Having a regular menstrual period (menorrhea), bleeding regularly every month, is something that many women expect as part of their normal body function. A regular menstrual period is associated with regular ovulation.
- If you ovulate, then you will usually bleed within 12-16 days after ovulation if you are not pregnant.
- If you ovulate and your period has not come 16+ days after ovulation, then chances are high you are pregnant.
- A positive pregnancy test means that the pregnancy hormone hCG has been detected and that you are pregnant.
- A repeatedly negative pregnancy test after missing a period means there is no hCG in your body and it usually means that you are not pregnant.
To find out why your period hasn't come when you are not pregnant, you need to know the physiology or a regular menstrual period. A regular period usually comes from regular ovulation. And if you don't ovulate (anovulation) then you either have irregular menstrual periods or no period at all.
- Regular ovulation = Regular menstrual periods
- Irregular or no ovulation = Irregular or no menstrual periods
- No period = Either pregnant, no ovulation, or another problem
You can find out if you ovulate by doing a basal body temperature curve, checking for fertility signbs,having blood tests done for progesterone, or having a sonogram done. A biphasic temperature curve means that you ovulate and a monophasic curve means you don't ovulate.
Not getting a period, having amenorrhea without being pregnant can have different reasons including the following:
- Polycystic ovary syndrome (PCOS)
- Hypothyroidism (Low thyroid)
- Premature ovarian failure (POF)
- Hypothalamic-pituitary failure (medications, weight loss, stress, strenous exercise, rarely a tumor in the pituitary or hypothalamus)
- Adhesions (scar tissue) in the uterus or cervix (Asherman syndrome)
- Cushing syndrome
If you did not get your period, and you are not pregnant, then the following steps are usually taken to find out the reasons.
- A physical examination including weight and any signs of physical problems as well as checking to see if you have galactorrhea (milk production).
- Blood tests: Thyroid testing (TSH, thyrotropin), Prolactin, LH, FSH, estradiol.
- If TSH is elevated, then the diagnosis could be hypothyroidism.
- Progesterone Challenge Test (Provera) can be done to see if you bleed after the test.
Bleeding after progesterone
- Bleeding after progesterone means there is estrogen present and the diagnosis of the amnorrhea is likely anovulation (no ovulation).
- Many doctors feel that a blood LH- and FSH-level and a testosterone and DHEAS test may be helpful at this point.
If the LH is high (above about 10 mIU/ml) and the LH/FSH ratio is above 2:1, this supports the clinical diagnosis of polycystic ovarian disease (PCOS or PCO) although many patients with PCOS do not demonstrate this high LH/FSH ratio. Testosterone and DHEAS levels may also be useful in women with PCOS, especially in the presence of hirsutism (excess hair) or other signs of hyperandrogenism (excess male hormones).
Serum estradiol levels undergo wide fluctuations during the normal menstrual cycle. During the early follicular phase of the menstrual cycle, levels may be lower than 50 pg/mL. During the preovulatory estradiol surge, levels in the range of 400 pg/mL are not uncommon. In healthy menopausal women, estradiol levels are routinely lower than 20 pg/mL.
No bleeding after progesterone:
- An FSH level of approximately 40 mIU/mL is indicative of ovarian insufficiency. If a repeat value in 1 month confirms this finding and amenorrhea still persists, then the diagnosis of premature ovarian failure/primary ovarian insufficiency is confirmed. A high FSH indicates premature ovarian failure or menopause.
- If the FSH is normal, then a combined progesterone/estrogen dose is given.
- Bleeding after progesterone/estrogen may indicate Hypothalamic-Pituitary Failure (medications, weight loss, stress).
- No bleeding after progesterone/estrogen requires additional tests such as a hysteroscopy or a hysterosalpingography. This is usually indicative of outflow tract obstruction (scar tissue or adhesions in the cervix or uterus), which means the uterus or cervix are not letting the menstrual flow pass.