Depression, amenorrhea, and why your periods have stopped

amenorrhea and depression

Amenorrhea is a medical term for when your menstrual periods stop. There are, broadly speaking, two types of amenorrhea, primary and secondary. The former is when someone never starts their periods at all. Most people should have started their periods by the age of 16, and primary amenorrhea may often be due to anatomical abnormalities in which the ovaries do not form properly, or due to chromosomal disorders such as Turner syndrome.

Secondary amenorrhea is when you miss three or more periods in a row when your periods have previously been regular, or you have no periods for six months for people who have irregular periods, and when it is not down to pregnancy. Secondary amenorrhea can be caused by many things, including polycystic ovary syndrome (PCOS), high levels of male hormones in females, stress, anxiety, or depression.

Depression is where people have feelings of unhappiness and hopelessness lasting from several weeks, to months or more. It is a common condition, and affects 10% of people during their lifetime.1

Symptoms include loss of interest in activities, feeling tearful for no reason, anxiety, feeling constantly tired, poor sleep, loss of appetite and sex drive, generalised aches and pains, and amenorrhea. Some people with severe depression may also have suicidal thoughts.

There may not be an obvious cause for depression and it can come on out of the blue. Sometimes it can occur after life events such as death in the family, losing a job, or even after giving birth. People who have a family history or previous history of depression are more likely to have depression. While it is absolutely normal to experience short periods of low mood from time to time, if it lasts longer than a couple of weeks, it is worth going to seek help from your GP.

What’s the link between depression and amenorrhea?

If you are depressed, one of the symptoms you may experience is amenorrhea. When someone has depression they release a stress hormone called cortisol, which acts as a messenger that affects a part of the brain called the hypothalamus.

The hypothalamus is also the part of the brain that informs the ovaries to release an egg, by sending out a hormone called gonadotropin-releasing hormone. However, as the cortisol has affected the hypothalamus, this signal is disturbed, meaning that ovulation is either delayed or stopped. This results in a later period, or no period at all (secondary amenorrhea). When we are stressed or anxious, we may see the same thing happen, so it is likely that depression affects menstruation via this indirect method.

Depression can also affect appetite, meaning that those who are depressed may eat excessively, or not eat at all, leading to rapid weight loss or weight gain. This fluctuation in weight can lead to amenorrhea as the ability of fat cells to produce extra oestrogen is affected. When there is excessive oestrogen, or a lack of oestrogen, this affects the ovaries causing irregular or missed periods.

Can antidepressants affect your menstrual cycle?

Antidepressants that are used to treat depression may also affect the menstrual cycle, leading to amenorrhea. All antidepressants that belong to a group known as selective serotonin reuptake inhibitors (SSRIs), such as paroxetine, sertraline, and citalopram, can cause high levels of a hormone called prolactin to be released.

Prolactin works by affecting the nerves that are involved in the hormone release from the brain. High prolactin levels inhibit the release of follicular stimulating hormone (FSH) from the ovaries which stops the ovaries from releasing eggs, and menstruation does not occur.

Bupropion is another antidepressant which acts on a different set of biological targets in the brain, known as norepinephrine-dopamine reuptake inhibitors, and nicotinic receptor antagonists. This drug has been associated with shortened menstrual cycles, menstrual spotting, and amenorrhea, although the exact method of how it does this is unknown.

Selegiline is an enzyme inhibitor which is available as a skin patch to treat depression. There have been some reports of irregular periods with use of this drug, but the mechanism of this is not certain, it may be from the side effect of weight loss with the fat cells producing less oestrogen required for ovulation.2

How do you resolve amenorrhea linked to depression?

If you do suffer from depression, and you have ruled out any other causes for disruption to your menstrual cycle, then the best treatment is to try to treat the depression. You may need help from your GP to be referred for talking therapy for depression such as counselling, or cognitive behavioural therapy (CBT).

Your GP may advise that you start taking antidepressants. There are many types available and many don’t affect the menstrual cycle. If weight loss or weight gain is a problem, then having a look at either eating more, or losing weight, would help, although understandably this is unlikely to be easy if the depression is not first treated. Seeing a dietician may be useful when seeking advice on how to lose or gain weight healthily.

Does amenorrhea have any long term effects?

Amenorrhea does not necessarily mean infertility, and some women will experience amenorrhea for a while and then have their periods return completely back to normal. If your amenorrhea is due to depression, and your depression is treated, then regular period cycles can return, and fertility is not generally affected.

However, amenorrhea has many causes and could potentially be a sign of disease, or a chronic condition associated with infertility. It is not always easy to attribute stopped periods to low mood alone, and it is extremely important to exclude other causes.

If you are sexually active and have missed more than three periods in a row, it may be worth taking a pregnancy test in the first instance. If you are aged over 45 years, and have symptoms such as hot flushes, vaginal dryness, palpitations, and mood swings, then menopause may be a possibility.

Hormonal disorders such as high prolactin can lead to amenorrhea, so if there are other symptoms, such as milky discharge from nipples, headache, and change in vision (partial loss or double vision) this may be a cause.

Similarly, an underactive thyroid can lead to low mood, weight gain, and amenorrhea. There may be other signs of underactive thyroid such as sluggishness and intolerance to the cold. If amenorrhea is associated with sudden development of male features such as excessive body hair, deepen voice, and increased muscle bulk then this may be caused by an excess of male hormones (androgens), that can occur if someone has a tumour, or polycystic ovary syndrome.

Missing one period is rarely a sign of something serious. However, it would be advisable to seek help from your GP if you are not pregnant, and not taking a form of hormonal contraception which means you don’t get periods, and you miss three menstrual periods or experience a sudden change in your pattern of periods, all the more so if you are experiencing any associated symptoms.

References

  1. NHS Choices Health A-Z, ‘Clinical depression’, [website], 2016, https://www.nhs.uk/conditions/clinical-depression, (accessed 10 March 2018).
  2. MedlinePlus, ‘Selegiline Transdermal Patch’, [website], 2016, https://medlineplus.gov/druginfo/meds/a607003.html#side-effects, (accessed 10 March 2018).

Dr. Diana Chiu MBChB (Hons), MRCP, PGCERT (Med Ed), PhD

Diana received her medical degree, with honours, from the University of Manchester. She then went on to receive basic and specialist medical training within the north west of England. She carried out in-depth research in medicine and was awarded a PhD in 2016. Currently, she is finishing her medical training at a large teaching hospital, and one of her greatest interests is medical education. She is an advanced life support instructor and writes regularly for post-graduate examination websites, and also holds a PGCERT in medical education with distinction.

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