Eating well, exercising regularly, and working hard are usually considered to be healthy habits.
However, each of these three behaviors can become risk factors for a condition called hypogonadotropic hypogonadism1. In females, this may lead to hypothalamic amenorrhea2, which is characterized by a loss of menstrual period.
Hypothalamic amenorrhea (HA) awareness has increased in recent years—you may have seen some of your favorite “fitspos” or fitness influencers mention something about having HA or going “all in” to cure their HA. The “all in” approach, created by Dr. Nicola Rinaldi, involves increasing caloric intake and decreasing exercise and stress3.
Female health and fitness icons who display six pack abs all the time might not be as healthy as they look. While some females can sustain such a lean appearance long-term, most cannot. A certain level of body fat is necessary to maintain normal healthy functions, and butt and thigh fat in particular can actually protect against metabolic dysregulation and can enhance insulin sensitivity4.
While achieving an extremely low level of body fat or high level of conditioning might be necessary for your sport, it is important to be aware of the potential consequences and strategies to help recover from subsequent loss of menstrual period.
Who Is At Risk?
One or more of the following risk factors can lead to a suppressed hypothalamic-pituitary-ovarian axis: undereating, excessive exercise, and psychological stress2. And undereating doesn’t necessarily mean eating celery all day. Undereating can still include breakfast, lunch, dinner, and snacks every day.
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Undereating simply means that you do not eat enough to fuel all of the functions that your body needs to perform. As Dr. Rinaldi described to me, “Energy for exercise is expended, your body has no choice about that. So it has to work with what's left over.” This leftover energy has to be used for basal metabolism, digesting food, non-exercise activity thermogenesis (NEAT), and exercise post-oxygen consumption (EPOC)3.
If too much energy has to be used for exercise, then there might not be enough left to accomplish critical functions (such as ovulating).
You do not have to look a certain way to have HA. HA can happen with any body size or body shape. Individuals with HA who are at a normal weight have been found to have low adipose tissue and serum leptin concentrations5, indicating a relationship between HA and body fat and leptin rather than body weight.
Despite this possible connection, however, it is important to consider that someone may currently be at a different percent body fat than she was when her HA started. Thus, one’s physical appearance cannot be used to determine whether someone might have HA. Behavioral risk factors are more important to consider.
Difficult to Diagnose
As HA is a diagnosis of exclusion6, it can be difficult to diagnose. It is not uncommon to be misdiagnosed one or more times if you have HA. In a society that praises dieting and regular exercise, it may be difficult to shift your mindset and see these behaviors as risk factors.
HA is often misdiagnosed as polycystic ovarian syndrome (PCOS), which has many overlapping symptoms with HA3. In individuals with HA who also exhibit PCOS-like features, the PCOS-like features may resolve when a menstrual period is recovered7.
The tell-tale sign of HA is a history of dietary restriction and/or intense exercise and/or high stress. Due to the difficulty diagnosing HA, if you have one or more of these risk factors, you must advocate for yourself. There is still a misconception that you must be underweight to have HA, which further complicates the diagnosis process.
Additionally, it is important to note that hormonal birth control can mask the symptoms of HA. A bleed from a pill is not a real period. If you think you are at risk for HA but are taking oral contraceptives, you might want to consider speaking with your doctor about stopping for a month to see if you cycle naturally.
Symptoms of HA
Reported symptoms of HA include: feeling cold all the time, constant thoughts about food/eating, no natural lubrication, obsessiveness, no enjoyment of sex, anxiety, no libido, exhaustion, disordered hunger signals, mood swings, irritability, dry/brittle hair and/or nails, digestive issues, unable to eat treats without fear of bingeing, unable to manage stress, no enjoyment of food, poor sleeping, lack of social life, abnormal blood work, waking hungry in the night, unhappiness, night sweats, confused/unclear thinking, hair loss, and food allergies3.
HA is more complex than not getting a period, which in itself is a sign that the body is not healthy. While the most obvious consequence of HA is infertility, HA may also lead to sleep problems8, increased risk of injury, abnormal lipid profiles, depression, anxiety, low self-esteem, irreversible bone loss, and increased mortality9. Fortunately, many of the consequences can be improved or resolved after recovery from HA.
Recovering from HA
Recovery from HA involves reducing all forms of stress and supplying your body with adequate fuel. Generally speaking, this involves eating a minimum of 2500 calories per day and eliminating intense exercise3. Although 2500 calories per day is the minimum, there is no maximum calories per day for HA recovery.
Dr. Rinaldi emphasizes that “’all in’ in some ways is a short-term thing, in other ways it's for life.” While cutting out high-intensity exercise is necessary in the short-term for recovery, supplying your body with adequate fuel is necessary in the long-term.
When we don’t eat enough and/or exercise too much, low energy availability can trigger hormonal responses that lead to negative health consequences10. The long-term goal is therefore to make sure energy intake is high enough to fuel energy demands.
Laura Gledhill, who has recovered from HA, describes the “all in” approach:
"‘All in’ is getting back to the way we are supposed to eat. To trust our bodies. And to truly discover what intuitive eating is. I felt so broken before going all in. And my hunger was insatiable. I never thought I would get back to feeling hungry and full. And being satisfied after a meal. It’s changed my life. And I think if I look at my body now.
It doesn’t look like what magazines tell me is ‘healthy’ but I eat well. I sleep well, my hormones work, I move because I want to and not because I have to. My hair has stopped falling out and I don’t feel cold all the time anymore. I am the most healthy I have ever been. And we need to start promoting this narrative. Not the ‘aesthetics over all else’ one."
For many, the hardest part of recovering from HA is the mental aspect. Therapy, such as cognitive behavioral therapy (CBT), and participation in a support group, such as the ‘No Period Now What’ community on Facebook, have been reported to be helpful.
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One member of the Facebook community, Lara Moyano, describes, “[recovery] is harder because of diet culture and due to the way we've been told to be/eat… women have to eat. Yep, no more foods with pink packages and stupid statements on how we are supposed to nurture our bodies. We need food. Period. And though a good salad can be fine every now and then, in most cases a burger or a pizza suits our needs much better.”
As recovery can take anywhere from a few weeks to over a year, it is important not to compare your journey to anyone else’s. Someone may have a more or less robust hypothalamus. Some may be able to undereat and overexercise and never get HA. Every HA recovery journey is different.
Achieving your “ideal” body weight or composition may not be healthy. Dieting, overtraining, and other stress should only ever be short-term occurrences. If you need to diet or train hard for an event, have a recovery plan prepared. This recovery plan should include reducing all types of stress and eating enough to fuel your body.
Be wary of “hormone balancing” protocols or supplements when recovering from HA. It is imperative to get bloodwork done so you can see what types of “imbalances” are actually present, if any, before taking a supplement that may worsen existing problems. Consult with a professional who knows your specific case and what your bloodwork looks like before starting a treatment that does not involve rest and eating at least 2500 calories per day.
In a society that praises immediate results, it is tempting to try quick fixes such as “hormone-balancing” foods or supplements. However, there are no quick fixes for HA.
If you lost your menstrual period due to stress and/or excessive exercise and/or improperly fueling your body, know that you are not alone. There are plenty of others who have HA or who have recovered from HA. The ‘No Period Now What’ book and online community are great places to start. Thank you to the members of the Facebook group for contributing their insights to this article.
- Dwyer AA, Chavan NR, Lewkowitz-Shpuntoff H, et al. Functional Hypogonadotropic Hypogonadism in Men: Underlying Neuroendocrine Mechanisms and Natural History. J Clin Endocrinol Metab. 2019;104(8):3403-3414. doi:10.1210/jc.2018-02697
- Shufelt CL, Torbati T, Dutra E. Hypothalamic Amenorrhea and the Long-Term Health Consequences. Semin Reprod Med. 2017;35(3):256-262. doi:10.1055/s-0037-1603581
- Rinaldi NJ, Buckler SG, Waddell LS. No Period. Now What? A Guide to Regaining Your Cycles and Improving Your Fertility. 1st ed. Waltham, MA: Antica Press. 2016.
- Booth A, Magnuson A, Foster M. Detrimental and protective fat: body fat distribution and its relation to metabolic disease. Horm Mol Biol Clin Investig. 2014;17(1):13-27. doi:10.1515/hmbci-2014-0009
- Moskvicheva YB, Gusev DV, Tabeeva GI, Chernukha GE. [Evaluation of nutrition, body composition and features of dietetic counseling for patients with functional hypothalamic amenorrhea]. Vopr Pitan. 2018;87(1):85-91.
- Gordon CM, Ackerman KE, Berga SL, et al. Functional Hypothalamic Amenorrhea: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab. 2017;102(5):1413-1439. doi:10.1210/jc.2017-00131
- Carmina E, Fruzzetti F, Lobo RA. Features of polycystic ovary syndrome (PCOS) in women with functional hypothalamic amenorrhea (FHA) may be reversible with recovery of menstrual function. Gynecol Endocrinol. 2018;34(4):301-304. doi:10.1080/09513590.2017.1395842
- Tranoulis A, Georgiou D, Soldatou A, Triantafyllidi V, Loutradis D, Michala L. Poor sleep and high anxiety levels in women with functional hypothalamic amenorrhoea: A wake-up call for physicians? Eur J Obstet Gynecol Reprod Biol X. 2019;3:100035. doi:10.1016/j.eurox.2019.100035
- Berz K, McCambridge T. Amenorrhea in the Female Athlete: What to Do and When to Worry. Pediatr Ann. 2016;45(3):e97-e102. doi:10.3928/00904481-20160210-03
- Keay N, Francis G. Infographic. Energy availability: concept, control and consequences in relative energy deficiency in sport (RED-S). Br J Sports Med. April 2019. doi:10.1136/bjsports-2019-100611