Hypothalamic amenorrhea (HA), also known as functional hypothalamic amenorrhoea (FHA) is a condition characterised by the cessation or irregular arrival of menstrual periods in individuals with normally functioning ovaries. It is caused by disruptions in the hypothalamus, a region of the brain that plays a crucial role in regulating hormone secretion and the menstrual cycle. As a consequence, those with HA remain in a state of low oestrogen, which can have serious consequences for health if left untreated.
HA occurs when there is excessive stress on an individual including severe/prolonged mental stress, intense exercise, extreme/sudden weight loss and/or inadequate caloric intake. Addressing the underlying causes and restoring hormonal balance are essential for managing and recovering from HA.
In this article, we will explore what's actually happening in your body when you have lost your period due to HA, recognising signs and symptoms, and naturopathic recovery strategies for managing and overcoming this condition including what lifestyle changes you need to make, stress management techniques, and nutritional and herbal supplements that can support hormonal balance and aid in the recovery process.
Who Get's Hypothalamic Amenorrhoea?
The prevalence of HA can vary depending on the population being studied and the specific risk factors within that group. Generally, it is more commonly observed in certain subgroups of individuals.
For example, among athletes and dancers who engage in intense training and exercise routines, the prevalence of HA can be relatively high. Estimates suggest that up to 60% of female athletes may experience menstrual irregularities, including periods stopping.
Similarly, in those with eating disorders, such as anorexia nervosa or bulimia nervosa, the prevalence of HA is significantly high, with estimate of up to two-thirds of these individuals losing their period.
In the general population, the prevalence of HA is lower but still exists, especially in women who experience high levels of chronic stress, sudden or drastic weight loss (even if not underweight), or have certain lifestyle factors that can stress the body.
If you suspect you may be experiencing HA, it's essential to consult with a healthcare professional for proper evaluation and diagnosis. Early detection and appropriate treatment is essential for preventing health problems due to chronic low oestrogen.
Recognising the Signs and Symptoms
Menstrual Irregularities and Absence
HA is characterised by the disappearance of menstrual periods for at least 3 months. It can also be the case that periods never started at puberty due to HA, so some may never have experienced a menstrual bleed without the help of medications.
A subclinical form of HA can also exist where you are still getting a period but the underlying hormonal pattern still exists so the other symptoms (see below) are still being experienced.
Hormonal Imbalance Indicators
In HA, high stress hormones compromise the signal from the hypothalamis in the brain to the pituitary gland in the brain. This leads to reduction in the production of luteinising hormone (LH) and follicle stimulating hormone (FSH) from the pituitary. With low LH and FSH, the ovaries don’t get the stimulation they need from these hormones to produce oestrogen and grow an egg to be ovulated. Without oestrogen and ovulation (which causes progesterone to be released), the lining of the uterus does not thicken enough to have a period.
Other Related Symptoms
Low oestrogen levels have serious consequences beyond not having a period. Oestrogen is essential for maintaining heart health and adequate bone density so prolonged HA increases the risk of cardiovascular disease and osteoporosis. The importance of having adequate oestrogen for bone health should not be underestimated: it's easier to maintain your bone health now than battle to regain bone density later, so seek help if you have or have had a missing period. We also need oestrogen for energy and mood: it helps us feel happy, focused, motivated and satisfied, and without it we can have poor memory and focus, brain fog, depression and anxiety.
Fertility and HA
Fertility can be a significant challenge for those with HA. Without adequate oestrogen and ovulation, pregnancy cannot take place. However, it's essential to note that HA is not necessarily a permanent condition, and with appropriate lifestyle changes and treatment, fertility can be restored. Addressing the underlying factors that contribute to HA, such as reducing stress, adjusting exercise routines and ensuring adequate nutrition can help in restoring hormonal balance and improving fertility.
For women trying to conceive with HA, seeking medical guidance and fertility medications may also be beneficial to aid ovulation and increase the chances of becoming pregnant. You should also work closely with a care team to ensure your bone health is protected while child-bearing as this may represent an additional challenge for bone health. This might include a GP, specialist, exercise physiologist and naturopath.
What Causes Hypothalamic Amenorrhea?
There are 3 types of HA: stress-induced, exercise-induced and nutritional HA. Of course, a combination of these factors can also be behind HA and often-times it is, for example, a time of high stress on top of an already low-calorie diet that sends a person into HA.
Stress-Induced Hypothalamic Amenorrhea
Understanding the Impact of Stress on the Reproductive System
Stress-induced HA occurs when, in response to chronic stress, the hypothalamus initiates a hormonal cascade causing our adrenal glands to produce stress hormones, such as cortisol. These high stress hormones interfere with the hypothalamic brain signalling that controls our sex hormones.
As a result of this hormonal disruption, the brain's pituitary gland releases insufficient levels of luteinizing hormone (LH) and follicle-stimulating hormone (FSH), which are responsible for triggering ovulation, oestrogen production and maintaining the menstrual cycle. Without adequate levels of LH and FSH, the ovaries may not release an egg or produce sex hormones oestrogen and progesterone. Thus, menstruation may be disrupted or completely absent.
Behavioral and Lifestyle Factors that Influence Stress-Induced HA
Stress-induced HA can be triggered by various factors, including emotional stress, work-related stress and sleep disturbances. It is crucial to address the underlying stressors and adopt stress-management techniques to restore hormonal balance and promote the return of regular menstrual cycles.
Exercise-Induced Hypothalamic Amenorrhea
The Relationship between Intense Exercise and Menstrual Irregularities
In exercise-induced HA, the high levels of physical activity and energy expenditure can lead to a negative energy balance in the body. This negative energy balance, combined with other factors like low body weight and reduced body fat, are a source of physical stress on the body that can trigger high levels of stress hormones that disrupt the normal functioning of the hypothalamus, as above.
The amount and intensity of exercise required to trigger HA will vary from individual to individual. The threshold will be reduced if the person is not consuming enough calories to keep up with their energy expenditure.
Nutritional Hypothalamic Amenorrhea
Importance of Sufficient Caloric Intake for Hormonal Health
In those with low calorie intake, HA is an adaptive response to chronic energy deficit. The body will direct energy to systems needed for survival in preference of reproduction. Rapid weight loss as a result of calorie restriction, whether leading to a low body-mass-index or not, can trigger HA.
Calorie deficit causes metabolic stress, which causes the body to release coritsol to mobilise stored glucose for energy as there isn’t enough coming in from the diet. This stress response leads to the same disruption of hypothalamic control of the sex hormones and the menstrual cycle already described.
Restoring hormonal balance involves increasing caloric intake to provide adequate energy for the body's needs. Nutritional counseling and support are crucial to address dietary deficiencies and achieve a healthier body weight.
If you suspect or know you are dealing with an eating disorder it is essential to be accessing appropriate medical professionals, such as eating-disorder specialist psychologists and dieticians. Reaching out to your GP or accessing an organisation such as Eating Disorders Victoria is the place to start.
Nutritional Deficiencies and Their Effect on the Menstrual Cycle
Low calorie intake can also lead to micro-nutrient deficiencies that can have a significant impact on the menstrual cycle, fertility, bone health and long term overall health. When the body lacks key vitamins and minerals, such as iron, B-vitamins, calcium, zinc, omega-3 fats and protein, various physiological processes, including hormone production, can be affected.
Seeking Professional Help and Diagnosis
How to Know if You Have HA
When diagnosing HA, healthcare professionals use a combination of medical history, physical examination and specific diagnostic procedures to identify the condition, and rule out other potential causes of your lost period.
Some of the common diagnostic procedures and tests for HA include:
Medical History: going through a detailed personal history to identify possible contributing factors. This can include menstrual patterns, sleep patterns, stress, mood, mental health, exercise, weight fluctuations, history of and/or current eating disorders and diet.
Ruling out pregnancy: Possibility of pregnancy should be discussed so pregnancy can be ruled out if needed. It’s important to remember that if you have lost your period, you will ovulate BEFORE it comes back so it is possible to fall pregnant after many months of having no period.
Ultrasound: Transvaginal ultrasound may be used to assess the ovaries and uterine lining to ensure there are no structural abnormalities.
Blood tests: Hormone levels including FSH, LH, oestrogen, prolactin, progesterone and thyroid hormone levels are very useful in assessing the likelihood of HA. Androgen hormones may also be assessed to exclude polycystic ovarian syndrome as the cause of your lost or irregular cycle.
Medication and Hormonal Therapy Options
Identifying and treating the underlying cause of HA is essential for reinstating the menstrual cycle, improving fertility and reducing the health risks associated with HA. Beyond this, the contraceptive pill may be prescribed to cause a monthly bleed and provide a form of oestrogen and progesterone. It’s important to remember that these hormones are not quite the same as our body’s own hormones and do not reduce the risk of bone density loss from HA.
If trying to conceive with HA, medications may be offered to help with ovulation. These do not always work and best results are achieved if the underlying energy deficit or stress is being addressed at the same time.
Naturopathic Recovery Strategies for HA
The appropriate recovery strategy depends on identifying the underlying drivers and working with a support team to overcome them, which may include an experienced naturopath. Your naturopath can help you to restore energy balance, manage and reduce physical/mental stress, and monitor your progress.
Restoring Energy Balance
Restoring hormonal balance often involves increasing caloric intake to provide adequate energy for the body's needs. Your naturopath can help you work out your energy needs and which foods to increase in your diet, whilst maintaining a healthy weight. They will refer you for medical management regarding your relationship with food/eating disorders, where appropriate.
Your naturopath will also help you ensure you are not suffering any nutrient deficiencies, working toward a nutrient-rich diet and supplementation where indicated.
Reducing Stress Levels
Stress Management Techniques
Managing stress is all about finding out what works for you as this will vary from person to person. Seeing a counsellor or psychologist is an excellent way to work through managing your stress and developing techniques for reducing and dealing with it. Some other ideas include:
Meditation or mindfulness practice
Gentle forms of yoga such as Yin, Hatha or Restorative Yoga
Deep breathing techniques, like diaphragmatic or belly breathing, activate the body's relaxation response, reducing stress hormones and promoting a sense of calm.
Social Support: Sharing feelings and experiences with supportive friends, family members, or a support group can provide emotional comfort and reduce feelings of isolation.
Lifestyle Changes to Reduce Stress
To be free from HA you may need to make significant changes around work and life commitments and expectations to allow adequate time for rest and reparation. The following lifestyle changes are also very helpful:
Limiting Stimulants: Reducing or avoiding the consumption of stimulants like caffeine and nicotine can help prevent exacerbating stress and anxiety.
Sleep Hygiene: Prioritising enough time for 8-9hrs of sleep per night and good sleep habits, such as maintaining a consistent sleep schedule, creating a relaxing bedtime routine, and ensuring a comfortable sleep environment, is essential for enhancing resilience to stress and reducing your cortisol levels.
Adjusting Exercise Routines
Adopting a Balanced Exercise Approach
Initially, recovery often requires cessation of all high intensity exercise and focusing in on gentle, restorative exercise such as yoga, swimming and walking. Once the menstrual cycle has been restored, physical activity can be increased but likely not to the degree that caused the HA in the first place.
Working with an exercise physiologist to set an appropriate exercise routine that promotes bone density whilst also seeing an experienced naturopath to monitor your hormones will help identify the level of exercise that your body thrives on and ensure that a tipping point into HA isn’t reached again.
Listening to the Body's Signals
During times of stress, physical activity may need to be down-regulated to those restorative types again to avoid recurrence of HA. Listen to your body and rest if you are tired. If an exercise session makes you feel exhausted rather than uplifted it is probably a bit much. Likewise if you have poor recovery from exercise the next day, pull back to a more gentle level.
Naturopathic Remedies and Supplements for HA Recovery
While addressing the underlying causes of HA is crucial for recovery, some natural remedies and supplements may be beneficial in supporting hormonal balance and overall health. It's essential to consult with a naturopath before starting any herbs or supplements to ensure they are safe and appropriate for your specific situation.
Herbal and nutritional medicines for HA
High quality, professional grade herbs and nutrients are incredible tools for helping your body break the cycle of high stress hormone production, lowering cortisol levels, calming the nervous system, supporting the adrenal glands, promoting restorative sleep and reducing the impact of stress on your body. You will still need to address energy balance, sources of stress and exercise balance to recover from HA but herbs, and nutrients can be an important part of your recuperation.
Hormonal herbs may be a useful adjunctive treatment in those trying to conceive but primary treatment will always be treating the underlying cause of the HA as this will have the most powerful effect.
Maintaining Long-Term Hormonal Health
Recovery from Hypothalamic Amenorrhoea often requires ongoing attention to prevent relapse. It’s important to remain in contact with your healthcare professionals and support team to monitor your health and maintain healthy habits for sustainable hormonal balance. As time goes on your body may become more resilient to short term stressors but avoiding chronic, unmanaged mental or physical stress is key to long-term management.
HA is a complex condition that can have far-reaching effects on a person's health and well-being. It's not only about your period stopping but also the resulting low oestrogen levels and health risks that come with that. Understanding the causes and factors contributing to HA is crucial for effective management and recovery.
Throughout this article, we have explored the various types of HA, including stress-induced, exercise-induced, and nutritional HA. Each type can be triggered by different factors, but they all share the common thread of hormonal disruption in the hypothalamus. Recognising the signs and symptoms of HA is essential for early detection and intervention, as it can impact not only menstrual regularity but also bone health, cardiovascular health, fertility, and emotional well-being.
If you suspect you may be experiencing hypothalamic amenorrhea, seeking professional help and diagnosis is essential for proper evaluation and personalied treatment. Recovery from HA is possible but often requires a multifaceted approach, involving lifestyle modifications, stress reduction, nutritional support, and, sometimes, herbal medicine or hormonal therapy.
Naturopathic treatment offers a holistic approach to managing and overcoming HA and an experienced reproductive health naturopath, such as the team at RH: Reproductive Health is a valuable part of your recovery plan. Please reach out for a complimentary discovery call if you need help.