Hypothalamic Amenorrhea: what to do if you're missing your period
Perhaps I should start this by addressing how taboo menstruation is. Think about it: none of us would be here without a period. None of us would have come into existence if somebody had not menstruated. Society has made it awkward for us to talk about a normal, healthy bodily function-- let’s change that!
Hypothalamic amenorrhea (HA), or the absence of multiple periods (3 or more cycles), is caused by a combination of factors. Often, this includes too much exercise coupled with inadequate energy (calorie) intake. Think: intense training with minimal fueling and restoration through food, increased cardio and cutting carbs or fat or a whole food group. Think: what society teaches us to do in order to become thin and fit into society’s standards.
What society and diet culture don’t address, however, is the potential outcomes and dangers associated with the combination of restriction and over-exercise. Restricting intake is stressful on the body. We focus on each little detail of every food that might enter our mouths, and spend time and energy deciding if something is “safe.” And don’t forget all the other potential, inevitable, stressors in our lives— the death of a loved one, work, finances, living through a pandemic….. these add up. So suddenly, this perfect storm spawning from wanting to be healthy (exercising, dietary habits, weight loss, stress) turns into a missed period…then two…then...where’d it go?
HA can often be swept under the rug by health care providers (HCP) by overlooking the root of the issue: too much stress, too much exercise, too little food. Providers may brush it off saying, “oh, no big deal, you’re a runner, right?”, and prescribe hormonal birth control. While birth control is highly personal, it is not a solution for HA. It is a bandaid. This is where weight bias can show up in the medical setting- providers assuming that a person is “healthy” based on weight or by looking at their patient. A “dedicated” athlete who is committed to their sport in the eyes of the HCP could actually be silently struggling with compulsive over-exercise, undereating or poor body image. This is incredibly problematic.
How does HA happen?
Out bodies are amazingly sophisticated and complex. It is amazing to think of all the little things our bodies do throughout the day without us realizing it. From metabolizing food to controlling our breathing, regulating our blood sugar and pH levels, we get to go about our lives while our bodies are working extremely hard for us.
Photo from Happy Healthy You https://happyhealthyyou.com/blogs/articles/importance-of-stress-meditation-and-hormonal-balance
In regard to menstruation, there’s a lot at play. Stress (as described above) causes an increase in production of cortisol, your fight-or-flight hormone. The cortisol then acts on the HPG Axis (hypothalamic-pituitary-gonadal axis // the reproductive system) and alters the hypothalamus’s function. The hypothalamus is the part of the brain responsible for releasing hormones, so as it is impacted by cortisol, it causes a decreased production of LH and LSH. LH (luteinizing hormone) and FSH (follicle stimulating hormone) are responsible for follicle growth and ovulation. When there are significantly decreased amounts of these hormones in the body, ovulation may be disrupted or stopped, and periods may disappear. Females may also become at risk for poor bone mineral density due to low hormone levels, and subsequent increased risk of stress fractures. This change in hormones and loss of period is often associated with being underweight (namely, having insufficient body fat), restricting calories or nutrients (like carbs), exercising excessively, and/or being under too much stress.
But I’m not “Underweight”??
Being underweight (per the BMI chart) isn’t required in order to lose a period. Recent weight loss can have a similar impact to being underweight, regardless of starting weight. In fact, studies have shown that although some females with a BMI classified as underweight have HA, others with BMIs >22 can also experience HA. This demonstrates that someone could very well be at too-low of a weight for their unique body, which is determined by each individual genetic blueprint. A “healthy” weight for one person may very well be underweight for another person, and people in all body sizes can be malnourished.
A disclaimer:
While we are on the subject of BMI, let’s chat. This is a huge topic that we could dive into but I will leave it short and sweet. BMI was created by an astronomer as a tool to assess a population (namely, the white male population), and while it may be used as a screening tool in medical settings or in research, BMI has been transitioned to be seen as a measure of fatness. (Click here to learn more!) BMI, however, does not assess the percent body fat of a person, nor does it assess a person’s muscle mass, and it CERTAINLY has no merit on how healthy a person is or how well someone is taking care of themselves through health-promoting behaviors. Thus, many people with significant amounts of muscle mass may be categorized as “overweight” or “obese” according to BMI, pathologizing a person based on height and weight. Really all I need you to remember is that BMI is another number, and generally speaking, a pretty poor indicator of health. Numbers have no moral value. Numbers have no meaning without a comparison. How can we consistently make judgements and refer back to a system based off of “normal young adult males” in 1835?
“Normal?” 1835? Perhaps things have changed.
How do I know if I have HA?
HA is a diagnosis of exclusion, meaning that a doctor will conduct a history, physical exam, and blood labs to ensure that the loss of period cannot be attributed to another cause. With a diagnosis of HA, it is expected to see a low LH and estradiol, a growth hormone involved with reproductive organs. A transvaginal ultrasound may also be conducted to rule out PCOS (it is VERY important to make the distinction between these two and get a formal diagnosis).
Will I ever get my period back?
YES! It will take some work, and hopefully the support of a treatment team, but most people with HA are able to achieve regular periods within a number of months. There is no prescribed time in which your period will return to normal, but stay positive and find a treatment team that supports and encourages you. Take the time to learn about your body and become in-tune with your cycle and signs of ovulation. You will need rest, food, and lots of love for your body. We refer to this treatment process as the big four: Food, Exercise, Stress, Sleep. Our top priority is to establish adequate intake, which might feel like much more food than the person is used to, because the body needs that energy to make restorations.
Something to sit with…
Despite what the media may show as great accomplishments or “body goals,” there is so much to appreciate and celebrate about our bodies.
What if society highlighted people with incredible bone density instead of visible, defined abs? Or what if females were put on the cover of magazines for having regular periods?
What if we cared about physical and mental health as much as we admired appearance and aesthetics?
Maybe this sounds absurd, and maybe that’s because society isn’t there yet. But that doesn’t mean you can’t start to think about health in different terms from what makes an appearance in the tabloids. Having a regular period, practicing gentle movement or exercise because it feels good and not because it feels like a requirement, and enjoying food with family and friends are all wins in my book.
Sources
Nuttall FQ. Body Mass Index: Obesity, BMI, and Health: A Critical Review. Nutr Today. 2015;50(3):117-128. doi:10.1097/NT.0000000000000092
No Period Now What? By Dr. Nicola Rinaldi
IE/HAES aligned interventions for female hormone diseases and conditions Webinar by Robyn Nohling
Liu JH, Patel B, Collins G. Central Causes of Amenorrhea. [Updated 2016 Mar 1]. In: Feingold KR, Anawalt B, Boyce A, et al., editors. Endotext [Internet]. South Dartmouth (MA): MDText.com, Inc.; 2000-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK278939/
