What is the exact definition of this term?

Primary amenorrhea: no first period by age 15 (or within 3 years of breast development).

Secondary amenorrhea: periods stop for ≥3 months (previously regular) or ≥6 months (previously

Common causes

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Always rule out pregnancy first.

Hypothalamic: stress, weight loss, over-exercise, eating disorders, chronic illness.

Pituitary: high prolactin, pituitary tumors, Sheehan syndrome (postpartum).

Ovarian: polycystic ovary syndrome (PCOS), primary ovarian insufficiency, natural menopause.

Uterine/cervical: Asherman syndrome (intrauterine adhesions) after infection or surgery, cervical stenosis.

Thyroid disease (hypo or hyperthyroidism).

Evaluation

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History (period pattern, weight/exercise, stress, medications), pelvic exam.

Tests may include: pregnancy, TSH, prolactin, FSH/LH/estradiol, and androgens if features of PCOS.

Pelvic ultrasound (uterus/ovaries); consider progestin challenge to assess estrogen status; additional testing based on findings (e.g., MRI pituitary if high prolactin).

Treatment

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Treat the cause (e.g., nutrition and stress support for hypothalamic amenorrhea; thyroid or prolactin disorders; PCOS management; hormone replacement for primary ovarian insufficiency to protect bones/heart until the average age of menopause).

If pregnancy is desired, ovulation induction may be offered depending on cause.

Why it matters?

Long-term low estrogen can weaken bones and affect heart health; prolonged untreated anovulation with estrogen exposure can raise the risk of endometrial overgrowth.

Deep Dive

Primary amenorrhea prompts evaluation of puberty timing, genetics, and anatomy (e.g., Müllerian anomalies). Secondary amenorrhea focuses on lifestyle, endocrine, and structural causes.

Key labs explained:

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Prolactin: high levels suppress ovulation; symptoms can include milky nipple discharge or headaches/vision changes.

FSH/LH/E2: high FSH suggests decreased ovarian reserve or primary ovarian insufficiency; low FSH/LH suggests hypothalamic suppression (stress/weight/exercise).

Bone health: with long-term low estrogen, we may recommend calcium/vitamin D, weight-bearing exercise, and in some cases hormone therapy to protect bone density.

Fertility planning: many causes are reversible; even with primary ovarian insufficiency, spontaneous ovulation can occur unpredictably—contraception is still needed if pregnancy is not
desired.

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