Why Have I Not Gotten My Period?

Meet Sara, a regular girl in her late teens going through a seemingly regular life which included her period every month. One month, she missed her period. She did not think too hard about it. Maybe it was just stress. Another month passed, and then a third, and still no period. Sara started to think that there was something wrong and spoke to her doctor. The doctor just told her to wait and see, it would come back eventually. Sara waited and waited, not knowing if or when she would ever wear another pad. Sara came to us asking, “What should I do?”

Amenorrhea, which translates to “without menstruation” is the umbrella term used for when a female does not get her period. There are two main categories: primary amenorrhea and secondary amenorrhea, of which secondary is more common. If you do not get your period by age 14, it is called primary amenorrhea. If you did get your period and it suddenly disappeared, it is known as secondary amenorrhea. Primary and secondary amenorrhea have different causes. It is important to understand the root cause so that you can get the treatment that works best to help your body.

What causes primary amenorrhea?

Primary amenorrhea can be related to structural issues or genetic conditions. Before we get into this section, it is important for you to understand some basic anatomy about the female reproductive system as it relates to your period.

Every month, your ovaries release one egg. Your uterus prepares for the chance of a pregnancy by building up its tissue lining. If the egg is not fertilized by a sperm, a period occurs and your uterus sheds its lining as blood via the cervix to the vagina and out past the hymen. If any of these body parts do not develop properly, it can lead to primary amenorrhea as well.

The first of the developmental conditions happens when the hymen covers the entire opening of the vagina. This is called an imperforate hymen and happens in 0.05%-0.1% of women (4). For most women, the hymen only covers a part of the vagina so blood can still flow out during a period. If you have an imperforate hymen, you would still go through puberty normally but have painful periods because the blood from your uterus is not able to come out properly. (1)

A second and more rare condition happens when a horizontal wall of tissue forms within the vagina. This is called transverse vaginal septum. Similar to the imperforate hymen, it blocks the flow of blood during a period but does not affect normal puberty. This condition only occurs in 0.05% of females. (1)

One of the more extreme conditions is called Mullerian agenesis. This development happens before you are born and can result in a missing uterus and/or vagina. It is very rare and seen only in 0.01 to 0.025% of females worldwide. There are treatment options available, however they may impact chances of fertility in the future. (1)

Is it genetic to not get your period?

Genetic conditions are responsible for 30% to 40% of the cases of primary amenorrhea, not secondary amenorrhea. The conditions are seen on the sex chromosomes, which are the ones that determine if you are a male or a female. They are related to defects in reproductive organs, specifically the uterus in females. The most frequently seen genetic conditions are Turner syndrome, in which an individual is missing one of their sex chromosomes, and Swyer syndrome, in which an individual is unable to produce the right amounts of sex hormones. Since these conditions are related to the genes, they are usually checked for before birth. If your mother received all necessary medical screenings during pregnancy, you would already know if you had one of these conditions. (1)

How do you treat primary amenorrhea?

Treating primary amenorrhea depends on the root cause. For the genetic conditions, the best treatment option is hormone replacement therapy. If you were screened for either of the conditions listed above, speak to a medical provider soon to start providing the necessary hormones. Estrogen and cyclic progesterone are very important if you are between 13 and 14 years old to make sure you go through normal puberty. For the issues related to structural blockages, you can go through surgery to remove the tissue causing the blockage. Treatment options for conditions like mullerian agenesis are more complicated and involve speaking to a variety of medical providers and counselors. (1)

Do I have secondary amenorrhea?

As mentioned earlier, the other more common form of amenorrhea is secondary amenorrhea.

The definition of secondary amenorrhea depends on whether your periods were regular or irregular:

1. If your periods were regular (i.e., come every month): missing three consecutive periods
2. If your periods were irregular (i.e., do not come every month): you have not gotten a period for six months

Secondary amenorrhea is unfortunately very often under-diagnosed. For that reason, many do not receive proper treatment. Secondary amenorrhea is associated with multiple conditions such as PCOS and hypothalamic amenorrhea. Each of these conditions has its own unique set of root causes. To learn more about the different conditions and how to accurately diagnose them, read our blog post on Do I have Secondary Amenorrhea?

Is it bad to not get your period?

If you go too long without getting a period, you are at risk of long-term consequences. Your body may not have enough estrogen which can affect your bone density, increase your risk of heart disease, and speed up memory loss. It is important to get the right diagnosis so that you can get the right treatment. (3)

Getting a period means more than just bleeding for a few days every month. It is a sign that your body feels safe and has normal levels of sex hormones. Although many girls take their period for granted, it can actually be seen as a form of cleansing. The reproductive tract does a refresh and washes away the lining that it built up over the course of the past month, ready to start anew in the coming month. For girls like Sara, only once she lost her period did she learn to respect this beauty. Now she feels empowered, knowing her next steps. If you’d like to learn more about irregular cycles and how to treat missing periods, check out all our “Irregular Periods” blogs here!