Amenorrhea is one of the common symptoms of gynecological diseases and can be caused by various reasons. It is generally classified into primary and secondary; true and false; as well as pathological and physiological.

1. Those who have reached the age of 18 without the onset of menstruation are considered to have primary amenorrhea, which is often caused by congenital abnormalities, including developmental anomalies of the ovaries or Müllerian tissues.
2. Secondary amenorrhea refers to the absence of menstruation for more than six consecutive months after the establishment of a menstrual cycle, usually resulting from secondary diseases.
3. True amenorrhea refers to the absence of menstruation due to certain factors, such as psychological factors, malnutrition, anemia, subcutaneous nodules, excessive curettage, or endocrine dysfunction.
4. False (or concealed) amenorrhea refers to the condition where menstruation cannot be discharged due to congenital developmental defects or acquired injuries causing adhesion and atresia of the lower genital tract.

bubble_chart Etiology

Based on the different anatomical sites of the primary disease causes, amenorrhea can be classified into four types: uterine, ovarian, pituitary, and hypothalamic.

1. Uterine amenorrhea and its causes: Uterine amenorrhea refers to the absence of menstruation due to the lack of uterine lining caused by uterine diseases. Since the uterine lining is absent, both progesterone and artificial cycle tests yield negative results. The causes of uterine amenorrhea include:
   1. Congenital absence of the uterus or underdevelopment. The uterus may be nodular, and the absence of the vagina can lead to primary amenorrhea. These patients typically have normal body types and development but often accompany skeletal underdevelopment, spinal curvature, and kidney malformations. Ovarian function is normal, with ovulation, biphasic basal body temperature, and normal gonadotropin levels.
   2. Acquired uterine lining injury. Severe postpartum infections, severe subcutaneous nodular endometritis, or radiation therapy can cause amenorrhea; excessive curettage during late-term induced abortion, leading to scarring or adhesions in the uterine cavity, can also result in amenorrhea.
   3. Poor uterine lining response. Prolonged breastfeeding or long-term use of contraceptive pills can lead to chronic deficiency of sex hormones, causing excessive atrophy of the uterine lining and resulting in amenorrhea.
2. Ovarian amenorrhea and its causes: Ovarian amenorrhea occurs due to ovarian reasons that lead to endogenous estrogen deficiency. The artificial cycle test is positive, and gonadotropin levels are elevated. The main causes of ovarian amenorrhea include:
   1. Congenital absence of ovaries or underdevelopment (rare).
   2. Ovarian destruction. For example, surgery, radiation therapy, inflammation, or tumors damaging the ovaries can cause amenorrhea.
   3. Ovarian tumors. Some androgen-producing tumors can inhibit ovarian function, leading to amenorrhea; estrogen-producing ovarian tumors can suppress ovulation and cause amenorrhea.
   4. Premature ovarian failure. Amenorrhea and menopause before the age of 40 are considered premature ovarian failure. Symptoms of varying degrees of menopause may appear.
3. Pituitary amenorrhea and its causes: This occurs due to pituitary damage, pituitary tumors, or primary pituitary hypogonadism. Common causes include:
   1. Pituitary injury. Head injury, intracranial surgery, radiation, or inflammation can damage the pituitary, leading to hypopituitarism, decreased ovarian function, and amenorrhea.
   2. Pituitary tumors. These are the most common organic causes of amenorrhea, and some may present with galactorrhea.
   3. "Empty" sella syndrome. This congenital condition causes amenorrhea but does not progress to pituitary failure.
4. Hypothalamic amenorrhea and its causes: Hypothalamic amenorrhea is commonly caused by the following factors:
   1. Psychogenic and neurological factors. Sudden or prolonged psychological stress, such as anxiety, fear, worry, environmental changes, or cold stimulation, can disrupt neuroendocrine function and lead to amenorrhea.
   2. Wasting diseases and malnutrition. Examples include severe pulmonary subcutaneous nodules, anemia, and neurogenic anorexia in young women.
   3. Drug-induced suppression syndrome. For instance, some women may experience amenorrhea after discontinuing long-term or short-term contraceptive use. Medications like reserpine, chlorpromazine, and meprobamate can also cause amenorrhea.
   4. Disorders of the adrenal, thyroid, or pancreas can affect the pituitary through the hypothalamus, leading to amenorrhea.
   5. Other diseases. Conditions such as obesity-related reproductive dysfunction, amenorrhea-galactorrhea syndrome, polycystic ovary syndrome, and diabetes can also cause amenorrhea.

bubble_chart Diagnosis

Examination of uterine function:

1. Pharmacological tests. Progesterone tests can be used; if there is no response to progesterone, an estrogen test can be performed.
2. Diagnostic curettage.
3. Hysteroscopy.
4. Basal body temperature measurement. If a biphasic pattern is observed, it indicates that the cause of amenorrhea lies within the uterine membrane, and ovarian function is normal.

Examination of ovarian function:

1. Diagnostic curettage.
2. Examination of cervical mucus crystallization. If aligned ellipsoid bodies are seen on the smear, it suggests the influence of progesterone at the estrogen level.
3. Vaginal exfoliative cytology examination, with vaginal smears performed twice weekly to dynamically and indirectly assess ovarian estrogen levels.
4. A biphasic basal body temperature indicates normal ovarian function, ovulation, and corpus luteum formation.
5. Measurement of blood levels of estrogen and progesterone. Low levels suggest abnormal ovarian function or failure.

Examination of pituitary function:

1. Sella turcica imaging to rule out pituitary tumors.
2. Measurement of serum levels of follicle-stimulating hormone (FSH), luteinizing hormone (LH), and prolactin (PRL). FSH levels higher than the normal range (2.5 μg/L) indicate hyperfunction of the pituitary and hypofunction of the ovaries; LH levels below the normal range (6 units/L) suggest hypogonadotropic function; if both FSH and LH levels are low, it indicates hypofunction of the pituitary or hypothalamus; elevated PRL levels beyond the normal range suggest milk regurgitation amenorrhea syndrome.

bubble_chart Treatment Measures

1. Western Medical Treatment

Corresponding treatment methods and principles are adopted based on the causes of amenorrhea:

1. General supportive therapy includes psychological reassurance, alleviating concerns, improving nutrition, balancing work and rest, and moderate exercise to enhance constitution. If systemic diseases are detected, they should be treated first. For those with lactation periods exceeding one year, breastfeeding should be discontinued.
2. Treatment for organic sexually transmitted diseases causing amenorrhea: For intrauterine adhesions, the uterine cavity can be dilated, adhesions separated, and an intrauterine device placed to prevent re-adhesion, supplemented with estrogen and progesterone to promote endometrial proliferation and shedding. For ovarian or pituitary tumors, or imperforate hymen or vaginal atresia, surgical treatment can be performed after diagnosis. For patients with genital tract subcutaneous nodes, anti-tuberculosis therapy is administered.
3. Estrogen and progesterone replacement therapy: For congenital ovarian dysgenesis or ovarian function suppression/destruction leading to failure, exogenous ovarian hormones can be used for replacement therapy. These patients lack normal follicles and oocytes and do not secrete sex hormones. Administering estrogen or estrogen-progesterone artificial cycle therapy can correct the physiological and psychological effects of estrogen deficiency, promote the development of reproductive organs and secondary sexual characteristics to some extent, improve sexual life, and induce periodic withdrawal bleeding resembling menstruation.
4. Ovulation induction: For patients seeking fertility with preserved ovarian function, hormones or similar drugs can be used to induce ovulation.
   1. For pituitary insufficiency, follicle-stimulating hormone extracted from postmenopausal women's urine can be used to promote follicular development and estrogen secretion, combined with chorionic gonadotropin therapy, achieving a high ovulation success rate.
   2. For patients with normal pituitary and ovarian function but hypothalamic insufficiency or dysfunction, clomiphene can be used to correct the hypothalamic-pituitary-ovarian axis and induce ovulation.
   3. For hypothalamic insufficiency leading to insufficient luteinizing hormone-releasing hormone (LH-RH) secretion, pulsed microdose LH-RH injection can be used to induce ovulation.

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Dietary therapy, drug therapy, etc., can be employed. Identify the disease causing amenorrhea and treat accordingly, such as anti-tuberculosis therapy for subcutaneous node endometritis; dilation of the uterine cavity and placement of an intrauterine device to prevent re-adhesion; surgical treatment, radiotherapy, chemotherapy, or other comprehensive therapies for pituitary or ovarian tumors.

2. General Treatment

1. Arrange work and life reasonably, pay attention to nutrition, and consume a diet rich in vitamins and proteins.
2. Strengthen physical exercise and maintain mental well-being.
3. Actively treat primary diseases, such as anemia, subcutaneous nodes, or other endocrine disorders, with specialized care.
4. For imperforate hymen or vaginal atresia, surgical treatment is indicated.

3. Drug Treatment

1. Hormone therapy is suitable for hypothalamic, pituitary, or ovarian endocrine insufficiency and uterine hypoplasia. Progesterone, estrogen, thyroid hormones, etc., may be selected based on the condition.
2. Chinese herbal medicine treatment.
3. Acupuncture treatment.

1. Treatment for uterine or vaginal hypoplasia or intrauterine adhesions.
2. For ovarian virilizing tumors, surgical removal should be performed as early as possible after diagnosis.

bubble_chart Prevention

Strengthen the constitution and improve overall health. Engage in regular physical exercise, such as health-promoting gymnastics, Tai Chi, or middle-aged and elderly disco dancing. Avoid mental stress, maintain emotional stability, and ensure smooth circulation of qi and blood. During menstruation, keep warm, especially the lower back and below, ensuring the feet are not exposed to cold or immersed in cold water, and avoid consuming raw or cold fruits. Since the body's resistance is weaker during menstruation, avoid heavy physical labor, balance work and rest appropriately, and harmonize the qi and blood of the Chong and Ren meridians. Avoid taking cold or cooling medications during menstruation. Enhance nutrition and take care of the spleen and stomach. When appetite is good, consume more meat, poultry, eggs, milk, and fresh vegetables, while avoiding spicy and stimulating foods. Eliminate chronic sexually transmitted disease foci, avoid prolonged breastfeeding, exercise caution with artificial late abortion procedures, and use oral contraceptives correctly. Obese individuals should moderately restrict their intake of food, water, and salt.