Hypothalamic Amenorrhea Recovery

Have you lost your period? 

One of the reasons that this can occur is due to hypothalamic amenorrhea and it’s an area I specialise in.

Hypothalamic amenorrhea (often shortened to just HA) is a long sounding name, but let me explain a little about what it is, what are some of the causes, how it’s diagnosed, what are the consequences (because this is about more than not menstruating) and how you can regain your period again.   

What Is Hypothalamic Amenorrhea?

To best understand what hypothalamic amenorrhea is, let’s break down what the words mean. 

Hypothalamic refers to a part of the brain called the hypothalamus (something I’ve written about here). The hypothalamus is a tiny region of the brain that is a powerhouse despite its size; it’s often referred to as the master controller and it oversees the release of many different hormones in the body.

The word amenorrhea means the absence of menstruation or getting your period.

So, when we put this together, this describes the absence of menstruation that is being caused or directed by the hypothalamus.

What Causes Hypothalamic Amenorrhea?

There are several factors that can contribute to the cause of hypothalamic amenorrhea.

The first of these is energy debt or being in a low energy state. 

The food that you eat is converted into energy and this energy is then used to run all of your various systems.  

When your body is getting everything it needs, it can give enough energy to all your systems and things run smoothly (or as smoothly as a fallible human body can run).

But when your body is getting less than what it needs, it has to decide how to allocate these limited resources. Triage theory is one explanation for how it does this – it looks at what functions are paramount to survival and which functions are less important.

Reproduction is rather low down on the list of priorities from the perspective of your survival. So when there is not enough energy coming in, it can be one of the systems to receive fewer resources than it would ideally need. And with this change, your period can cease.

Now, there can be many routes to getting into a low energy state because it isn’t just about taking in less energy, it can also be about using up large amounts of energy, often through movement or exercise.

This is something I go into detail about in this podcast, but some of the drivers and/or indicators for a low energy state are:

• RED-S (Relative Energy Deficiency in Sport)
• An eating disorder, like anorexia, orthorexia or avoidant/restrictive food intake disorder (ARFID)
• Under eating calories
• Under eating specific macronutrients (carbohydrates, protein and fat)
• Over exercise (which can occur, even if you don’t think you’re exercising that much)
• Low body weight
• Weight loss (irrespective of where your weight might be on the BMI scale, losing weight can lead to a low energy state and HA)

What is most common with the clients that I see is a combination of the above. Over a period of months or years exercise has increased, total calorie intake has decreased, specific macronutrients (like carbs or fat) have been reduced or specific foods like bread, pasta, butter or oil have been removed or heavily reduced.

These changes have led to a decrease in weight over this time and subsequently periods have ceased. (This progression is something I detail in this article.)  

The Pill Can Hide Hypothalamic Amenorrhea 

For many clients, the discovery that their period has stopped occurs well after the fact and this is because these clients were taking the oral contraceptive pill.

The pill works by providing your body with hormones that prevent the ovaries from releasing an egg. These hormones also help the body to produce the lining of the womb.

There are different types of pills. Some you take for 21 days, then have a 7-day break. Others you take for 28 days, but the last 7 days are dummy pills and don’t contain any hormones.

In both cases, it is during these last 7 days, that the hormone levels drop because you are no longer ingesting them. And this change leads to the body shedding the lining of the womb. This will lead to a bleed that is similar to a period, but it is being controlled and dictated by the pill. So, it is more accurate to refer to this as a pill bleed rather than a period.

For many clients, during the time they were taking the pill is when they made changes that affected their energy balance. This decrease hit a tipping point, where the body no longer had enough coming in for it to prioritise reproduction. But the pill masked this shift because the hormones it received each month created a pill bleed. 

So, it was only after coming off the pill and when periods didn’t recommence that there is the awareness that this shift has happened. 

Anovulatory Cycles

Another factor that can make understanding when problems began to arise is anovulatory cycles. 

An anovulatory cycle is when you have a period but no ovulation occurred. Your body is producing enough reproductive hormones that allow some build-up of the uterine lining, but not enough hormones to trigger ovulation.

At some point in the formation of HA, these hormones decrease even further, to the point that periods cease altogether. But for many people, before the complete cessation, there has been an amount of time (months or even years) where ovulation had stopped (or was intermittent) but they were unaware because they were still getting a period. 

[Note: If you want to understand more about the physiology of reproduction, with the different organs and hormones involved, I go through it in this episode]

Psychological Stress And Cognitive Dietary Restraint

So far I’ve focused on energy debt or a low energy state being the driver behind hypothalamic amenorrhea but there are other factors. 

Psychological stress can also be a driver. This can include things like a stressful job, divorce, the death and grief of losing someone you love. But it doesn’t necessarily have to be big events of this nature and stress can also work by having a cumulative effect, with lots of small stresses building up.

Psychological stress can be powerful enough to stop reproduction all by itself, even without any drop in energy intake.

Sometimes psychological stress is connected to the desire to lose weight. In this podcast, I talk about cognitive dietary restraint, which is the perceived ongoing effort to limit dietary intake to manage body weight.

What’s key to understand is that cognitive dietary restraint is about the mental process, not what does or doesn’t happen with actual restricting. Someone could be following a strict diet and be experiencing cognitive dietary restraint.

Or they could be wanting to follow a strict diet and failing, but they are still thinking about their weight and wishing they could follow the plan, and this is also cognitive dietary restraint.

In both instances, there is a mental and cognitive load that occurs with this constant thinking and ruminating, and this is a form of psychological stress. And as covered in this podcast, this can affect reproduction.

Genetics

Another factor is genetics. For some people, they can enter into a lower energy state or have much higher amounts of psychological stress and their body will still continue to prioritise reproduction so that periods don’t stop.

For others, they are much more susceptible and even a minor downturn in the amount of energy coming in or a small increase in stress means that reproduction is deprioritised and periods stop. 

Where someone falls on this continuum is at least in some part dictated by genetics.

Other factors that can be connected and can play a role are alcohol intake, insufficient sleep and shift work (I go into these in more detail here). At least for the clients I see, these factors usually have a small impact and the driver is something else.

Or these factors are symptoms of the main driver; for example, someone is over-exercising and under-eating putting them in a low energy state which means they are unable to fall asleep or stay asleep. 

How Is HA Diagnosed?

There can be many reasons why periods can cease and hypothalamic amenorrhea is just one of them. This means a diagnosis of HA is made only after other potential causes are ruled out (the medical term for this is a diagnosis of exclusion). So it’s necessary to get this diagnosis from your doctor. 

Some of the other causes that can create amenorrhea:

• Pregnancy
• Pituitary tumour
• Chromosomal abnormalities
• Asherman’s syndrome (the bonding of scar tissue that lines the walls of the uterus, preventing bleeding)
• Many autoimmune conditions (like Cushing’s syndrome, lymphocytic hypophysitis, oophoritis or thyroid issues, to name a few)
• Thyroid conditions
• Polycystic ovarian syndrome (PCOS)
• Hyperprolactinemia (high prolactin levels)
• Ovarian failure
• Certain medications

Hormone levels are also something that is used as part of the diagnostic process. For hypothalamic amenorrhea the hormones patterns that are most usually seen are:

• Low to low normal Luteinising Hormone (LH)
• Low to normal Follicle Stimulating Hormone (FSH)
• Low to low normal oestradiol (E1)

Low LH is the most common of the hormones to predict HA, although it can still occur with normal LH levels.

In conjunction with the blood test results, it’s also likely there will also be a thin uterine lining (less than 4mm) and ovaries that appear polycystic. This means a diagnosis of hypothalamic amenorrhea is given after a combination of blood tests, ultrasound and taking a case history.

Consequences of Hypothalamic Amenorrhea

If you don’t understand the seriousness of HA, it can be rather easy to justify that it doesn’t matter that you’re not getting your period. Especially if you aren’t currently wanting kids, it may even seem like a benefit to not have to deal with a period each month.

But getting a period is only one small part of this and while it’s probably the most obvious signal of where your body is at, many other issues can be occurring that are not so obvious.

Via BMJ: https://bjsm.bmj.com/content/48/7/491

As I go through in detail in this article and this podcast episode (and you can see in the image above), when the body is in an energy deficient state, this can have an impact on many of the body systems apart from just reproduction. These include:

Bone health – it’s common to see clients in their 20s and 30s who are suffering from osteopenia or osteoporosis, which indicates bones that are less dense and more fragile. Weaker bones increase the chance and occurrence of injury and fracture. Something I cover in more detail here. 

Endocrine (hormones) – it’s not just reproductive hormones that are affected, but all hormones, particularly those modulated by the hypothalamus (as I go through in this article). This includes hormones connected to stress, blood sugar, thyroid function, blood pressure, growth and repair, memory and social behaviours.   

Metabolic – this is the cell’s ability to turn the food you eat into energy. In a low energy state, this is severely impaired, meaning you start getting even less energy from the food consumed, further impacting all systems of the body. 

Haematological (blood) – the blood is the body’s way of transporting oxygen and nutrients to the lungs and tissue, forming clots to prevent excessive blood loss and carrying cells and antibodies as part of the immune system. Probably the most common way that this shows up as an issue in energy deficiency is the development of anaemia.

Cardiovascular – one system that is closely related to blood is the cardiovascular system. It can be impacted because of the quality of the blood that is available. It can also be impacted by directly compromising the organs and circulatory apparatus of the cardiovascular system – heart, arteries, veins, and capillaries.

Growth and development – the body should be in a constant state of anabolism and catabolism; breaking down old cells and replacing them with new ones. When energy levels are low, this rebuilding process is diminished, leading to less turnover and repair. 

Psychological – our brain is an organ and it too can be impacted by not enough energy. This low energy can either directly affect the brain, in terms of shrinking it (as covered here) or making conditions like Alzheimer’s more likely. But our psychology can also be impacted by the state of our hormones and our nervous system. This can lead to wide-ranging changes in personality, thoughts, beliefs and feelings, particularly in connection to food, exercise and one’s body (as detailed here).

Gastrointestinal – being in a low energy state can affect the organs of the digestive system as well as how the digestive system functions. Digestive issues are incredibly common in clients I see and unfortunately it can be the digestive issues that in part mean these clients have removed more and more foods in an attempt to identify what’s causing the upset. 

Immunological – the immune system can behave in widely different ways in an energy-depleted state. For some, they find that they are regularly ill – they have an upper respiratory infection that they finally get over and then they get a UTI; they fight off the UTI and then get a cold. For others, they have the opposite experience and never get sick. Unfortunately, this “never being ill” is often the proof they use for why this really isn’t a problem and that it shows they are healthy.

As you can see, the issues of HA are far-reaching and often not so obvious (or at least can feel like a separate issue; “of course my digestive issues have nothing to do with not getting a period”). 

Part of the reason for many of the above changes is the decrease in so-called “reproductive hormones” like oestrogen and progesterone. For example, outside of reproduction, oestrogen and progesterone impact the heart, liver, brain, bones, skin, hair, muscles, mood, sleep, hearing, colon, blood, immune system and bladder.

So, it’s no wonder then if reproduction is turned off and these hormones are reduced (often dramatically so) that this whole host of issues arises.

But it’s not just because of these hormones, it’s also because of resource allocation. When there are fewer resources to go around, your various systems have to get by using less. And this has a direct impact on the ability of these systems to do a good job. This is something I cover in detail in this podcast on energy flux, a concept that is well worth understanding.

One of the best real-life examples of what happens when the body enters into a low energy state is the Minnesota Starvation Experiment. It was an experiment conducted between 1945 and 1946 with 36 men, where, for a period of 24 weeks, their calorie intake was roughly cut in half. Despite being an experiment that was run exclusively with men, it is still relevant here.

In terms of reproduction, the men saw many changes. The desire for sex completely disappeared, they stopped getting erections and their sperm count and sperm motility plummeted. But it wasn’t just reproduction that was impacted, every system of the body was ravaged.

If you’ve never heard of the Minnesota Starvation experiment I recommend checking out this podcast here or reading the transcript here.

This wide-ranging impact is something I see with most of my clients with hypothalamic amenorrhea. Not only have their periods ceased, but they also have digestive issues, have osteopenia, unstable energy, trouble sleeping, difficulty concentrating, memory issues and have many fears and anxieties relating to food, exercise and many other facets of life.

What Do You Do For Hypothalamic Amenorrhea Recovery?

Despite how scary the above may sound, there is good news. The human body is incredible at healing and HA recovery is possible. And this reversal also includes all the other health issues that are arising alongside the lack of menstruation.

Several things need to happen for this reversal to occur (which is what I help clients to achieve). 

The main physiological goal is to get the body out of the state of energy debt so that it can start prioritising reproduction again. For this to happen:

• Total food intake needs to increase
• Macronutrients that are being avoided or minimised, like carbs or fat, need to be increased
• Exercise needs to cease for a period or at the very least be significantly reduced
• Weight needs to increase, as this is necessary for true healing and repair to take place (as detailed in my podcast on Minnesota Starvation Experiment) 

To make this a permanent change, other things need to be addressed:

• Changing beliefs about your self-worth and how this is connected to your weight, shape or identity, say as the “healthy one,” “fit one” or “sporty one”
• Your relationship with food and ideas around “health,” allowance/permission, how much you need or “deserve”
• Learning to be in tune with your body and supporting it, rather than it being an adversary
• Your relationship with exercise and the ability to be in total control with take timing off and knowing when you are truly supporting it versus pushing it beyond its limits
• The ability to be spontaneous with eating and other aspects of life, moving away from perfectionism and the need for certainty

Undoubtedly the above lists may sound daunting or even overwhelmingly challenging. And this is the benefit of working together so that you aren’t doing this on your own. 

You have my support to deal with the difficulties that arise and with figuring out a way through.

I can help you continue to move forward so you don’t get stuck in a place where things have improved a little, but there is much more that can be achieved.

I also help to celebrate the wins; because there will be many and sometimes it takes an outside person to point out how much things have changed otherwise it can be missed.

Getting Support For HA Recovery

Hypothalamic amenorrhea is the outcome of what happens when certain beliefs, habits and behaviours have become entrenched for years or decades. And while in some sense it is about reproduction, as I’ve detailed in the article, it is about much more than just this.

If you have been diagnosed with HA or you suspect that this is what is going on with you and you’d like help dealing with it, I’d love to help.

I’ve been helping clients for well over a decade and HA recovery is an area I have much experience and expertise in. Here is a conversation I had with a past client as a demonstration of what can be achieved. 

I’m a leading expert and advocate for full recovery. I’ve been working with clients for over 15 years and understand what needs to happen to recover.

I truly believe that you can reach a place where the eating disorder is a thing of the past and I want to help you get there. If you want to fully recover and drastically increase the quality of your life, I’d love to help.

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