= Solution
\b[Absent <menstruation> is a sign with several causes; treatment must distinguish physiological absence, failure of menstrual cycling and obstruction of outflow.] The word “suppression” does not establish that retained <blood> is poisoning the body or that producing a bleed will cure the underlying problem.
First distinguish <primary amenorrhoea>, where <menstruation> has never begun, from <secondary amenorrhoea>, where established cycles have stopped. Ask about the previous pattern, possibility of <pregnancy>, breastfeeding, age, illness, nutrition, exercise, medicines and associated symptoms. <Pregnancy>, <lactation> and <menopause> can explain physiological absence. <Pregnancy> must be considered before any proposed menstrual stimulant, with assessment for complications when pain or abnormal bleeding accompanies the missed period.<Current evaluation of amenorrhea by ASRM>[2024, definitions, causes and secondary amenorrhea evaluation; pregnancy exclusion]{ref}
A second group has impaired hormonal signalling or ovarian function. Severe illness, inadequate energy intake, major exertion and stress can suppress the <hypothalamic–pituitary–ovarian axis>. Other possibilities include <thyroid disease>, <hyperprolactinaemia>, <primary ovarian insufficiency> and chronic <anovulation>. These modern categories separate processes that an 1866 clinician might group under debility, constitutional disease or disordered ovarian activity. <Anaemia> and wasting deserve investigation and treatment when present, but are not universal explanations for every missed period.
A third group has an anatomical explanation. Cyclical pain with absent visible <menstruation> can indicate retained menstrual material behind an <imperforate hymen> or other outflow obstruction. Congenital absence or abnormal development of reproductive organs is different again. Acquired scarring of the uterine cavity may interrupt bleeding after instrumentation or disease. The response to obstruction is diagnosis-specific correction by an appropriate specialist; neither a “tonic” nor a drug intended to provoke <uterine contraction> repairs an absent or blocked passage.<Current evaluation of amenorrhea by ASRM>[Primary amenorrhea, outflow anatomy; secondary amenorrhea, anatomical causes and imaging]{ref}
In period terms, treatment of a genuine associated illness, improved nourishment and protection from exhausting conditions could be sensible. Warm baths and drugs called <emmenagogues> were also employed, but their use should not be mistaken for proof of efficacy, or attempted before excluding <pregnancy>. Menstrual absence should not automatically be interpreted as the cause of mental or systemic illness.
\b[Modern correction: investigate the relevant physiological pathway and treat its cause.] Selected investigations include a <pregnancy test>, <prolactin>, <thyroid-stimulating hormone>, ovarian and pituitary hormone measurements and <pelvic ultrasonography>. For functional hypothalamic suppression, restore energy availability and address contributing illness or disordered eating; simply imposing withdrawal bleeds can conceal persisting energy deficiency. Hormone replacement may be appropriate for ovarian insufficiency, while thyroid, prolactin-related and anatomical disorders need their own pathways. Management of chronic <anovulation> includes reproductive goals and protection of the <endometrium>, rather than just the appearance of regular bleeding.<Functional Hypothalamic Amenorrhea guideline by the Endocrine Society>[Recommendations 3.2–3.6, energy correction and limitations of oral contraceptives for restoring spontaneous cycles]{ref}<Amenorrhea: Absence of Periods by ACOG>[Treatment of primary and secondary amenorrhea; ovarian insufficiency, endocrine conditions and anatomical causes]{ref}
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