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If a girl has not started to menstruate by eighteen years of age, the diagnosis is "primary amenorrhea." If, however, there has been menstruation and it stops, the condition is called "secondary amenorrhea." Although both types of amenorrhea can be related to organic problems, stress is the most frequent cause of secondary amenorrhea.

The mind-body chain of events works like this: stress is perceived and messages are sent through the nervous system to activate the fight, flight, or fright emergency systems. Since the reproductive system is not an emergency support system, its hormone levels are lowered and menstruation is not triggered.

Imagine this: A sexual encounter has caused Sally great anxiety, fear, and guilt. She is distraught at the notion that she may have become pregnant. She worries and worries and waits breathlessly for her period. Her period is delayed by her stress, and her anxiety increases. The scene is set for temporary amenorrhea.

Imagine this: Fran is about to leave home to attend boarding school. She realizes that she will be on her own in a real way for the first time in her life. She is fearful yet determined, nostalgic yet excited, reluctant yet committed. She is experiencing an approach-avoidance conflict. These strong mixed feelings have raised her stress level, and the scene is again set for amenorrhea. "Boarding school amenorrhea," in fact.

Imagine this: Carol has decided to transform herself into a facsimile of a Vogue model. She begins to diet drastically. She eliminates desserts. Then breads. Then fats. Then sweets. Her menus have been stripped down to celery and bouillon, and she has been stripped down to skin and bones. She has lost her stomach, her hips, her waist, and her period. Amenorrhea!

Imagine this: It is Lissa's last summer before college. This is her last chance to see if she wants an academic life or the life of a professional dancer. She joins a semiprofessional troupe and starts a round of classes at 6 a.m., rehearsals at 1 p.m., and performances at 7 p.m. She makes more and more demands on her body and is proud of its response. She gains a pirouette and loses a period—then another, and another. Again, amenorrhea.

Imagine the many other stressful situations that can also lead to amenorrhea. Depression, prolonged grief, and unrelieved anxiety can produce the same effects. Although mature women do not typically lose their periods, the menstrual cycles of young women are more vulnerable. In fact, young anorexics are frequently nonmenstruating.

A famous study of women college students shows how responsive the female reproduction system is to psychological and social factors. M. K. McClintock reported that although dorm-mates were menstruating at different times throughout the month when they first arrived at college, by the end of the school year their periods were synchronized far beyond chance or coincidence.

What can be done about amenorrhea? Relief from the stress is often enough, although sometimes a normal cycle returns even while the stress continues. Researchers tell us that some concentration-camp victims who developed amenorrhea when they were first imprisoned began to menstruate once again after a few months of confinement—even though their terrible circumstances had not been altered. Just as psyches can adjust to even the most stressful situations, so too can bodies often gradually adapt to stress and change.

Sometimes this does not happen, however. When stress-triggered amenorrhea continues and a normal cycle does not spontaneously reoccur, a physician should be consulted. Although the problem may not have started with an organic condition, chronic stress may lead to one. The physician may suggest therapy based on hormones or a drug called clomiphene.

The doctor may, however, suggest psychotherapy instead. Psychotherapy can help patients deal with the immediate stress causing the amenorrhea and helps to eliminate the risk of future stress symptoms by encouraging the development of more effective coping strategies for the future. Psychotherapy can also help women explore the cultural messages that make menstruation a high-risk target for the Female Stress Syndrome.

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