By Dr. Franco Recano
What is amenorrhea?
Amenorrhea is a lack of menstruation, and it must be borne in mind that there are periods in a woman's life in which this deficiency is physiological: before puberty, after menopause, during pregnancy and, for a longer or shorter period, during the 'feeding time.
An alteration of the menstrual function (a fortiori the lack of menstruation) is nothing but a manifestation, a symptom we could say, of an alteration in the succession of the phenomena that take place at the expense of the endometrium, therefore the sign that something in the adjustment mechanism does not work properly. We must first of all make an important distinction between amenorrhea "primary" (which is observed in girls or women who, despite having passed the age of puberty, never had menstruation) and amenorrhea "secondary" (which instead appears after a period during which the menstrual function took place in a regular way).
Primary Amenorrhea - Causes
If the menstrual flow does not appear within 16 years of age, it is called primary amenorrhea.
The fact that at the time of puberty (12-13 years) does not appear menstruation can be linked both to causes directly connected with the genital apparatus, and to causes that only indirectly affect the genital function. Among the genital causes we must remember the serious malformations of the sexual apparatus (lack or insufficient development of the ovary or uterus). There can also be cases in which the regulating mechanism of ovarian and menstrual function acts regularly: these girls, at the time of puberty, have a normal body development, with the appearance of pubic hair, and armpits, development of the breasts and organs external genitals, however they have no menstruation. It is believed that in these cases there is an insensitivity of the uterine mucosa to hormonal stimuli (estrogen and progesterone) coming from the ovary.
The extragenital causes are varied. They can be linked to dysfunctions of the diencephalon and pituitary gland, which modify or abolish the production of hypothalamic and pituitary hormones; the latter stimulate the ovary, causing the production of estrogen and progesterone. Still in the field of the endocrine system, a serious deficiency of thyroid activity (cretinism) can cause primary amenorrhea. Other factors may include severe states of malnutrition, avitaminosis, chronic infectious diseases (tuberculosis) and severe anemias.
Secondary Amenorrhea - Causes
This term indicates the cessation of the menstrual function after a period in which this took place regularly. Outside the period of pregnancy and lactation, during which the interruption of menstruation is physiological, secondary amenorrhea is the expression of a pathological state. Genital causes include those conditions which, by causing the destruction (or removal) of one of the organs directly involved in the menstrual function, cause their definitive disappearance. They are represented by the surgical removal of the ovaries or uterus (see: hysterectomy).
Among the most important causes of secondary amenorrhea, is that linked to the alteration of pituitary function. In these cases the stimuli caused by the pituitary hormones on the ovary cease and together with them its normal function. This pathology is accompanied by a severe decrease in the activity of all the endocrine glands that are under the control of the pituitary gland.
The phases of the menstrual cycle in the uterine mucosa depend on the action of the hormones produced by the ovary (estrogen and progesterone or, more precisely, on the quantity of one with respect to the other; an imbalance between these hormones can be caused by amenorrhea. In fact, while a notable deficiency in the production of estrogen prevents the endometrium from entering the proliferative phase (a fact which constitutes the necessary premise so that the secretory phase and menstruation can be determined), if the quantity of progesterone is normal, the action of this last is not enough to let the endometrium enter the secretory phase.The endometrium is thus arrested in the proliferative phase.The excessive production of progesterone causes the arrest of the cycle in the secretory phase.
Among the extragenital causes, states of severe malnutrition can determine the interruption of the menstrual function, as well as the abrupt climatic changes, nervous, mental, sudden and violent emotions, daily stress and stress from sports in competitive athletes.
Also in sports, amenorrhea, associated with osteoporosis and eating disorders, is commonly included in a framework known as the "triad of the female athlete". This condition is commonly found among professional athletes and, more generally, among women who practice a lot of physical activity without eating properly.
