The absence of periods is most commonly due to chronic anovulation resulting from some of the following

• Lifestyle induced low body weight, excessive exercise, stress… more

Exercise Induced Amenorrhea (EIA)– is more likely associated with

• High intensity exercise which shifts estrogen metabolism to a form which disrupts gonadotrophin-releasing hormone (GnRH) pulsatility (I.e.GnRH secreton is reduced)
• Activities associated with low body weight- running, ballet, dancing
• Sports with competitive scoring-gymnastics and figure skating
• Sports with a lower association with EIA are swimming and biking

Amenorrhea may persist in up to a third of cases despite correction of BMI and reduced exercise

Consequnces of chronic amenorrhea are

• Infertility
• Vaginal and abreast atrophy
• Reduced bone mineral density
• Increased total cholesterol

• PCOS
• Hypothalamic failure and hypopituitarism… more

The pituitary is small gland at the base of the brain responsible for many body functions including reproduction and childbirth. The pituitary gland may not function normally if it does not receive the right stimulatory hormones from another close region of the brain, the hypothalamus, then a range of metabolic and constitutional symptoms may result including also affects upon reproduction.

• Hypothyroidism (low thyroid function)
• Hyperprolactinemia more

Prolactin is the hormone secreted by the pituritary gland that is responsible for normal lactation. In some cases prolactin may be high abnormally such as from nipple stimulation, breast exams, physical and mental stress or pituitary tumors. When chronically elevated it can interfere with GnRH secretion from the hypothalamus which consequently interferes with normal ovulation.

• Structural and or anatomic abnormalities more

These abnormalities are often associated with primary amenorrhea where there is a total absence of periods from the time of puberty and beyond the age of 16yrs and is often related to developmental issues and is not common.

Endometriosis is the presence of functioning endometrial glands and stroma (supporting tissue) outside of the uterine cavity (womb).

Endometriosis may affect 25-35% of infertile women, the average age of diagnosis is between 25-29yrs and the common symptoms are pain and infertility although it can also be asymptomatic.

The cause is unknown but some theories include retrograde menstruation, , a transformation of some cells in the pelvis to endometrial type tissue, altered immune function (Immunologic Theory)  and induction from unknown substances, maybe environmental substances inducing immature cell lines to develop into endometrial cells  .Interestingly, dioxin, a known industrial pollutant is present in higher amounts in women with endometriosis versus control subjects. (Mayani, Hum Reprod 12(2):373 1997

Endometriosis may cause cysts, nodules, flat or only microscopic lesions and may give rise to pain including severe dysmennorhea (painful periods), fallopian tube obstruction and bowel and bladder symptoms.

Surgical treatment is possible but is associated with a high recurrence rate. For  infertility treatment IVF is ususally considered the better option.

For 95% of women there are only 12% of remaining prebirth non growing follicles in the ovary by the age of 30 years. By 40 years of age only 3 % remain.

Despite age,  some younger, normally cycling women may experience early pregnancy loss, or not respond well to IVF stimulatory drugs and may not always have good IVF outcomes.

While this does not mean these women do not ovulate and that they will not produce good eggs with or without stimulatory medication, it does mean however that there is no way to selectively stimulate and recruit more of the good eggs for a particular cycle.

Different protocols and approaches can help in these situations.

Premature ovarian failure

This uncommon condition may be associated with such situations as previous cancer treatment or potentially  a genetic anomaly  such as  Fragile X

Donor eggs can be an approach to treatment in this instance.