Usually your physician will begin by ruling out pregnancy. The most common reason, besides pregnancy, not to have your periods is because you aren’t ovulating. This condition, known as anovulation, is most commonly caused by insulin resistance. It is also known as Polycystic Ovarian Syndrome or PCOS.
Your ovaries need your body to be exquisitely insulin sensitive in order to ovulate every month. Ovaries contain hundreds of thousands of follicles that could potentially ovulate one day. These follicles appear to be small cysts on ultrasound. Remember, the ovaries make cysts for a living. Every month, a few hundred of these follicles step up to the plate and complete to become the dominant follicle that will ovulate midcycle. This follicle gets bigger and bigger, wipes out the others, and bursts midcycle at which point the egg is released and can be fertilized. The process of the dominant follicle getting much bigger than the others, wiping out the others, and bursting (i.e. ovulation) is due to complex set up of hormone interactions within the ovary. These interactions are blocked if your body is resistant to insulin.
Insulin resistance is often, but not always, genetic. Women who have a family history of Type 2 diabetes are more likely to inherit the gene for insulin resistance. Weight gain also causes the body to become more insulin resistant, and in women with a genetic predisposition to diabetes, the amount of weight gain that triggers their body to stop ovulating might be very small. Some medications, such as Prednisone, may make the body more insulin resistant as well.
Here’s what happens in a normal cycle in women who are ovulating: In the first half of the cycle, the ovaries produce mostly estrogen, which acts like fertilizer on the lining of the uterus, making it thick and plush. After you ovulate, the remains of the dominant follicle produces progesterone, which acts like a lawn mower on this lining trimming it down, and letting you have a menstrual period.
If you are not ovulating, a few things happen. First of all, your uterine lining only sees the fertilizer effect of the estrogen, not the lawn mower effect of the progesterone. So you don’t get your period, and in the meantime, the lining builds up and left long enough, can develop into a precancerous condition called endometrial hyperplasia. Or it may begin to slough off irregularly and cause heavy sporadic bleeding with no pattern or cycle.
Second, if you are not ovulating, all of those little follicles remain in a state of limbo, none ever becoming the dominant follicle. All of those little follicles produce a lot of testosterone. Testosterone levels in women with this condition are usually higher than normal and can cause abnormal hair growth on the upper lip, chin, between the breasts, and between the belly button and pubic hairline. Acne is also more common in women with this condition, because of the higher testosterone levels.
Several years ago, it was noted that women who were menstruating less often than five times a year often had multiple tiny cysts within their ovaries, often around the periphery of the ovaries, called a ring of pearls appearance. But now we know that 30 percent of women diagnosed with anovulation have not yet developed this classic ultrasound appearance of their ovaries, which occurs over time. It is because we’re making the diagnosis much earlier. So ultrasound is not reliable in diagnosing or ruling out this condition, instead, it is a clinical diagnosis, based on symptoms and physical exam.
Most women who do not menstruate spontaneously, and who are under forty-five, have this condition. But about five to ten percent may have another condition, such as thyroid problems, oversecretion of a hormone called prolactin, enzyme deficiencies in the adrenal gland, premature menopause, not producing adequate pituitary hormones to initiate ovulation, or rarely tumors of the brain, adrenal glands or ovaries. So if your periods are happening less than every three months, it is important to see your doctor.
Your physician will probably also order tests to rule out overt diabetes. For many women with diabetes, their first symptom was that their periods slowed down or stopped. It is also common for your doctor to look for high cholesterol, since this condition is more common in women with anovulation.
Women with anovulation due to insulin resistance (polycystic ovarian syndrome) are also at higher risk for obesity, heart disease, and stroke. So it is important to recognize and treat this condition early.
So what can you do about it if you have this condition? it depends if you are trying to become pregnant or not. If you are not trying to conceive, your physician will usually offer hormone balancing product in the form of the birth control pill, the Nuvaring, or simply progesterone supplementation. Excess hair growth and acne are typically treated with medications to help prevent new growth of coarse black hairs on the face and elsewhere. Typically this is prevented with medications such as spironolactone and Vaniqa, which prevent testosterone from being converted to its potent cousin, DHT (dihydrotestosterone) at the level of the skin. This treatment, along with oral contraceptives, it effective prevention. Treating the existing hair usually requires cosmetic laser or electrolysis, both of which treats existing hair, but don’t prevent new coarse hair from being recruited from regular light hair. So a combination approach is required.
Exercise and weight loss are important in managing this condition since both make the body more insulin sensitive and help prevent heart disease, stroke, high cholesterol, and diabetes. Often women start menstruating again even with just a ten to twenty pound weight loss, or with an exercise program of thirty minutes of walking six days a week. As your body becomes more insulin sensitive, weight comes off more easily. The medications called Metformin or Glucophage is an insulin sensitizer that can often help with PCOS.
If you have this condition and are trying to become pregnant, management is a little more complex, and often requires the use of these and other techniques to induce ovulation on a predictable basis.
While not having your period may seem like a convenience, it is often the sign of underlying health problems. Fortunately much can be done to treat and reverse this condition.
Insulin resistance is often, but not always genetic. Women who have a family history of Type 2 diabetes are more likely to inherit the gene for insulin resistance.
by Debra Ravasia, MD