Hypothalamic Amenorrhea: Information & Recovery Tips

This article was written by Associate Registered Nutritionist (ANutr) Sophie Gastman, and reviewed by Registered Dietitian Maeve Hanan.

What is Hypothalamic Amenorrhea?

Not having a period is called amenorrhea. There are two types of amenorrhea. Primary amenorrhea, which is the absence of a period altogether by the age of 16, and secondary amenorrhea, which is the absence of 3 or more periods in a row after previously having periods.  

Secondary amenorrhea can be normal, e.g. in pregnancy or menopause.

But hypothalamic amenorrhea (HA) is something that should be addressed. HA occurs due to stress related to weight loss, excessive exercise and/or psychological stress.

When the hypothalamus in the brain perceives stress, it loses control of signalling and stops producing enough hormones to maintain a regular menstrual cycle (1). This causes an oestrogen deficiency which has serious consequences that many young girls and women are unaware of (2). 

While we may associate this problem with elite female athletes, HA can also be caused by psychological stress and disordered eating, or a combination of the two, making it a fairly common occurrence in today’s normalised high stress society.

In fact, it is estimated that approximately 17.4 million women worldwide between the ages of 18 and 44 are affected by HA (3). 

This article will go over the three main causes and consequences of HA in greater detail, as well as provide recovery tips and information on how to work towards regaining your period.. 

Note: periods can stop due to other conditions such as PCOS so it is advisable to speak to your GP if you have noticed this.

What Causes Hypothalamic Amenorrhea? 

Energy Deficit 

If you don’t eat enough, the hormones needed for ovulation, luteinizing hormone (LH) and follicle-stimulating hormone (FSH)  will stop being produced (4).

Essentially, your body enters a state of ‘fight or flight’ in response to the stress of not having enough food and will prioritise basic functions to keep you alive above nonessential ones, like menstruation (5). 

Not eating enough can be unintentional due to a lack of awareness or it can be related to disordered eating.

According to one study, 48.8% of women with HA reported eating disorder behaviours and scored significantly higher in behaviours associated with dieting, bulimia, and food preoccupation when compared to a healthy control group (6). 

Exercise

Exercise is constantly touted as a great form of ‘stress-relief’, and there’s no denying that it’s good for us, but it can also be a form of stress to the body, especially if we’re doing too much or taking it too intensely.

The amount of exercise that’s considered ‘too much’ will vary from person to person, but doing more than our bodies can handle will also limit the secretion of reproductive hormones that keep your period going (7). 

Secondary amenorrhoea occurs in up to 44% of women who exercise vigorously but, this is most likely due to a combination of low energy availability, low body weight and over exercising (8).

Stress

As previously stated, not eating enough and exercising excessively will both stress the body, but we are also prone to experiencing stress as part of our daily lives, such as at work, in our personal lives, and so on.

When we are stressed, our bodies react by triggering a complex biological response involving the nervous, endocrine, and immune systems. The hypothalamic-pituitary-adrenal (HPA) axis and the sympathetic nervous system are involved, which when activated release hormones such as adrenaline and cortisol. These hormones are known to interfere with our reproductive system and hormones related to menstruation (9).

Also, as touched on before, the ability to have a baby is not essential for survival and requires lots of energy, so it stands to reason that it is suppressed by stress.

Because stress is so common in our society and way of life, some people may be unaware of the stress they are experiencing, dismissing it as the “norm,” and may be unaware of the impact it is having on their bodies. Modern life exposes us to these stressors on a regular basis, constantly evoking a ‘fight or flight response’.

Whilst this may have served us well in the past as a survival mechanism, unfortunately our bodies can’t tell the difference between being chased by a predator and doing a high-intensity workout. 

Consequences of Hypothalamic Amenorrhea

The idea of not having a period may seem idyllic because we all know how inconvenient they can be, but if you aren’t pregnant or postmenopausal and you aren’t getting a period, it’s your body’s way of telling you that something isn’t working properly and can lead to serious consequences if not addressed. 

Sometimes it can be difficult to know if you have a regular period — for example if you use forms of hormonal contraception that suppress your period. It’s important to be aware that if you use a contraceptive pill where bleeding occurs during the ‘break week’ off the pill, this is a withdrawal bleed which isn’t the same as a natural period. In fact a withdrawal bleed can mask a missing period due to HA.  

Some risks that have been linked to the absence of a period are: 

• Higher cardiovascular disease (CVD) risk – low levels of oestrogen, like those seen in women with HA are associated with increased CVD risk (10). 
• Decreased bone density – oestrogen deficiency as a result of HA can also negatively affect peak bone mass and increase risk of osteoporosis or osteopenia (11). 
• Increased depression and anxiety – even though stress can be a cause of HA, HA can in turn cause a lot of stress for the individual. According to one study, women with HA had significantly higher levels of depression and anxiety than the healthy controls (12). 
• Infertility – HA occurs during peak reproductive years and, if left untreated for an extended period of time, can have an impact on reproductive health. Without enough oestrogen, the ovary cannot release an egg for fertilisation, making a natural pregnancy extremely difficult (13). 

Tips for Recovery and Regaining Your Period 

Whilst the consequences of HA can be quite serious, the good news is that it’s reversible!

One long-term study found that over 70% of women affected by HA had recovered (14). 

Diet 

Gaining weight or eating more can feel really daunting, but if you aren’t having a period because of HA, your body is telling you that you need more food.

Recovery from HA requires prioritising meeting energy needs from all macronutrient groups, including carbohydrates and fats.

Carbohydrates are essential for making sure your body has enough energy available to support hormone balance, and to fuel daily function and exercise. You can read more about the impact of carbohydrates on female hormones here.

A sufficient amount of fat in the diet is also required to support hormones and overall health.  

Fasting in general, and especially fasted training, should be avoided, as well as going long periods without food as this puts stress on the body and reduced energy availability for the reproductive system.

Eating more during your recovery might look like: 

• Incorporating more snacks into your diet, e.g. introducing an evening snack before bad
• Eating more frequent, smaller meals throughout the day 
• Eating less frequently throughout the day and prioritising full, balanced meals if snacking fills you up 
• Fuelling properly before and after exercise
• Not skipping breakfast 
• Eating more calorie dense foods, such as nut butters, full fat dairy and starchy vegetables and avoid filling up on low-calorie veg 

If eating more than you’re used to feels particularly difficult then it’s important to seek help from a registered dietitian to support you and help you change your attitude towards food. 

Exercise 

Reducing or cutting out intense exercise completely is key in HA recovery.

If the idea of cutting out all intense exercise seems impossible for you, try lower intensity activity or include more gentle movement into your day. 

Examples of lower intensity forms of movement include: 

• Stretching 
• Going for gentle walks 
• Low intensity yoga
• Doing housework 
• Dancing 

Although, if you are going to do light activity on a daily basis, it’s really important that you are eating enough to balance it out. 

It’s also perfectly ok if you don’t feel like exercising at all and want to prioritise rest and recovery. It’s far better to take a complete break period than accidentally overdo it and prolong the recovery process. You can also seek individual advice form an exercise professional who has experience with HA.

Stress 

Stress is nearly impossible to avoid altogether, but learning how to manage it is so important. 

Here are some tips for stress management: 

• Develop healthier coping strategies for stress – this could be journaling, meditation, talking to friends, being in nature etc. Whatever it looks like for you, if you can engage in these behaviours when you’re stressed, you’ll be less likely to engage in harmful ones like restrictive eating or over-exercising.
• Prioritise sleep –   getting enough sleep allows your body to rest and repair itself.
• Have a support system – surround yourself with people you can trust and confide in or ask for help to stay on track when needed. Talking things out with a close friend or family member can sometimes be all you need to release those feelings of stress 

Click here to read more about stress and tips for stress management. 

Conclusion

HA is a result of too much stress on the body, whether that be in the form of undereating, overexercising, psychological stress or all of the above.

These stressors disrupt the signalling and hormone needed for menstruation, resulting in the loss of a period.

Working on your relationship with food, exercise and stress can help to balance your hormones and allow your body to function normally.

If you are looking for support with HA, an Eating Disorder or Disordered Eating, you can find out about our support services here.

References 

1. Marcus, M.D., Loucks, T.L. and Berga, S.L. (2001) “Psychological correlates of functional hypothalamic amenorrhea,” Fertility and Sterility, 76(2), pp. 310–316. Available at: https://doi.org/10.1016/s0015-0282(01)01921-5. 
2. Torbati, T., Dutra, E. and Shufelt, C. (2017) “Hypothalamic amenorrhea and the long-term health consequences,” Seminars in Reproductive Medicine, 35(03), pp. 256–262. Available at: https://doi.org/10.1055/s-0037-1603581. 
3. Pettersson F, Fries H and Nillius SJ. Epidemiology of secondary amenorrhea: I. Incidence and prevalence rates. American journal of obstetrics and gynecology. 1973;117:80–86.
4. Martin, B. et al. (2008) “Caloric restriction: Impact upon pituitary function and reproduction,” Ageing Research Reviews, 7(3), pp. 209–224. Available at: https://doi.org/10.1016/j.arr.2008.01.002. 
5. Wade, G.N., Schneider, J.E. and Li, H.Y. (1996) “Control of fertility by metabolic cues,” American Journal of Physiology-Endocrinology and Metabolism, 270(1). Available at: https://doi.org/10.1152/ajpendo.1996.270.1.e1. 
6. Tranoulis, A. et al. (2020) “Adolescents and young women with functional hypothalamic amenorrhoea: Is it time to move beyond the hormonal profile?,” Archives of Gynecology and Obstetrics, 301(4), pp. 1095–1101. Available at: https://doi.org/10.1007/s00404-020-05499-1. 
7. Ahrens, K.A. et al. (2014) “The effect of physical activity across the menstrual cycle on reproductive function,” Annals of Epidemiology, 24(2), pp. 127–134. Available at: https://doi.org/10.1016/j.annepidem.2013.11.002. 
8. Speed, C. (2007) “Exercise and menstrual function,” BMJ, 334(7586), pp. 164–165. Available at: https://doi.org/10.1136/bmj.39043.625498.80. 
9. Meczekalski, B. et al. (2022) “Stress, kisspeptin, and functional hypothalamic amenorrhea,” Current Opinion in Pharmacology, 67, p. 102288. Available at: https://doi.org/10.1016/j.coph.2022.102288.
10. ​​O’Donnell, E., Goodman, J.M. and Harvey, P.J. (2011) “Cardiovascular consequences of ovarian disruption: A focus on functional hypothalamic amenorrhea in physically active women,” The Journal of Clinical Endocrinology & Metabolism, 96(12), pp. 3638–3648. Available at: https://doi.org/10.1210/jc.2011-1223. 
11. Gordon, C.M. and Nelson, L.M. (2003) “Amenorrhea and Bone Health in adolescents and Young Women,” Current Opinion in Obstetrics and Gynecology, 15(5), pp. 377–384. Available at: https://doi.org/10.1097/00001703-200310000-00005. 
12. Marcus, M.D., Loucks, T.L. and Berga, S.L. (2001) “Psychological correlates of functional hypothalamic amenorrhea,” Fertility and Sterility, 76(2), pp. 310–316. Available at: https://doi.org/10.1016/s0015-0282(01)01921-5. 
13. Torbati, T., Dutra, E. and Shufelt, C. (2017) “Hypothalamic amenorrhea and the long-term health consequences,” Seminars in Reproductive Medicine, 35(03), pp. 256–262. Available at: https://doi.org/10.1055/s-0037-1603581. 
14. Falsetti, L. et al. (2002) “Long-term follow-up of functional hypothalamic amenorrhea and prognostic factors,” The Journal of Clinical Endocrinology & Metabolism, 87(2), pp. 500–505. Available at: https://doi.org/10.1210/jcem.87.2.8195.