Secondary Amenorrhea: A Description, Not A Diagnosis

Question:

Hello Dr. Ramirez,

I'm 20 and 293 pounds. I have had  Secondary Amenorrhea for close to 4 years now. It is apparently being caused by my weight. I'm not planning to TTC for at least another 12 or 13 years. I don't hate babies but it's not just a good time on the emotional or financial level to have them. If I'm able to get down to a decent weight and get rid of this disease,  What are my chances of getting pregnant when it's time for me to TTC???

There's a history of Diabetes in my family and I haven't had a asthma attack since I was 8.My mom had thyroid disease before I was born but I don't think that's genetic. But I don't have any other diseases than the SA at the current moment and my hormone levels were just fine at my last doctor appt which was last October. I've been on progesterone more than I count and it gets me a period but I want to have it without the help of drugs. Is there some kind of natural cure to SA??

I know that it seems a bit silly to ask about this NOW but I'm not getting any real answers about this disease from my OB. Everytime I asked my OB about this, she would tell me not to worry about it or brings a therapist in the room to basically tell me that I'm crazy.

She's since moved her practice out of state and I have a new OB that I'll start seeing very soon. But how in the hell am I crazy for wanting to be proactive about my own health?? I'm sorry for the language but I'm just so fed up about this and at my wits end.

I know that I'm not producing eggs right now but what else could this be doing to my body?? Do I have a reason to be concerned about it besides the obvious infertility scare?? If I do get rid of this disease,  Is there some kind of leftover side effect that could cause me to get Ovarian Cancer in the future??

I don't have these answers and I need to know what's going on. Please help me clear at least some of this up.

Thank You. D. R. from Michigan.

Answer:

Hello D. R. from the U.S. (Michigan),

Good riddance to your previous Ob doctor!  "Secondary Amenorrhea" is a description of a problem and NOT a diagnosis.  It just means that you used to have periods and now you don't.  It doesn't explain the cause.  The most common reason for old women to have secondary amenorrhea is menopause.  The most common reason for young women to have secondary amenorrhea is pregnancy.  However, a close second is an ovarian disorder called "Polycystic ovarian disease."  This diagnosis is manifested by irregular or rare natural menstrual cycles and at least one of the following findings: ovaries that look like PCO ovaries on ultrasound, inverted FSH/LH ratio, obesity, hirsuitism (increased facial hair), elevated testosterone levels, diabetes, elevate insulin levels signifying insulin resistance.  I think that you have PCOD but without a thorough endocrine evaluation, I cannot say for sure. 

With this disorder, you have a hormonal imbalance and that needs to be corrected.  The most simple way to do that is to use a low androgen birth control pill such as Yaz.  Once you are ready for pregnancy, then you will have to use fertility medications, which actually do not increase your fertility but induce your ovaries to ovulate, so that you can give off an egg to get pregnant.  You need to see a COMPETENT gynecologist or a reproductive endocrinologist to be evaluated and treated correctly!

You may want to see a more detailed explanation of Polycystic Ovarian Disease on my website.

Glad you wrote! Good Luck,

Edward J. Ramirez, M.D.
Executive Medical Director
The Fertility And Gynecology Center
Monterey Bay IVF

www.montereybayivf.com

Monterey, California, U.S.A.

 

Sixteen Year Old Does Not Have Her Period Yet: What To Do?

Question: Hi, writing from Califonia!

My name is E. and I am 16 years old, will be 17 on June 9th, 2013. I'm 5'9" and I am overweight, but not terribly obese or anything. I have always been active, and I have been a swimmer since I was 7.

I am wondering if something is wrong with me. I still have not gotten my period. Ever. I just feel so out of place when my friends are all talking about theirs and I just stand there. I don't understand why I haven't gotten it yet. I have pubic hair, I have leg hair, armpit hair, I have breasts, and sometimes I see that my underwear is like a light brown (and it smells weird, but not terrible) but it has never been red.

My Dr. told me that if I don't have it by the time I'm 18 then to come in for some tests.

I just wish so badly that it will have it already. Is there anything I can do? Could this in anyway help the process of it starting?

http://www.amazon.com/gp/product/B0009ETA6M/ref=ox_sc_act_title_1?ie=UTF8&smid=ATVPDKIKX0DER

I heard that drinking lots of green tea can help?

Could it be me being overweight? I am currently in the process of losing weight and I have lost 15lbs so far. I also heard that it might have been because my mom breastfed me for longer? She nursed me until I was 3, not a lot after the first year, she said it was normally just to get me to sleep.

Please help! E. from California.

Answer:

Hello E. from the U.S.(California,

Since you have secondary sexual characteristics (pubic hair etc.), that means that your ovaries are functioning and producing estrogen. It may just be a matter of time now before the periods start, but it is a little unusual to not have periods by 17 years old. I don't agree with your doctor. This is something you might want to talk to you mother about and urge her to allow you to see a pediatric endocrinologist, adolescent gynecologist or reproductive endocrinologist. These are all specialists with more advanced training in hormones than your regular pediatrician or family practice doctor. A blood test can be done to check your hormones to make sure there is not something amiss. Medicine can also be given to help you start periods, or if your hormones are unbalanced, to help balance them.

Having a hormonal imbalance can cause long term side effects, like facial hair, that is not reversible so I would not recommend doing nothing.

As a side note, don't buy anything on the internet that says it does something medical. Anything that is medically effective has to have FDA approval and then it is sold in a pharmacy or doctor's office. Only non-medical items can be sold via the internet to non-medical people.

Thank you for writing and try to see a specialist soon. Good Luck,

Dr. Edward J. Ramirez, M.D., FACOG
Executive Medical Director
The Fertility and Gynecology Center
Monterey Bay IVF Program
www.montereybayivf.com

Monterey, California, U.S.A.

Marathon Runner Has Amenorrhea And Is Trying To Conceive: May Need Gonadotropins

Question:

Hi, I am a 25 year old, PhD student and I am a competitive marathoner. My husband and I would like to get pregnant over the next 8 months. I was on the pill until last April, when I went off the pill. I had been on the pill for nine years and my cycle was regular before I went on the pill. During the years I was taking the pill my cycle was fairly regular, light and short in duration, but still regular. I have not had a period since I went off the pill 6 months ago. I am 5 7' and about 108lbs.

I have met with my Dr and she suggested that I go on the pill for a month so I can at least have my period to shed my uterine wall. Then she said if my period does not stick around I may need to gain a bit of body fat. I have also done blood work to make sure there are no other issues. Do you think that I will have to gain weight before I can get pregnant? Or can I just cut back on my training and lose some muscle mass and avoid gaining weight? Also can I get pregnant with my period being absent? Thanks! A. from Canada

Answer:

Hello A. from Canada,

The problem with competitive runners is that they lose a tremendous amount of body fat and so cannot produce hormones. They develop a disorder called hypogonadotropin hypogonadism. For this reason, they do not cycle normally. The birth control pill artificially takes over ovarian function and so you have an artificial period, but it is not because the ovaries are working. Having stopped the BCP (birth control pill), you are now at your normal state and your ovaries are not working. This is the reason your doctor recommended that you gain fat weight. Hormones are made from cholesterol. It is the chemical basis for all hormones. Unless you gain fat weight, you will not ovulate naturally and so will be unable to get pregnant.

I would not recommend another course of BCP's at this time, however. You can wait and see if you get a period, which you only need to have every three months at a minimum, and if it does not occur by itself, then you can take progesterone for 5 days to start the period. That way you will have the opportunity to become pregnant should ovulation occur.

The only other option for getting you pregnant would be to give you the hormones that your brain is not making to stimulate the ovaries. This is a medication called a gonadotropin. We would use a medicine called Menopur that is FSH and LH hormone. These hormones stimulate the ovaries to ovulate. You cannot use Clomid or Femara because the hypothalamus needs to be working for these to work and yours is not working.

Although there are many reasons for primary & secondary amenorrhea (absence of menstruation), I believe yours is due to your pattern of exercise and has a good chance of being corrected. See the Mayo Clinic website for more information: "Amenorrhea: Causes".

Good Luck,

Edward J. Ramirez, M.D., FACOG

Executive Medical Director

The Fertility and Gynecology Center

Monterey Bay IVF Program

http://www.montereybayivf.com/

Monterey, California, U.S.A.

Excercise Induced Amenorrhea Leads To Poor Health & Infertility

QUESTION: I have been over exercising for about 10 years now. I get my period fine on birth control pills but when off birth control, I do not get it. I have been off it now for 6 months because the pills are expensive. Is this harmless not to get my period because of over exercising? I got a scan back in June and my gyno ruled out polycystic ovarian disorder. Since I know it's from the exercising and don't want to cut back, could this cause a problem with my fertility? What if I wanted to get pregnant right now? Would that even be possible? Thank you. N. from the U.S.

ANSWER:

Hello N. from the U.S.,

If in fact the reason why you are not getting a period is because you have "exercise induced amenorrhea", that is the result of a dysfunction of the hypothalamus. It is detrimental to your health because, you are not forming the hormones that your body needs. The purpose of the birth control pill was not mainly to have a period, it is not needed in a person who is not making a uterine lining, but the birth control pill gives you the essential hormone estrogen. In addition, the hypothalamus is important for production of other hormones as well including thyroid hormone.

In terms of your fertility, your ovaries will be shut down so that you will have difficulty getting pregnant unless you decrease your exercising so that you have normal ovarian function (have natural periods) or you use fertility medications to replace the hormones the hypothalamus is not producing, to stimulate the ovaries to ovulate.

So, I know that you are an exercise junkie, but keep in mind that instead of making you more healthy, it may actually be more detrimental to your health in many ways, including achieving pregnancy.

Follow-up Question:

You mentioned the hypothalamus being important for the production of hormones including the thyroid, well I have an underactive thyroid and have been taking Levoxyl for at least 5 years now. Is this giving me the hormones I need? Also, I explained not getting my period to my OBGYN and after a scan of my area, he told me nothing was wrong. Why do you think he would say that when he knows of my period problems?

Follow-Up Answer:

Hi Again,

Adequate levels of thyroid hormone is measured by a blood test. We usually use TSH. If your thyroid replacement is adequate, the TSH levels should be in the normal range.

A vaginal ultrasound is only for anatomical abnormalities. It can see the ovaries and uterus, but cannot diagnose ovulation or hormonal problems. That is done by other testing as mentioned previously. If your doc only checks you out by doing an ultrasound, he is inadequately evaluating you for menstrual problems. Most menstrual problems are caused by hormonal problems, as mentioned previously. At least by the ultrasound you know that your ovaries, tubes and uterus are normal, but you don't know anything more than that. So from that point of view, anatomically nothing is wrong, but that is only anatomically. I would suggest you find a better doctor!

Good Luck,

Edward J. Ramirez, M.D., FACOG

Executive Medical Director

The Fertility and Gynecology Center

Monterey Bay IVF Program

http://www.montereybayivf.com/

Monterey, California

Amenorrhea & Secondary Infertility In A 29 Year Old: Needs Evaluation For POF, Thyroid Or Pituitary Disfunction ASAP!

Hi Dr. Ramirez,

I am a 29 yr old healthy female with two daughters, ages 13 & 12. Me and my husband conceived with no problem. I was 16 when we had our first daughter. I started having irregular menstrual cycles when my youngest was 2. We tried to get pregnant again and haven't been able to since then. I have not had a cycle in about 6-7 yrs.

I went to the doctor a few years back, they did blood work, exams, internal ultrasounds and they put me on birth control and hormones, but no period came. I have since stopped going to the doctor and am not taking anything. I am highly concerned on how this is affecting my health. Hoping for your advice.

Thank you, N. from the U.S.

Answer:

Hello N. from the U.S.,

It is highly unusual for you not to have at least one period per year in your age group. I would be worried that you might have a severe ovarian dysfunction like premature ovarian failure (POF or early menopause) or some other hormonal problem with your thyroid or pituitary. You need to undergo an evaluation to find out what is going on.

The problem with not having a period is that you are not producing estrogen. Estrogen is a vital hormone for a woman's body. It impacts many different areas like your bones, skin, heart, brain, vagina. Women who undergo menopause, where they are no longer producing estrogen, have an increased incidence of heart disease, osteoporosis as well as: bone loss, decreased concentration, decreased memory, thinning of the skin, thinning of the hair, vaginal shrinkage and dryness, skin dryness and wrinkling, and accelerated aging. It is one of the most vital hormones in your body. So, if your ovaries are not working and not producing estrogen, or very little estrogen, then you need to go on hormone replacement with something like a birth control pill. If you are interested in getting pregnant, and your ovaries are not menopausal, then you need to take fertility medications to induce your ovaries to ovulate produce and give off an egg.

The bottom line is that you cannot continue like this because it is harmful to your health. You want to stay young for your children and husband, so please go see a Gynecologist as soon as you can.

Sincerely,

Edward J. Ramirez, M.D., FACOG

Executive Medical Director

The Fertility and Gynecology Center

Monterey Bay IVF Program

http://www.montereybayivf.com/

Monterey, California, U.S.A.

Primary Amenorrhea In 32 Year Old

Question:

I am 32 years old and never had a period. My mom took me to the doctor when I was 20 yrs old and they did an ultrasound of my abdomen which showed no cysts in the ovaries and a hormone test which showed that my FSH and LH levels were low. The TSH was normal.

A genetics test confirmed that I am xx. I used the contraceptive pill and had a bleeding. I have always had excess hair growth since puberty and acne issues. Do you think something is seriously wrong with me or I should just let things stay the way they are?

Answer:

There is absolutely something wrong, and it should have been taken care of a long time ago. Without specific laboratory information I cannot tell you what the problem is, but you have some type of ovarian dysfunction. In other words, your ovaries are not working. The bad part of this is that you are probably estrogen deficient. Estrogen is the female hormone and is important for many different parts of your body. As a consequence, you have an elevation in the male hormone, testosterone, because your ovary is not making estrogen. If you keep up like this you could suffer the following consequences: increased facial and body hair, loss of head hair (male pattern baldness), increased acne, deepening of the voice, obesity, diabetes, osteoporosis, increased heart disease.

The reason for the birth control pill was to give you the female hormones that you need and block the male hormone production. If you are not planning on getting pregnant, then you need to go back on the birth control pill. I would recommend that you go on Yasmin or Yaz, which blocks the male hormone better. Bottom line is that you need to see an Endocrinologist or Reproductive endocrinologist.

Good luck and be sure to follow through with my advice!

Edward J. Ramirez, M.D., FACOG
Executive Medical Director
The Fertility and Gynecology Center
Monterey Bay IVF Program
www.montereybayivf.com

19 Year Old With Very Irregular Periods May Have PCOD

Question:

I am a 19 year old female (obviously). I had my first period when I was approximately 11 years old and for the first three to four months I had a regular cycle. After that period of time my cycle became irregular (which is in no way odd for someone of that age), being that I would menstruate every other month rather than every single month. After approximately 4 to 5 months of this my menstruation stopped completely. Over the course of the next 3 years I would have a period perhaps once every 5 to 6 months, and there would never be any mood swings, cramping, bloating, or overly heavy flow. The intervals between menstruation began to increase from there, lengthening to 8 months between periods (give or take two months).

This month and last month, however, I have had my period. Two months in a row after almost 13 months without anything. This past month, however, I have experienced severe cramping and moodiness. I know that it is not uncommon for cramping to occur after a prolonged period of time without menstruation, but the fact that I was incapacitated and in bed for two days was unbelievable to me.

I have had no problem developing secondary sexual characteristics, which would probably be signals of a pituitary or other glandular disorder. I am not obese, nor am I incredibly tall or short, which, from what I have gathered, excludes most thyroid issues.

I have no health insurance at current. During the course of my teenage years I would occasionally see an MD for various checkups, and I would bring up the matter of my irregularity. Every doctor I has ever seen has sloughed off the issue as probably having to do with "stress". This answer does nothing to satisfy me, as it seems like a knee-jerk reaction because they were either at a loss or because I could not afford whatever tests might actually tell me.

My worry, for quite some time now, has been the question of fertility. I have no actual plans to have children at any point in the near future, and I am not (nor have I ever been) sexually active. However, I need to know if I even CAN have children, for my own piece of mind. I know that without an examination, there's only so much you can tell me, but any information on what you might think is amiss would be greatly appreciated.

Answer:

Thank you for your question. For a 19 year old, your writing is incredibly sophisticated and impressive. You seem to be well educated. Most women do not know about "secondary sexual characteristics" or how the "pituitary or other glands" affect their cycles. Bravo to you for this knowledge.

Your irregular period is far from normal. There is a very common disorder, which you seem to be alluding to, called polycystic ovarian syndrome or PCOS. This is an ovarian dysfunction disorder caused by the ovary not processing the pituitary hormones correctly, leading to the lack of ovulation. Without ovulation, there is no subsequent menses, assuming you are not pregnant. We know that this disorder begins in the teen years in many women. So the doctor's previous explanations of "this is normal for your age group", is incorrect. There are problems that occur from PCOD in the long term such as increased weight gain, diabetes, increased facial and body hair growth, excessive bleeding episodes, irregular bleeding, endometrial cancer and infertility. Because of this, we DO NOT recommend continuing with the irregular cycles.

In women that are not attempting pregnancy, we use the birth control pill protocol to over-ride the ovaries and keep a normal cycle. This gives the essential female hormones, estrogen and progesterone, that your ovaries are not producing, and that you are lacking, because of the lack of ovulatory cycles. When you decide to become pregnant, this has to be substituted with ovulation inducing fertility drugs. PCOD is a clinical diagnosis, and although we do hormone testing to check the thyroid, pituitary and other hormones, it is not a diagnosis made by these lab tests. From your description of your symptoms, you probably suffer from it. If you do further internet searching, you will come upon a description of patients that have this disorder, that you do not fit. However, keep in mind that there are variations on this theme and even normal appearing females can have a milder form of the disorder. Not all patients are hairy and obese :).

In terms of your future pregnancy, bravo for getting through your teen years without having had a sexual experience. When you do contemplate getting pregnant, I do not see any reason that you would be unable to become pregnant, except for your ovulatory disorder. Assuming that this is corrected with fertility drugs, you should have a pregnancy rate commensurate with your age group. I have had many PCOS patients that get pregnant with the proper protocol , though sometimes they need more than one try before they get their cycle exactly right.

I would advise you to seek another opinion with this information in hand, preferably a good OB/Gyn.

Sincerely,

Edward J. Ramirez, M.D.

Executive Medical Director

The Fertility and Gynecology Center

Monterey Bay IVF program

http://www.montereybayivf.com/

Monterey, California, U.S.A.

No Period, Low BMI Can Equal Hypoganodotropic Hypogonadism

Question:

I'm a 27 year old woman. I'm not pregnant. I went off the pill 7 months ago, and have not had a period since, though I had light spotting in response to a progesterone challenge. I'm about to be evaluated for PCOS, but I have a hard time believing this is what I have.

I have always been thin, and in the past I was told this was why I did not menstruate when I tried to go off the pill. I have made the effort to gain a little weight and my BMI is about 19 now. I work out regularly, though not more than 50 minutes a day. I have no family history of PCOS, diabetes or insulin resistance.

In the past 7 months I have developed benign PVC's of my heart, and have had a mild increase in facial hair and hair around my navel (this is why they think I might have PCOS).

My question is, are there any other conditions that might cause my symptoms that I should be aware of when I go to have the blood tests? Should I be tested for premature ovarian failure and hyperprolactinemia as well?

Thank you so much!

Answer:

Thank you for your question.

Your history does not quite fit PCOS. The most likely diagnosis is hypoganodotropic hypogonadism. It is a long name for saying that your brain is probably not stimulating the ovary. It is likely due to a lack of adequate body fat. Not premature ovarian failure. Since you had a little response to the Provera challenge, that shows that you are making a little estrogen, but the increase in hair growth is consistent with an elevation of the male hormone testosterone. If the ovary is not stimulated to ovulate, it does not produce estrogen and the available hormone precursors go to make testosterone.

Body fat is important because it is the chemical basis for the production of all hormones. If the body fat is too low, because of excessive exercise or anorexia or bulimia, the brain shuts down the production of FSH and LH. This leads to a lack of stimulation of the ovary, hence the above result.

This diagnosis can be made with blood testing. You should be tested for FSH, LH, Prolactin, TSH, Estradiol and Testosterone. This would test all the possible sources of your lack of menstruation. They will probably find that your FSH and LH are very low. Your thyroid may also be out of sync because of the same problem. TSH is the preliminary test for thyroid function.

It would be best if you could get your BMI up above 20, and increase your body fat content.

I hope this helps.

Sincerely,

Edward J. Ramirez, M.D.
Executive Medical Director
The Fertility and Gynecology Center
Monterey Bay IVF Program
http://www.montereybayivf.com/

Monterey, California, U.S.A.

Amenorrhea and Bulimia

Question:

I have not had a period since July of 2008 and my gynecologist told me that is is not dangerous to NOT bleed, only dangerous to bleed too much. At first, I assumed the loss of the period was because I had started working out so much and lost a decent amount of weight. However, (ironically) after joining the military, I've been less active, but still have not had a cycle. Someone suggested to me that amenorrhea can be caused by athletic activity or eating disorders. At age 16 I was diagnosed with bulimia, but stopped seeing my psychologist shortly thereafter as he thought I was better.

Truth be told, I've never completely stopped the binge/purge cycle because I don't know how to break it. Now I'm afraid I may have affected my cycle after 7 years of abuse. I don't know what to do and this scares me. I can't talk to doctors on my military post because I don't want them to find out about my issues (as this can lead to separation from the service). Does this type of amenorrhea mean infertility? Is there any way to reverse the effects? Who should I talk to or what should I do? Any help is greatly appreciated. Thank you in advance.

Answer:

Hello.

Your gynecologist is incorrect in advising that not having a period is okay. It is not okay for lots of reasons, one of which is that you may have a hormone imbalance that can have negative long term effects on your body. At the very least, you should be cycled on birth control pills to correct the estrogen/progesterone imbalance.

It is certainly possible that if your weight is too low, that is you have a low body fat content, as occurs with professional athletes, the hormones cannot be created because there are no fat cells and cholesterol to produce the hormones. Also, the hypothalamus can shut down so that the hormones are not produced. This is NOT an acceptable situation. Not only can it be a source of infertility, but it can lead to all the problems that menopausal women have.

In terms of your bulimia, that is also abnormal and needs to be treated. You should not worry that the doctors you see will cause you to be released from the military. That is not true. I was a military doctor (US Army) for 9 years. The requirement that all medical information remain confidential (doctor-patient confidentiality) applies to military doctors as well. I would request to see a gynecologist or medical endocrinologist to begin an evaluation or your hormones and get a referral to a psychiatrist. You should get immediate care for both these problems!

Take care of yourself and don't delay. Good Luck,

Edward J. Ramirez, M.D., FACOG
Executive Medical Director
The Fertility and Gynecology Center
Monterey Bay IVF Program
Monterey, California, U.S.A.
www.montereybayivf.com

Secondary Amenorrhea...Low Estrogen?

Question:

Hi! I'm writing from the UK and hoping I can finally get some answers!
I had my last depo provera in Dec 2008. This ran out in March, and I had a light menstrual bleed in April but nothing since. It is now November!

My husband and I are wanting to conceive so in July we went to my GP and I was given Noresthisterone, 3 times a day for 10 days. I did NOT get a withdrawal bleed. I had some blood tests done, and I was told by a lucum doc that they were all normal. But in my opinion he didn't look sure, as he kept looking at them.

I have read that if you don't get a withdrawal bleed it could be due to low estrogen. Do you think this could be the case with me? And if it is, what would be the next step? I am desperate for my menstrual cycle to return so we can start to conceive.

Can you give me any advice, or anything that I could ask my doctor about? Many thanks!

Answer:

Hello,

You are correct in that if you do not get a withdrawal bleed after progesterone (Norethindrone), then that indicates that the uterus was not primed i.e. you did not have estrogen aboard to create an adequate uterine lining. Hormone testing would be the first check. Unfortunately, the FSH, LH test needs to be interpreted, not just checked against the laboratories normal and abnormal. A woman cna have an abnormal level but be within the normal limits for the laboratory testing results. For example, the FSH level could be 35, indicating ovarian failure or menopause, yet this is within normal testing limits. The reason this is important, is because if the FSH level is elevated, that indicates that you ovaries have shut down. An example of this occurring at a young age is called premature ovarian failure. In this case, you will be unable to become pregnant naturally, and without using an egg donor. I am not saying that is what you have, but the hormone test is very important to know where you stand.

Most likely, you have an ovarian dysfunction, whereby the ovary is not working correctly so that you are not ovulating and not producing estrogen. This is the most common reason. The FSH and LH levels would be normal and less than 20. In this case, you will need fertility medications to stimulate the ovaries to ovulate so that you can become pregnant.

I would recommend that you see a fertility specialist if you can. He/She will be able to make the diagnosis and recommend an appropriate treatment. A GP cannot do those and does not have the appropriate knowledge base to help you.

Sincerely,

Edward J. Ramirez, M.D.,FACOG
Executive Medical Director
The Fertility and Gynecology Center
Monterey Bay IVF Program
Monterey, California, U.S.A.
Check me out on Facebook and Twitter with me at @montereybayivf

No Menstruation

Question:

I am 26 and have two children. I am about 5'7.5" tall. My last spontaneous menses was April 6, 2005. After this, I became pregnant with my first child. After her birth, I dropped from 168 pounds (the same weight as prepregnancy, but since I stopped drinking alcohol and eating unhealthily and started walking daily, I maintained healthily) to 113 pounds in 10 months while breastfeeding and walking. I stopped breastfeeding and walking to try and gain weight to get pregnant with my second, but even after gaining 20 pounds, taking progestin and estrogen, there was no menses. After estrogen therapy plus clomid, I menstruated, took Clomid again, and got pregnant with #2. After her birth, my weight fell from 171 at her birth to 113 with breastfeeding and running. I never menstruated. She was born March 1, 2008.

Four months ago, I was prescribed the NuvaRing for amenorrhea after progestin again failed to produce a period. I have had four successful withdrawal bleeds. After this month, however, I have to stop; we cannot afford my taking it and pills make me sick.

I am currently training for a half marathon and run 50 miles per week. I am about 117 pounds now. I don't want to have more children but am concerned that after all of this time I won't be able to get my period back. I will cut back my running after my October 3 race, but what do I do to get my period back? CAN I get my period back? After gaining weight in late 2006/early 2007 there was no menses. There are no blockages or anything abnormal, though I may have mild subclinical hyperthyroidism as a byproduct of my running; my follicles are just dormant.

I want to be normal and healthy. I MISS my period, however odd that may sound to some. How can I get this back?

Answer:
Hello Bethany from the U.S.,

The problem that you have is more long-term than short term. The fact that you are not having periods is a sign that your ovaries are not functioning an therefore not ovulating. Because of that, you are NOT producing the essential female hormones, Estrogen and Progesterone. Without estrogen, you will be at long term risk for osteoporosis, heart disease, vaginal dryness and shrinkage. Once these occur, they are not reversible.

It is most likely that you have a disorder called "hypogonadotropic hypogonadism" which is a lack of hypothalamic stimulation to produce the hormones that the pituitary produces to stimulate the ovaries. The thyroid is one of those hormones that the pituitary stimulates as well. You need to see a Reproductive endocrinologist or Gynecologist to solve this problem. It is not so much that you need to have a period, that is just the monthly shedding of the uterine lining if you don't become pregnant, but the lack of hormone is worst. You need to be evaluated to make sure that you don't have some other underlying cause, other than your weight and decreased body mass.

In terms of replacing hormones, the birth control pill is the best because it has both estrogen and progesterone in it. If you can't tolerate the pill because of gastric side effects, then you can consider the patch. A progesterone only contraceptive of any type is NOT adequate. You need estrogen.

Sincerely,

Edward J. Ramirez, M.D., FACOG
Executive Medical Director
The Fertility and Gynecology Center
Monterey Bay IVF Program
http://www.blogger.com/www.montereybayivf.com

Monterey, California, U.S.A.