Missing Periods for 6 Months? Causes of Amenorrhea and Next Steps

Absence of menstruation for ≥6 months in a woman of reproductive age is defined as secondary amenorrhea (primary = never menstruated by age 15). It warrants systematic evaluation.

Common Causes

Initial Workup

1. β-hCG (urine or serum).
2. TSH, prolactin, FSH, LH, estradiol.
3. If androgen excess suspected: total/free testosterone, DHEAS, 17-OHP.
4. Pelvic ultrasound (ovarian morphology, endometrial thickness).
5. Progestin challenge (medroxyprogesterone 10 mg × 10 days) – withdrawal bleed indicates estrogenized endometrium.

Management

Target the underlying etiology: lifestyle modification (weight, stress), thyroxine, dopamine agonists (prolactinoma), ovulation induction (PCOS), hormone replacement (POI), hysteroscopic adhesiolysis (Asherman’s).

Long-Term Risks of Untreated Amenorrhea

• Bone loss (osteopenia/osteoporosis).
• Cardiovascular risk (estrogen deficiency).
• Endometrial hyperplasia/cancer (unopposed estrogen in PCOS).
• Infertility.

When to See a Specialist

If amenorrhea >3 months (or >6 months if previously oligomenorrheic), or if accompanied by galactorrhea, hirsutism, hot flashes, visual changes, or severe headache.

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Category	Examples
Pregnancy	Most common cause; always rule out first.
Hypothalamic/Pituitary	Stress, excessive exercise, low body weight, eating disorders, hyperprolactinemia, pituitary tumor.
Ovarian	PCOS (most common endocrine cause), premature ovarian insufficiency (POI), ovarian failure.
Uterine	Asherman’s syndrome (intrauterine adhesions post-D&C), endometrial ablation.
Thyroid/Adrenal	Hypo-/hyperthyroidism, congenital adrenal hyperplasia, Cushing’s.
Medications	Hormonal contraceptives (especially depot, implant, IUD), antipsychotics, opioids, chemotherapy.
Chronic Disease	Uncontrolled diabetes, celiac, IBD, renal/liver failure.