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Missing a period can be very difficult for infertile women ! Every time you miss a period, you hope ( against hope) that maybe you are finally pregnant ! However , you are worried about getting your hopes up too high, because you are scared that they will come dashing down again – and you remember all the false alarms you have had in the past !

There are many reasons for missing a period, including stress ; side effects of medications you are taking; and a systemic illness. The first step, of course, is to rule out a pregnancy. You can do this by checking with a urine pregnancy test kit. The new ones are very reliable, and a negative test result usually means that you are not pregnant. If you are unsure, you can repeat the test in 2 days. A better option is to do a blood test to check your HCG level. This is much more reliable ( but it’s also much more expensive !) . A blood level of less than 10 mIU/ml confirms you are not pregnant.

If you miss three menstrual periods in a row, your doctor will make the diagnosis of “secondary amenorrhea “. This is just medical jargon for – “ has missed more than three menstrual periods”. It’s not really a diagnosis – just a description of your problem.

So what are the reasons for a missed period ? And what can you do about this ?

Let’s review some basic biology first. The reason women who ovulate get a natural menstrual period is because of a drop in the circulating blood levels of the reproductive hormones, estrogen and progesterone hormones. When these levels drop, the uterine lining loses its hormonal support, as a result of which it is shed as a menstrual period. This is called a estrogen primed progesterone withdrawal bleed.

A missed period means there is a problem with the normal balance between estrogen and progesterone in your body. This usually happens when you do not ovulate. This is called anovulation.

Most women ( for example, those with PCOD) have high estrogen levels, but because you have not ovulated, your progesterone levels remain low, as a result of which you do not get a withdrawal bleed.

In other cases, the corpus luteum forms a functional cyst. Because this continues to produce estrogen and progesterone, there is no progesterone withdrawal, and the lining remains thick and does not shed.

Others have low estrogen levels ( as a result of which your uterine lining remains thin and does not develop at all). This is commonly seen in lean athletic women who exercise a lot. The missed period in these women is called hypothalamic amenorrhea.

In order to come to the right diagnosis, the doctor may need to do a vaginal ultrasound scan .
This should check for the following.
a. Is there a cyst in the ovaries ? Are the ovaries small ? What’s their volume ? The antral follicle count ?
b. The endometrial thickness and texture.

Patients with PCOD will have a thick uterine lining, which suggests they have high estrogen levels. Women with hypothalamic amenorrhea have small ovaries with a thin lining; as do perimenopausal women who have reached the oopause and whose ovaries are failing. A functional cyst will be easily apparent on the scan.

It’s also possible to confirm this diagnosis by checking the blood levels of estrogen and progesterone.

After making a diagnosis, it’s easy to induce a period, based on the problem.

If the uterine lining ( endometrium) is thick, this means that the level of estrogen in the body is already high ; and it's easy to induce a period by taking 5 days of progestins, such as medroxyprogesterone acetate. There are many options available. These include:Tab Provera ( medroxyprogesterone acetate), 10 mg, twice a day. The period will usually start 3-7 days after taking the last tablet. This is called inducing a withdrawal bleed with progestins.

On the other hand, in women with low estrogen levels who have a thin uterine lining, we first need to build up the lining with estrogens and then induce a period with progesterone . We give the estrogen and progesterone hormones sequentially, thus mimicking a natural cycle. This is what a typical prescription would look like.

Estrogen tablets from Day 1 - Day 25. There are many options available. The least expensive is Tab Ethinyl estradiol ( Lynoral), 0.05 mg daily. Other choices include:
Tab Premarin, 1.25 mg daily; or
Tab Progynova ( estradiol valerate, 2 mg), 2 tab daily. You may feel some nausea and have some temporary fluid retention while taking the estrogen.

Progestin tablets, from Day 16 - Day 25. There are many options available. These include:Tab Provera ( medroxyprogesterone acetate), 10 mg, twice a day.

This regimen is called Hormone Replacement Therapy , and is available commercially in some countries in the form of a pack, called CycloProgynova.
The withdrawal period ( menstrual period) will start approximately 3-6 days after you take the last tablet, as the levels of the administered hormones decline in your body because they get excreted in the urine.

It’s also possible to achieve the same results with a 21 day course of birth control pills, since these contain both estrogen and progesterone. It's best to take the old-fashioned monophasic birth control pills, which contain a sufficient amount of estrogen and progestins ( combined together in one "active" tablet). A typical choice would be Ovral, which contains 50 ug of ethinyl estradiol and 500 ug of norgestrel ( a type of progestin). The withdrawal bleeding induced when you take birth control pills may be scanty as compared to a regular period. This is normal.

If the reason for the missed period is a functional cyst, you may have to wait till it resolves. It will usually do so on its own. If needed, the doctor can induce a period with mifegest ( RU-486), a very powerful antiprogestin.

Premature Ovarian Failure (POF), also known as premature ovarian insufficiency, primary ovarian insufficiency , premature menopause and primary ovarian failure, hypergonadotropic hypogonadism, is the loss of ovarian function before the age or 40. hypoestrogenism. POF affects 1% of the population.

On an average, in a normal woman the ovaries will produce eggs until the age 51, which is the average age of natural menopause. In some women, the ovaries stop functioning much earlier. This is called premature ovarian failure. Most women with POF will have irregular menstrual cycles. Initially, these are light or infrequent; and soon stop completely. The age of onset can be as early as the teenage years but varies widely. If a girl never begins menstruation, this is called primary ovarian failure. The age of 40 was chosen as the cut-off point for a diagnosis of POF. This age was chosen somewhat arbitrarily, as all women's ovaries decline in function over time.

POF is diagnosed by finding abnormally low levels of estrogen and high levels of FSH, which demonstrate that the ovaries are no longer responding to circulating FSH by producing estrogen and developing fertile eggs. On ultrasound scanning, the ovaries are small ( atrophic) with a very low antral follicle count. Women suffering from POF usually experience menopausal symptoms, which are generally more severe than the symptoms found in older menopausal women. The symptoms vary from patient to patient and the disorder may occur abruptly or spontaneously or it may develop gradually over several years. Women may experience hot flashes, night sweats, irritability, moodiness, sleep disturbance, decreased libido, hair coarseness and vaginal dryness.

In most patients with POF , the cause cannot be determined. Some cases of POF are attributed to autoimmune disorders, others to genetic disorders such as Turner syndrome and Fragile X syndrome. Radiation treatments for cancer can sometimes cause ovarian failure. Family history and ovarian or other pelvic surgery earlier in life are also implicated as risk factors for POF.

Serum follicle-stimulating hormone (FSH) measurement can be used to diagnose the disease. Two FSH measurements with one-month interval have been a common practice. Because the eastradiol levels in patients with POF are low, the FSH levels are very high. The typical FSH level in POF patients is over 40 mlU/ml (post-menopausal range). Many women get confused with their FSH levels. They feel that the high FSH is the cause of the POF; and if this can be treated, then their problem with get solved. The fact is that while it’s very easy to suppress the high FSH level back to the normal range by using estrogen tablets, this will not help the patient with POF to grow eggs or to have a baby.

A new and more reliable marker for ovarian function today is the blood test for checking the AMH level. The diagnosis can be confirmed by checking the AMH level, which is very low in patients with POF.

Often the diagnosis comes as a rude shock – both to the patient and the doctor. Most young women have irregular periods because of another disorder called PCOD, which is much commoner. Many doctors assume that a young woman with irregular periods have PCOD, as a result of which the correct diagnosis of POF is often missed for many years. The cessation of menstrual periods is often incorrectly attributed to a variety of conditions, such as stress, without appropriate testing or consideration, delaying the diagnosis even further. In addition, many women who are affected by POF may have been incorrectly treated for irregular bleeding with oral contraceptives, which may have masked symptoms. All too often, POF is not diagnosed until the woman becomes interested in fertility and the oral contraceptives are stopped when the patient wants to conceive.

Currently no fertility treatment has been found to effectively increase fertility in women with POF. While some women with POF can and do become pregnant on their own, this is unpredictable and uncontrolled. Medically, the best treatment option is the use of donor eggs. While it can be very difficult for young women to come to terms with the fact that they may have to use donor eggs to have a baby, the good news is that this option has a very high success rate in patients with POF. Other options include: embryo adoption; childfree living; and adoption.
Patients with POF have low estrogen levels and this can result in painful sex ( because of lack of vaginal lubrication); as well as osteoporosis. Hormone replacement therapy ( HRT) with estrogens and progesterone can help to deal with these problems very effectively. However, while HRT can help women with POF to have regular cycles, it will not help them to have a
baby !


Many women find this very confusing, because they feel that if the medications can help them to have regular periods, they should be able to help them to have a baby as well. Sadly, the woman with POF has no eggs left in her ovaries, which means we cannot help her to grow these.