Hypothalamic Amenorrhea: When You’re too “Heathy” to Get Your Period
What’s hypothalamic amenorrhea? Here’s what it looks like:
You’re the picture of health, a dedicated morning runner or an every-day-after-work Cross Fit enthusiast. You follow the vicissitudes of nutritional consensus on gluten the way some people follow basketball or the primaries. You look great in a tank top—healthy, strong, and slender. But there’s one problem, a problem that the friends and colleagues who admire your healthy lifestyle will never notice: your period has gone missing.
If this sounds like you, you may have hypothalamic amenorrhea, a condition where your period stops due to increased stress that usually comes from a combination of over-exercising and under-eating. It’s estimated that 30 percent of women who lose their periods may be suffering from hypothalamic amenorrhea. Many of them don’t realize they have a problem until they decide they want to get pregnant, stop taking birth control pills … and never get their period.
The good news is that in most cases, women with hypothalamic amenorrhea are able to recover and get pregnant naturally. This post answers all your questions about this condition and tells you how to recover.
What are my chances of getting pregnant when I have hypothalamic amenorrhea?
If you have hypothalamic amenorrhea, you won’t be able to get pregnant until you have made lifestyle changes to recover, or receive fertility treatment. Your doctor may recommend medication to induce ovulation such as Femara or Clomid, but they are more likely to be effective if you’re already actively recovering. If those don’t work, you can try injectables or IVF, but for healthier pregnancy, breastfeeding, and general wellbeing it’s best to remove the lifestyle factors that caused your amenorrhea in the first place.
What is hypothalamic amenorrhea doing to my health?
Fertility aside, hypothalamic amenorrhea is a serious health issue. It’s associated with bone loss, dry hair and skin, digestive issues, exhaustion, poor sleep, decreased sex drive, and increased risk for heart disease. Luckily, studies show that resuming natural cycles can reverse these changes.
What causes hypothalamic amenorrhea?
According to leading hypothalamic amenorrhea researcher Dr. Nicola Rinaldi, a combination of five factors can lead to women developing this condition:
- Exercise: While the amount of exercise among women who develop hypothalamic amenorrhea can vary widely, many women with this condition share a love for high intensity exercise combined with inadequate fueling for activity levels.
- Under-eating: Regardless of how much you weigh or what you look like, eating too few calories for your activity level can be stressful for your body. Women with hypothalamic amenorrhea often restrict calories or food groups and can be preoccupied with eating “clean.”
- Weight and weight loss: We usually associate hypothalamic amenorrhea with women who are very thin, but it is possible to develop this condition at higher weights. However, hypothalamic amenorrhea is more common among women with BMIs around 20 or below. Significant weight loss (10 pounds or more) can be a trigger for hypothalamic amenorrhea—even if ending weight was still “normal.”
- Stress: Physiological stress can be a factor in developing hypothalamic amenorrhea (and exercise can be interpreted by the body as a form of physiological stress). When chronic stress is combined with intense exercise and insufficient calories, it can result in a potent ovulation-suppressing cocktail.
- Genetics: A few recent studies have found that some women may be more susceptible to developing hypothalamic amenorrhea than others.
How is hypothalamic amenorrhea diagnosed?
Hypothalamic amenorrhea is a diagnosis of exclusion, meaning that other possible explanations for your missing periods are ruled out first. If your doctor suspects hypothalamic amenorrhea, they may do the following tests:
- Blood test: Your doctor will want to rule out high prolactin, which can also cause your period to stop. Low levels of luteinizing hormone relative to follicle stimulating hormone are also common among women with hypothalamic amenorrhea.
- Check your weight: While it’s possible to get hypothalamic amenorrhea no matter your BMI, the condition is very common among women who are on the low end of healthy or underweight on the BMI scale.
- Ask about your diet and exercise routine:
What’s the difference between hypothalamic amenorrhea and PCOS?
Many women with hypothalamic amenorrhea are initially diagnosed as having PCOS, since both conditions can cause missing periods. Similarities between the two conditions include:
- Missing periods
- Multiple follicles on ovaries
Due to these similarities, ultrasound may not be sufficient to distinguish between the two conditions. Differences between the two conditions include:
|Luteinizing hormone||Low to normal, and lower than FSH levels||Normal to high, and higher than FSH levels|
|Estradiol||Low to normal||Normal to high|
|Total testosterone||Low to normal||Normal to high|
|Free testosterone||Low to normal||Normal to high|
|Free androgen index||Low to normal||Normal to high|
|DHEAS||Low to normal||Normal to high|
When a woman has any of the following characteristics, hypothalamic amenorrhea should be ruled out before a diagnosis of PCOS is made:
- Low BMI or weight loss of 10 pounds or more
- Stress fracture or low bone density
- Restrictive eating habits
- Regular exercise
- Chronic or acute stress
For more information about the difference between hypothalamic amenorrhea and PCOS, visit Dr. Nicola Rinadli’s website.
What’s happening in my body when I have hypothalamic amenorrhea?
Your hypothalamus is the part of your brain that regulates sleep, hunger, body temperature, and your menstrual cycle. It releases gonadotropin-releasing hormone (GnRH), which stimulates the release of luteinizing hormone (LH) and follicle-stimulating hormone (FSH)—both hormones essential in the ovulation process. In a woman with hypothalamic amenorrhea, the hypothalamus doesn’t release as much GnRH. As a result, there isn’t enough LH or FSH for ovulation to occur.
How do I recover from hypothalamic amenorrhea?
The most important factors for most women in recovering from hypothalamic amenorrhea are:
- Eat. The best diet for recovery is one that has plenty of calories and does not restrict any food groups. Many women with hypothalamic amenorrhea find that they need to eat a bare minimum of 2500 calories per day—some may need more.
- Rest. It’s best to cut out all forms of intense exercise, including running, cross fit, and weight lifting. Instead, focus on more gentle activities like walking and yoga.
- Reduce stress. Focus on stress reduction and activities like yoga and meditation. If you are accustomed to using intense exercise as your primary method of stress reduction, it will be crucial to focus on finding other ways to reduce stress during recovery.
- Be patient. Median time to recovery for women with hypothalamic amenorrhea is about six months after lifestyle changes were initiated.
Your recovery will depend on what lifestyle factors caused you to lose your period in the first place. If you lost a lot of weight, you will need to eat more. If you over-exercised, you may be able to cut back on exercise without changing your diet very much. If you were chronically stressed, you should focus on finding healthy coping techniques like meditation and yoga.
For many women, recovery from hypothalamic amenorrhea requires addressing each of these areas: weight, exercise, and stress. The absence of your period is a sign that your lifestyle is causing your body stress, even if you don’t feel like you’re stressed. Examine your lifestyle, especially the changes you’ve made since losing your period, and think about how to reduce stress.
How much exercise can I do while I’m trying to get my period back?
As little as you can stand. The fastest way to recover from hypothalamic amenorrhea is to immediately cut out all intense exercise.
Most women who get hypothalamic amenorrhea find it very difficult to cut back their exercise so drastically, and try to increase their calories while keeping their exercise levels the same or only moderately reduced. But exercise itself, regardless of eating habits, has multiple cycle-suppressing effects. Opioids—the mood-boosting chemicals created by exercise—inhibit the secretion of GnRH, an important reproductive hormone. Excessive exercise also suppresses leptin, which stimulates the release of GnRH. Finally, exercise increases cortisol secretion—a sign of physiological stress.
If you’re having trouble reducing your exercise, remember that it’s only temporary. Many women who recover from hypothalamic amenorrhea are able to return to their former exercise routines without losing their cycles again. But it’s very difficult to regain your cycles while exercising intensely.
Even a greatly reduced exercise routine can still be too much for your cycles to return. If you’ve reduced your exercise, increased your calories, and you’re still not getting your period after several months, try limiting yourself to only walking (gentle strolls, not frenzies uphill marches) and yoga (relaxing yoga, not Bikram).
How much should I eat to regain my cycles?
When you’re recovering from hypothalamic amenorrhea, all food is good food. What your body needs to recover is calories, and it really doesn’t matter much whether those calories come from kale and quinoa or from donuts and chocolate. In fact, you’re probably better off with the donuts than the kale, since eating high fiber, low calorie foods can make you feel full before you’re able to consume enough calories. (Try consuming 500 calories worth of broccoli. It won’t feel—or smell—very good!)
There are a few foods that are helpful to emphasize:
- Full fat dairy: Recent studies have suggested that women who eat at least once serving of full fat dairy per day are less likely to have ovulatory disorders than those who consume low- or nonfat dairy products. Estrogen dissolves in fat and therefore is present in full fat dairy.
- Simple carbs: You may be accustomed to avoiding sugar, white bread, and pasta, but these and other high glycemic index foods can be especially helpful in recovering your period. High concentrations of glucose in the body cause your GnRH nerve cells to fire at a faster rate, which leads to an increased production of FSH and LH—and more growing eggs!
Weight bearing exercise is good for bone mass. Does this offset the bone loss caused by hypothalamic amenorrhea?
Unfortunately, no. The beneficial effects of weight bearing exercise on bone are not sufficient to prevent the adverse effects of estrogen deficiency.
How much weight will I have to gain?
In studies that track women who recovered from hypothalamic amenorrhea, the weight gain tends to bring them to a BMI of 22-23. But everyone is different. How much did you weigh when you first got your period? How much weight did you lose before losing it?
If you’re an over-exerciser and not really a restrictive eater, you may be able to get your period back simply by cutting back on exercise and not gaining much weight. One study found that injured dancers regained their periods when they couldn’t exercise, even though their body weight did not change.
Should I go on the pill while I’m recovering from hypothalamic amenorrhea?
If you’re trying to get pregnant right away, oral contraceptives are obviously not an option.
But for women who aren’t trying to conceive immediately, some doctors prescribe birth control pills. The thinking is that hypothalamic amenorrhea means that you have low levels of the hormones that protect against bone loss, and birth control pills can help offset this. However, the increase in bone mineral density that typically accompanies the return of natural cycles is significantly greater than can be achieved by treatment with birth control pills or other estrogen treatment. In other words, birth control pills won’t help as much as lifestyle changes, and they may mask the underlying problem.
For the bible on hypothalamic amenorrhea recovery and pregnancy, check out No Period Now What.