How To Get Your Period Back with Hypothalamic Amenorrhea
December 1, 2021
Whilst the idea of not getting your period can be quite appealing, it may be a sign that something is not quite right. The menstrual cycle provides key insight into the body’s hormonal balance and its absence it can be a cue that the body is under excessive stress and needs to conserve energy to protect itself. This is a common indication of Hypothalamic Amenorrhoea.
What Is Functional Hypothalamic Amenorrhea?
When a person loses their period outside of menopause, the effects of contraception or another diagnosed condition, it may be due to functional hypothalamic amenorrhea (FHA).
FHA specifically occurs when the body is under a lot of stress such as;
- In times of immense psychological or emotional stress,
- Lack of sleep
and/or when energy intake is very low such as in;
- Disordered eating
- Eating disorders
- Aggressive dieting
- High levels of physical activity paired with consistent under-fuelling
In these circumstances, our bodies may down regulate our reproductive system as a way to conserve energy for more important bodily processes like keeping our primary organs working (1).
The mechanism of FHA is due to suppression of gonadotropin releasing hormone (GnRH) in the hypothalamus. Which has a cascading effect on several other hormones including a reduction in oestrogen.
This then results in a lack of endometrial thickening leading to the loss of a menstrual cycle (1).
What If I Have Recently Come Off Birth Control?
For most people who had a healthy and regular menstrual cycle prior to birth control, periods should return to normal not long after they stop using hormonal contraception.
However, if birth control was prescribed to regulate an already irregular or absent period, it is unlikely to have fixed the problem.
While the use of estrogen replacement in the form of birth control will provide a withdrawal bleed, it is not intended to support the resumption of normal menstrual cycle.
Using birth control in this way is simply a band aid solution for a more complicated problem.
Other dietary or lifestyle interventions should occur to solve the root cause of why your period has stopped in the first place.
Why Is Your Period Important?
A loss of one’s period can have significant affect’s on fertility. FHA does reduce fertility and is often not addressed until a person is wanting to become pregnant.
However, even if you have no plans of getting pregnant now or in the future, the hormonal imbalances associated with FHA have negative impacts beyond reduced fertility.
FHA is linked to an increased risk of:
- poor bone health
- heart disease
- low libido
- vaginal dryness
- impacts on mental health (1).
Hypothalamic Amenorrhea & Bone Health
Similar to what is seen in menopause, the reduction in estrogen levels seen in FHA can lead to premature bone thinning (2).
Lower estrogen levels actually reduce calcium absorption in the intestinal tract. With lower calcium bioavailability, calcium may be taken from the bones for more vital functions such as keeping the heart pumping.
Over time this leads to degradation of the bones and may result in osteopenia and/or osteoporosis.
It is estimated the mean bone mineral density of a young woman with ONLY six months of hypoestrogenemia seen in FHA is equivalent to that of a woman 51 years of age (3).
Women with FHA have also been found to have higher cortisol levels. Cortisol also results in reduced intestinal absorption of calcium. Additionally, cortisol is associated with an imbalance in vitamin D absorption, further impacting bone health (1).
Hypothalamic Amenorrhea & Cardiovascular Disease
One of the lesser known functions of estrogen is its role as a potent vasodilator.
While there is not much known about the cardiovascular impact of low estrogen levels, some research suggests that low oestrogen levels at a young age may increase long term risk of heart disease.
Research from the Nurses’ Health Study of over 82,000 women that self-reported menstrual cycle history demonstrated that the more irregular the menstrual cycle in young women the greater the risk for future cardiovascular events (4).
This was up to a 50% increase in risk.
Nonetheless, menstrual cycle irregularities have also been linked to early onset menopause. Those who undergo menopause under the age of 45, have a two and a half fold increased risk of heart disease compared to age-matched premenopausal women (1).
Hypothalamic Amenorrhea & Mental Health
Psychological and emotional stress can be a risk factor for developing FHA. However, it can also be a symptom of FHA.
The relationship between mental health and loss of the menstrual cycle is bidirectional. So it can occur in both directions, even at the same time (1).
People with FHA have significantly higher depression scores, greater anxiety, and increased difficulty coping with daily stress (5).
This is likely due to higher cortisol levels (the stress hormone) associated with FHA.
How Do I Get My Period Back With Hypothalamic Amenorrhea?
Get a proper diagnosis
The process of diagnosing FHA is done looking at an array of blood markers (mostly hormonal) as well as a process of elimination.
So it is important that you get an individual assessment with a medical professional before embarking on your journey to restore your period.
FHA is reversible by addressing the root causes of why it is occurring.
However, if your period is irregular or absent for another reason, these strategies may not be helpful. Restoring your menstrual cycle is about focusing on the factors that may be influencing it to be absent.
2. Increase your calorie intake
For many people, FHA occurs due to a large discrepancy in energy intake and energy expenditure. Meaning they are eating too few calories for how many calories their body is burning on a daily basis.
For example, it is very common amongst people with eating disorders, those who are dieting aggressively and athletes who consistently under fuel.
The REFUEL study found that an increase of just 300-360 calories per day is enough for many people with FHA to resume their period. To put that into a food context, that is a handful of nuts and a piece of fruit worth of food (6).
If you are unsure how to ramp up the calories or have concerns about doing so, it is likely best to speak with a dietitian to get you on the right track.
It is important to note that you do not have to be a low body weight to experience FHA from very low calorie intake.
Whilst a low body weight can be a factor in FHA, low energy availability alone can be enough to send the body into “battery saver mode” and stop the menstrual cycle.
3. Increase Fat In Your Diet
Very low fat diets can also be a cause of FHA. Fats play an important role in hormone production. When fat intake is very low, hormone production is interrupted.
Iff you are eating enough calories, also aim for a diet containing at least 0.6g of fat per kilo body weight and focus on getting in some omega-3 rich foods.
Aim to include a wide variety of foods rich in healthy fats including nuts, seeds, avocado and plant based oils.
If you eat fish, you can also include oily fish such as salmon and sardines which are rich sources of omega-3.
If you are vegan you can opt for flaxseed, chia seeds and walnuts as a source of omega 3 or you may choose to take a marine-algae based omega-3 supplement.
4. Increase Your Body Weight
A low body weight may also result in the down regulation of the reproductive system (7).
A great example of this is in bodybuilding or bikini competitors. It is very common for stage lean athletes to lose their periods.
Although, this is likely also due to the fact they are on very low calories for extended periods of time. Every person is different with how much body fat they naturally carry and what their body is comfortable with.
But if you start to increase your calories to a reasonable level and you gain some body fat, you may have been below your personal threshold. Increasing body fat does not always have to be part of the process of regaining your period, but if you are currently underweight or have a very low body fat percentage, it may be an integral piece to the puzzle.
5. Reduce Exercise
Stress on the body can come in many forms including over-exercising.
If you are building up stress from exercise without allowing for proper recovery, this can not only lead to injury but loss of the menstrual cycle as well. How much exercise is too much exercise is completely individual.
Elite athletes who have spent years building up their tolerance to exercise may be able to train 9-5, 6 days a week. But that does not mean, someone who has just started their journey with exercise would be able to do the same without accumulating fatigue to the point of injury and illness.
If you are over-exercising and not allowing sufficient recovery, your body is going to give you many warning signs.
- Prone to injury
- Be getting sick often
- Experiencing high amounts of muscular pain
- Experiencing chronic fatigue
- Irritable with low moods
- Experiencing a reduction in performance
If you feel you may be over-exercising you can either reduce the intensity of your training, reduce the time spent training or even take a break from exercise altogether.
S tress outside of training and exercise can also lead to an over-accumulation of fatigue.
To the body, stress is stress. Whether that stress is occurring inside or outside of the gym. If you are going through personal or professional stress, you may need to pull back on your exercise or training for the time being even if you were able to handle that training load previously.
6. Focus On Stress Management
As previously mentioned, stress is stress. Whether it is over-exercising or the grief from a loved one passing away. The body will respond in the same way despite that stress feeling very different to us.
FHA can result from psychological and emotional stress. Due to this link, cognitive behavioral therapy (CBT) has been found to be an effective treatment option for many people with FHA.
In one study, women who had FHA that received 16 sessions of CBT had 75% higher rate of resuming their period than those who did not receive the sessions (8).
Functional hypothalamic amenorrhea is a warning sign that the body is under too much stress. Whether that stress is in the form of undereating, over exercising or emotional/psychological stress, FHA is a part of the body’s battery saver mode.
In the human body’s hierarchy of functions that are essential for life, the reproductive cycle is not one. So to conserve energy for more important things, the hypothalamus will shut down the reproductive hormonal cascade resulting in the loss of the menstrual cycle.
This can result in issues with fertility and an increased risk of heart disease and poor bone health later in life. It can also negatively impact mood regulation and mental health.
If you do lose your menstrual cycle due to FHA it is important to address the contributing factors leading to this condition. Which may include gaining weight, increasing caloric intake, increasing fat intake and focus on reducing stress.
Exactly how FHA treatment should be approached is going to be slightly different for every individual so it may be best to talk to your doctor or see a dietitian.
This article was written by Plant Nutrition and Wellness’s resident plant based sports dietitian and nutritionist Leah Higl. If you need help with improving your relationship with food, meeting your nutrient needs or optimising your nutritional needs, book in a consultation with the dietitians at Plant Nutrition and Wellness.
- Hypothalamic Amenorrhea and the Long-Term Health Consequences: Research Review
- Hypoestrogenism in young women and its influence on bone mass density
- Bone mineral content of amenorrheic and eumenorrheic athletes
- Menstrual cycle irregularity and risk for future cardiovascular disease
- Psychological correlates of functional hypothalamic amenorrhea
- The REFUEL Study
- Body mass index, body fat mass and the occurrence of amenorrhea in ballet dancers
- Recovery of ovarian activity in women with functional hypothalamic amenorrhea who were treated with cognitive behavior therapy