What Is Hypothalamic Amenorrhea And How To Recover From It?

If you’ve missed your period for 3 months or more in a row, you likely* have hypothalamic amenorrhea.

Hypothalamic amenorrhea is when you no longer have a menstrual cycle after having had one before. Skipping one or two periods once a year or two isn’t amenorrhea, it’s typically just a delay in your ovulation. Once you’ve been missing a period for 3 month onwards it is classified as amenorrhea.

The thing that a delayed period and hypothalamic amenorrhea have in common is that they are caused by the same issues:

• Stress

• Under eating

• Over exercising

Any one or a combination of all of these can cause your period to be MIA. It’s when these problems become chronic and prolonged that we see it move from just a single missed period to months, sometimes years and even decades. When this happens, it’s hypothalamic amenorrhea. It’s officially missing.

For example, imagine you went through a traumatic event or stressful time in April and you started a diet or training for a marathon at the same time. It probably wouldn’t shock you to not get a period in May and you likely would deduce that pretty quickly. When you stop training and get through the traumatic event your period will likely come back. This is a missed period and frankly…life.

Now say that you’ve started a diet in April and started training for a marathon…and you didn’t stop for years. No off days or weeks. No breaks from the diet. Oh, and you’re working a job or in school along with other responsibilities. In doing all of this you’ve lost your period and since then it has never returned.

Your period is GONE and it’s been a long time. That is hypothalamic amenorrhea.

What’s happening here is that the body is under fueled and over stressed. It’s working too hard with too little.

Often the irony is that you’re expecting your body to be at its healthiest and perform optimally because of everything that you’re doing. So hearing that your perfect diet and training regime is the problem can be really jarring. Insulting even.

But image this: you’re building a house and you have these beautiful plans. This house typically would cost you $500,000 to build.

You submit the blueprints to the builders and ask them to build this house, but on a $250,000 budget and you are insistent that they try.

What do you think they’re going to do? They’re going to build something that looks like what you’ve asked for on the outside but on the inside they’ve cut corners.

The bones of the house are not structurally sound (a common side effect of prolonged HA is loss of bone density), the plumbing is leaking (frequent urination is a common symptom), there is no air conditioning (poor body temperature regulation/always being cold - another symptom) and lord knows what else is compromised in the house.

What you’re doing when you allow yourself to be insanely busy, under fed and over exercised is that you’re asking your body to do more with less and it just doesn’t work like that.

You’re telling your body to comply with what you want to do and what you want to give it, but your body doesn’t live in our society with these expectations. Only your mind does.

Scientifically what’s happening here is that the hypothalamus, which is the control center of your brain, who is incharge of optimizing bodily functions is realising that there aren't enough resources to do the job of running all of your systems at full power. Now it’s cutting expenses and your reproductive system is one of them.

It’s not that you don’t need your reproductive system, you absolutely do for long term health. Your hypothalamus is shutting down the ovaries by lowering all of your sex hormones and telling them to wait until we’ve got enough resources to start back up again.

Prolonged periods of time with downregulated sex hormones are linked to bone, heart and brain health. Honestly, low estrogen is linked to almost everything so having low estrogen for years is a big problem.

Don’t worry, hypothalamic amenorrhea is entirely reversible and we have the research to show it. Yay!

How to get your period back

1. Eat enough calories
   It’s time to start eating enough food again to fuel your recovery. Now is not the time for a diet. Begin eating enough protein, carbohydrate and fat to support all of your bodies nutrient and caloric needs. Start to enjoy treat foods again that you may have once considered off limits. Eat in abundance and never from a place of scarcity.
   
   

2. Stop or heavily reduce exercise
   Now is also not the time for marathon training, extensive heavy lifting, HIIT (high intensity interval training), CrossFit, F45 or anything that is adding stress to your body.
   
   

3. Restore your bodyweight if you’ve lost a lot of weight
   Having sufficient fat stores are important – even if you think you already do! Sometimes it’s the loss of body fat in general and not what your overall body fat actually is that is the problem. If you’ve lost a few pounds try putting a few back on. This was the case with me. You can learn more about my story here.
   
   

4. Assess your life stressors and consider what you can take off your plate
   You might be expecting too much of yourself. Do you have a job, a school program, a workout regime, a strict diet and a family to be a part of? As much as society has told you that you can and should be all of these things, it’s actually a big, unrealistic ask. Reassess and bring your responsibilities and expectations down where you can.

As you can imagine, restoring your missing period can be a life changing experience. It can alter how you see your body, nutrition, diet culture and society's expectations of you and your health.

The above steps are simple in theory but as I always tell my readers, listeners and viewers, it’s much harder than it seems. Making these changes is psychologically difficult and oftentimes we can’t easily change our behaviours, cross our fingers and dive in.

Need help? My team and I have worked with hundreds of women to help them restore their periods both as a part of our membership program and as 1:1 coaching clients.

*I have to say likely because I’m not your doctor and I cannot diagnose you with a blog post. You should always seek medical advice for health concerns. Please note that many doctors are not trained to identify hypothalamic amenorrhea and have often not heard of it. Don’t let that deter you from researching this further.

Research and Studies:

• Bernstein, Matthew T, et al. Gastrointestinal Symptoms before and during Menses in Healthy Women. 22 Jan. 2014, www.ncbi.nlm.nih.gov/pmc/articles/PMC3901893/.

• Heitkemper, M M, and M Jarrett. “Pattern of Gastrointestinal and Somatic Symptoms across the Menstrual Cycle.” Gastroenterology, U.S. National Library of Medicine, Feb. 1992, www.ncbi.nlm.nih.gov/pubmed/1732122.

• Whitehead, W E, et al. “Evidence for Exacerbation of Irritable Bowel Syndrome during Menses.” Gastroenterology, U.S. National Library of Medicine, June 1990, www.ncbi.nlm.nih.gov/pubmed/2338190.

• Zimmerman, Y et al. “The effect of combined oral contraception on testosterone levels in healthy women: a systematic review and meta-analysis.” Human reproduction update vol. 20,1 (2014): 76-105. doi:10.1093/humupd/dmt038.

• Battaglia, Cesare et al. “Clitoral vascularization and sexual behavior in young patients treated with drospirenone-ethinyl estradiol or contraceptive vaginal ring: a prospective, randomized, pilot study.” The journal of sexual medicine vol. 11,2 (2014): 471-80. doi:10.1111/jsm.12392.

• Sirakov, M, and E Tomova. Akusherstvo i ginekologiia vol. 54,5 (2015): 34-40.

• Mikkelsen, Kathleen et al. “The Effects of Vitamin B in Depression.” Current medicinal chemistry vol. 23,38 (2016): 4317-4337. doi:10.2174/0929867323666160920110810.

• Baker, James M et al. “Estrogen-gut microbiome axis: Physiological and clinical implications.” Maturitas vol. 103 (2017): 45-53. doi:10.1016/j.maturitas.2017.06.025.

• Merz, C Noel Bairey, et al. “Hypoestrogenemia of Hypothalamic Origin and Coronary Artery Disease in Premenopausal Women: a Report from the NHLBI-Sponsored WISE Study.” Journal of the American College of Cardiology, Elsevier, 1 Feb. 2003, www.sciencedirect.com/science/article/pii/S0735109702027638.

• Emma O'Donnell, Jack M. Goodman, Paula J. Harvey, Cardiovascular Consequences of Ovarian Disruption: A Focus on Functional Hypothalamic Amenorrhea in Physically Active Women, The Journal of Clinical Endocrinology & Metabolism, Volume 96, Issue 12, 1 December 2011, Pages 3638–3648, https://doi.org/10.1210/jc.2011-1223.

• Scott, Erin et al. “Estrogen neuroprotection and the critical period hypothesis.” Frontiers in neuroendocrinology vol. 33,1 (2012): 85-104. doi:10.1016/j.yfrne.2011.10.001.

• Khosla, Sundeep et al. “The unitary model for estrogen deficiency and the pathogenesis of osteoporosis: is a revision needed?.” Journal of bone and mineral research : the official journal of the American Society for Bone and Mineral Research vol. 26,3 (2011): 441-51. doi:10.1002/jbmr.262.

• Clarke, Bart L, and Sundeep Khosla. “Female reproductive system and bone.” Archives of biochemistry and biophysics vol. 503,1 (2010): 118-28. doi:10.1016/j.abb.2010.07.006.

• Gibson, J H et al. “Determinants of bone density and prevalence of osteopenia among female runners in their second to seventh decades of age.” Bone vol. 26,6 (2000): 591-8. doi:10.1016/s8756-3282(00)00274-x.

• Karen K. Miller, Ellen E. Lee, Elizabeth A. Lawson, Madhusmita Misra, Jennifer Minihan, Steven K. Grinspoon, Suzanne Gleysteen, Diane Mickley, David Herzog, Anne Klibanski, Determinants of Skeletal Loss and Recovery in Anorexia Nervosa, The Journal of Clinical Endocrinology & Metabolism, Volume 91, Issue 8, 1 August 2006, Pages 2931–2937, https://doi.org/10.1210/jc.2005-2818.

• Misra, Madhusmita et al. “Weight gain and restoration of menses as predictors of bone mineral density change in adolescent girls with anorexia nervosa-1.” The Journal of clinical endocrinology and metabolism vol. 93,4 (2008): 1231-7. doi:10.1210/jc.2007-1434.

• Catherine M. Gordon, Kathryn E. Ackerman, Sarah L. Berga, Jay R. Kaplan, George Mastorakos, Madhusmita Misra, M. Hassan Murad, Nanette F. Santoro, Michelle P. Warren, Functional Hypothalamic Amenorrhea: An Endocrine Society Clinical Practice Guideline, The Journal of Clinical Endocrinology & Metabolism, Volume 102, Issue 5, 1 May 2017, Pages 1413–1439, https://doi.org/10.1210/jc.2017-00131.

• Gordon, Catherine M et al. “Functional Hypothalamic Amenorrhea: An Endocrine Society Clinical Practice Guideline.” The Journal of clinical endocrinology and metabolism vol. 102,5 (2017): 1413-1439. doi:10.1210/jc.2017-00131.

• “Too Much of a Good Thing - Exercise Associated Amenorrhea.” Epigee.org, www.epigee.org/exercise-associated-amenorrhea-late-period.html.

• Black, Ryan. “Endocrine Society Releases Guidelines for Functional Hypothalamic Amenorrhea.” HCP Live, 23 Mar. 2017, www.mdmag.com/conference-coverage/endo-2017/endocrine-society-releases-guidelines-for-functional-hypothalamic-amenorrhea.

•  Rinaldi, Nicola, et al. “A Guide to Diagnosing Hypothalamic Amenorrhea vs. PCOS.” By the Authors of No Period. Now What?, edrdpro.com/wp-content/uploads/2018/01/Diagnosing_PCOS_vs_HA.pdf.

• Gordon, Catherine M et al. “Functional Hypothalamic Amenorrhea: An Endocrine Society Clinical Practice Guideline.” The Journal of clinical endocrinology and metabolism vol. 102,5 (2017): 1413-1439. doi:10.1210/jc.2017-00131.

• Catherine M. Gordon, Kathryn E. Ackerman, Sarah L. Berga, Jay R. Kaplan, George Mastorakos, Madhusmita Misra, M. Hassan Murad, Nanette F. Santoro, Michelle P. Warren, Functional Hypothalamic Amenorrhea: An Endocrine Society Clinical Practice Guideline, The Journal of Clinical Endocrinology & Metabolism, Volume 102, Issue 5, 1 May 2017, Pages 1413–1439, https://doi.org/10.1210/jc.2017-00131.

• Bearden, Caroline Young. “Clinical Nutrition: Functional Hypothalamic Amenorrhea - Today's Dietitian Magazine.” Today's Dietitian, Aug. 2017, www.todaysdietitian.com/newarchives/0817p12.shtml.

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