No Period, No Problem?

For many of us, that time of the month is filled with moods, monster breakouts, and mounds of chocolate. We dread its arrival and plan our white pants-wearing days around it. However, if you ever or are now missing periods, this “period piece” is timely. Your period (while off hormonal contraception, remember that no period on the pill is a totally different non-alarming situation) is sort of like the sixth vital sign; it provides a lot of information about the health of your reproductive system.

The arrival of a girl’s first period is sort of a big deal. In many cultures, for many centuries, it has marked the transition from girlhood to womanhood. Historically, it indicated the promise of life, new beginnings, and the start of something. While today the pomp and circumstance around this event are much more hush hush, it is still a very intimate moment shared by mothers and daughters.

And despite the unpleasant cramps and cravings, menses does mark the culmination of puberty and the commencement of the reproductive years. So (playing off the graduation theme), when do you order your cap and gown? When will this process begin? The answer, while seemingly simple, is really somewhat complicated.

Your ethnicity, your family history, your genetics, your weight, your living environment (urban versus suburban), your fitness level, and your stress level all play a role regarding when you go through puberty. In fact, even the century that you live in plays a role in the timing of this event. (In the past 60 years, we have seen a decrease in the age at which girls get their periods.) While the arrival of a period is usually abrupt (wow, what is that?!?), the process that brought this to you actually took years. A period marks the end of the process of puberty.

Puberty encompasses many physical changes (breast development, pubic/underarm hair) as well as cognitive and psychosocial changes (sorry, Mom, for all those wild emotional tirades!). While all these things seem to occur at once, there is actually an orderly transition to this process; increases in a hormone called LH and FSH lead to the production of estrogen. Estrogen stimulates the development of breasts. Androgens from your adrenal glands stimulate the production of pubic and underarm hair (oh joy…get out the razor!). Somewhere in the midst of this, all you have a growth spurt, and then ultimately, your period arrives.

For most girls, puberty begins with the development of breasts at around 10 years (range 8–12). On average, from start to finish, the process takes between 1 and 4 years. African-American and Hispanic females, girls who live closer to the equator and in urban areas, girls who are overweight, and girls whose female family members went through puberty early are more likely to start the process at an earlier age. On the contrary, Asian and Caucasian girls, girls who are underweight, girls who are athletic, and girls whose female family members went through puberty late are more likely to start the process at a later age.

Although that first period marks the beginning of a brave new world, one period does not write the entire story. It suggests that the system has been primed but does not mean it is ready to run on autopilot. Now, while it is quite common for periods in the first two years to be irregular (many cycles during this time period occur without ovulation), after this point, they should start to follow some order. This pattern is not only good for wardrobe planning but also for demonstrating the system has matured.

Regular periods offer a visual that the following systems are a go:

1) About two weeks before the period, ovulation (egg release) has occurred (ovaries: check!)

2) A uterus with an open path for the blood to exist is present (uterus: check!)

3) The signal from the brain to the ovaries has been activated (hypothalamus / pituitary: check!)

Medically speaking, the lack of a period is called amenorrhea (for all you Latin buffs, a- in Latin means without, and menorrhea is menses). When a girl has not gotten her period by age 14 without evidence of breast development or by 16 with evidence of breast development, this is called primary amenorrhea (primary because there has never been a period). When a female has had a period(s) and then they stop for whatever reason, this is called secondary amenorrhea. While some processes can cause both, the causes of the two are usually different.

Primary amenorrhea cases require more detective work and are much less common. They are more likely to be genetic in origin, a sign of poor ovarian development, or a uterine-vaginal blockage (septum)…basically, the rarities of medicine.

Secondary amenorrhea is something that GYNs deal with almost on a daily basis. (Trivia question: what is the most common cause of secondary amenorrhea? Answer: pregnancy!) But aside from pregnancy, common causes are polycystic ovarian syndrome (PCOS), thyroid disease, over-exercise, and stress. Although a few months off from Ibuprofen and tampons feels good, you shouldn’t let this go on for very long without contacting your GYN.

Even though the arrival of Aunt Flo just in time for that weekend beach party is no one’s idea of pleasant, it isn’t all negative. Getting regular periods, while sometimes a pain, can be a plus. It shows us that the system is functioning. While there is absolutely no problem with going on some form of hormonal contraception (pill, patch, ring, IUD) and keeping your periods at bay for a vacation or big work deadline, this is VERY different than not getting period while off hormonal contraception.

Think of the reproductive system as an orchestra. The conductor is the brain, and the ovaries, the uterus, and the fallopian tubes are the instruments. So if the periods abruptly stop or never start, the conductor called off sick, or one of the instrument players have gone on strike, it is our job as GYNs to find out who is sleeping on the job and try to fix it! Although it might be easier to play over the group who’s gone, the music won’t sound or come out right. Periods mean something, and if they stop, someone needs to hear about it.