain nutrients essential for hormone function. Iron status, specifically, may also be relevant as a contributing factor and thus worth testing.  

Adrenal function tests can also indicate the overall balance of stress/resilience in the system, a key aspect of functional hypothalamic amenorrhea.

Altered levels of prolactin can indicate that problems with the pituitary gland are affecting the menstrual cycle.

Conventional Treatment for Amenorrhea

While we always prefer to treat on the more root cause level, there are times when conventional therapies like hormone replacement can be an essential part of a functional medicine plan. In the case of secondary amenorrhea, sometimes hormone replacement therapy (HRT) or birth control can help restart the menses. Similarly, thyroid hormone replacement may be necessary if thyroid dysfunction is part of the root cause.

Integrative Medicine Treatment for Amenorrhea

Exercise can help regulate hormones, especially in cases of PCOS.

The diet should be balanced calorically with energy expenditures to promote the return to/maintenance of healthy (generally meaning adequate in this context) body fat levels.

As eating disorders can contribute to the stress and nutritional factors leading to amenorrhea, healing will involve treatment for any eating disorders.

The psychological factors contributing to the issues should also be addressed through lifestyle interventions and therapy.

Nutrition for Amenorrhea

In general, some principles to keep in mind regarding nutrition for recovering from Secondary Amenorrhea include:  

• Consuming adequate energy for the energy output
• Adequate protein and healthy fats
• Magnesium
• Iron

In cases of PCOS, where insulin resistance is often a factor, particular care should be taken to consuming lower carbohydrate or lower glycemic index foods.

Complementary and Alternative Medicine for Amenorrhea

Complementary therapies such as yoga, meditation, massage, and acupuncture may not directly impact the hormones driving amenorrhea. But, by modulating the stress response, they can play a vital role in reversing the root cause (stress) and providing healthy emotional coping outlets.  

One randomized controlled study with 40 women also showed that fennel tea, which is generally quite safe, may help to restart and maintain regular bleeding in amenorrhea.

Summary

In summary, a woman's menstrual cycle can be considered a window into her overall health. It will naturally be absent during certain periods of life, such as pregnancy, breastfeeding, and after menopause. But it can also stop as a result of other factors. Aside from pregnancy, the most common causes of secondary amenorrhea are inadequate nutrition, too much physical or mental stress, too much exercise, or some combination of these factors. Additionally, health issues in other areas of the body, such as thyroid dysfunction or cancer treatments, can cause a temporary loss of periods.

With the perspective of menstruation as a window into a woman's health, even if fertility is not top of mind at the present moment, missing more than three cycles or not menstruating for more than six months is cause to see a doctor.

As stress is one of the major things that can contribute to amenorrhea, coming back to balance often involves finding ways to reduce stress and increase high-quality nutrition and rest for the nervous system. With attention, in most cases, missing periods can be restored.