Do I Have Secondary Amenorrhea?

If your periods have been MIA for the past couple of months (or longer!), it’s crucial to understand what secondary amenorrhea is. Understanding that will help you get the proper diagnosis and treatment for your missing periods.

Secondary amenorrhea is one of the two main forms of amenorrhea. To read more about the difference between primary and secondary amenorrhea, check out our blog post linked here. In this blog, we’ll make sure you fully understand secondary amenorrhea and what to do about it! So, let’s dive in.

The definition of secondary amenorrhea depends on whether your periods were regular or irregular before. Someone would fall into the category of secondary amenorrhea IF…

1. Their periods were regular (i.e., used to come every month) but then they went missing for three consecutive periods/”months” OR…
2. Their periods were irregular (i.e., didn’t come every month) but then they went missing for six consecutive months

Unfortunately, secondary amenorrhea often goes undiagnosed, and many women and even medical providers disregard it as simply stress-related. Stress can play a role, but it is not the only reason for you to lose your period. In this post, we outline a step-wise approach that hopes to clarify the process of diagnosing what is causing you to not have a period. A proper medical assessment should go through every step in the flow chart below. We will walk you through all these steps in this blog so that you know how to advocate for proper care. Keep reading!

STEP 1: Background

Before getting tested for secondary amenorrhea, it is a good idea for your medical provider to gather some baseline information that relates to the lab tests. First, they will want to understand your menstrual history. When did you first get a period? Did they come regularly every 28-35 days? Was the flow heavy or light? They will next ask about your diet and exercise habits. How often do you exercise? Is it cardio, strength, flexibility, or a mixture of all three? Do you eat at regular intervals during the day? What do you normally eat? The next set of questions relates to any stressors your body is experiencing. Do you have any medical conditions or chronic illnesses? Are you currently taking any medications? Is there anything that causes you to be constantly anxious?

Finally, they will also measure your height and weight for reference. If your provider did not ask you all of these questions, they did not conduct a thorough investigation and are missing key facts that are crucial to your health. We urge you to seek another provider who will conduct a more thorough history. (1)

STEP 2: Pregnancy Test

A pregnancy test can be beneficial to rule out secondary amenorrhea if you suspect you are pregnant. When a woman is pregnant, the egg has already been fertilized so the ovaries do not need to release any more eggs. Instead of shedding, the uterus builds up its lining so that it can care for the developing fetus for the next 9 months. 2 At-home pregnancy tests can be purchased at the drugstore, health clinic, or a local Planned Parenthood.

If the test is positive, you should discuss with your healthcare provider options regarding the pregnancy.

If the test is negative, continue to the next step to test thyroid stimulating hormone and prolactin. (1)

STEP 3: TSH and Prolactin

The next step is to test thyroid-stimulating hormone and prolactin. These blood tests can be ordered by your medical provider, or they can be ordered by our clinic.

Thyroid-stimulating hormone (TSH) tells the thyroid gland how much thyroid hormones T3 and T4 to produce. T3 and T4 are used for many body functions including heart, digestion, muscles, brain development, and bones. The optimal range for TSH is less than 3 mIU/L, and the American Thyroid Association recommends a TSH of less than 2.5 mIU/L for preventing miscarriages. Furthermore, a TSH greater than 4.5 mIU/L is more likely to affect your period. If your TSH is high, this is called hypothyroidism and you should speak with your medical provider about treatment plans. (1)

Prolactin is the hormone that causes a woman to produce milk once she has a baby. It blocks egg production which is why women who are breastfeeding many times do not get their period. 2 For a woman who is not breastfeeding, high levels of prolactin can be associated with stress or a prolactinoma, a pituitary gland tumor. Prolactinoma is rare, only affecting .05% of the population. 3  It also has a high survival rate of 97%.

If both TSH and prolactin levels are normal, continue to the progesterone challenge step. (1)

STEP 4: Progesterone Challenge

The goal of this step is to see if a lack of progesterone is what is causing the amenorrhea. Your medical provider will prescribe a 5-7 day dosage of progesterone and monitor whether or not you bleed.

If you bleed, this is a sign of anovulation, a condition in which the body is not releasing eggs. Your issue lies with the ovaries since they are responsible for releasing the eggs. During a normal menstrual cycle, progesterone starts to build once the egg has been released from the ovary. Therefore, if there is no egg being released, progesterone will not be signaled. The condition is not related to hypothyroidism or hyperprolactinemia, as those two conditions were ruled out in the previous step. (1) Anovulation is frequently seen in patients with PCOS. For more information on PCOS, see our blog post linked here.

If you still do not bleed, continue to the estrogen/progesterone challenge step.

STEP 5: Estrogen/Progesterone Challenge

In this step, you are prescribed a combination of estrogen and progesterone for 21 days to see if you bleed. The patterns of these hormone medications are meant to mimic the natural fluctuations in the body which should trigger a period. (1)

If you do not bleed, you likely have a physical issue with one of the parts of your reproductive tract that is preventing the outflow of blood. Speak to your medical provider regarding treatment options. (1)

If you bleed, this confirms that you are physically able to release blood and that you have a hormonal issue. Continue to the next step to determine the exact cause of the amenorrhea. (1)

STEP 6: Test levels of FSH and LH

This final step is used to narrow down the cause of your secondary amenorrhea. You will be asked to do a blood draw to test levels of follicle stimulating hormone (FSH), luteinizing hormone (LH), and estradiol (i.e., estrogen) in your blood. (1)

If FSH is high (>25 mIU/mL) but estradiol is low, this may signal menopause. For women over age 45, menopause symptoms are normal. If you are younger than 40 and get FSH levels above 10 mIU/mL, this could be a sign of premature menopause, and you should consult with a medical provider for best advice. (1) We are pleased to have Stacey on our team as a menopause expert who can help guide you on best practices for premature menopause.

If FSH is high and estradiol is high, this may signal primary ovarian insufficiency, a condition in which a woman’s ovaries stop releasing eggs well before she is 40 years old. The only reason that the estrogen is high is because the body tries to push all its resources into releasing one more egg before hitting failure. For more information on primary ovarian insufficiency, please read our blog post linked here. (1)

If FSH and LH are normal, it is likely associated with stress-related hypothalamic amenorrhea. Look back at the background section from step 1 above to see if there are any stressors that could be causing the body to not want to have a period. These could be medical conditions, medications, or worrisome life events. (1)

If FSH, LH, and estradiol are all low, it is likely associated with diet-related hypothalamic amenorrhea. If you are not eating enough to nourish your body for your level of physical activity, it may not have enough energy or nutrients available to produce the necessary hormones to have a period. To learn more about how eating and exercise can impact your period, check out our blog post on eating disorders and amenorrhea. The best providers to help with this are registered dietitians, as the problem roots from a nutritional standpoint. (1)

We hope that this post clears up some of the unknowns related to secondary amenorrhea and empowers you to speak with your provider about getting the right tests done to understand why you are not getting a period. As a disclaimer, this approach is general and may not encompass all cases of amenorrhea. Use it as a guide and seek a medical provider’s guidance for further information. Our team of experts on integrative medicine and women’s health would be happy to support you by providing education, lab tests, nutrition & herbal medicine treatments, and referrals to other medical specialists when needed.