Functional hypothalamic amenorrhea (FHA), also referred to as hypothalamic amenorrhea (HA), is a medical term used to describe when an individual begins missing periods due to changes in hormone levels. It is commonly seen in women struggling with an eating disorder, but can develop in anyone who has been experiencing extreme stress or engaging in food restriction and excessive exercise.
A common misconception in eating disorder recovery is that only women with significant weight loss and very low body fat are at risk for missing periods. However, it is not that straight forward. Everyone’s body is unique in how it responds to an energy deficit and whether or not you are missing periods does NOT determine where you are at in the eating disorder recovery process.
Achieving a regular menstrual cycle is hard work and often requires many months of consuming an appropriate caloric intake to achieve. The good news is that full recovery is possible and the sooner hypothalamic amenorrhea is treated, the better for your overall health. A knowledgeable healthcare provider can offer appropriate medical advice and recommend lifestyle changes to help heal hormone levels and get your body back on track with a regular menstrual cycle.
What is Amenorrhea
Amenorrhea is the loss of one or more menstrual cycles. There are two types of amenorrhea: primary amenorrhea and secondary amenorrhea.
Primary amenorrhea is when someone has not gotten their first period by age 16 or within 5 years of puberty. This can be due to genetics or conditions that develop after birth.
Secondary amenorrhea is when someone has been getting their regular menstrual cycle, but then stops getting their period for more than 3 months. Hypothalamic amenorrhea is a type of secondary amenorrhea and will be the main focus of this article.
What is Hypothalamic Amenorrhea?
Hypothalamic amenorrhea means the loss of regular periods due to issues involving a structure deep within your brain called the hypothalamus. The hypothalamus is the control center for your brain and regulates the release of important hormones involved in temperature regulation, appetite, reproduction, and more.
The hypothalamus triggers the release of an important hormone involved in the reproductive system called gonadotropin-releasing hormone (GRH). GRH is responsible for stimulating the release of follicle-stimulating hormone (FSH) and luteinizing hormone (LH). Both FSH and LH are essential for making the sex hormones testosterone and estrogen. Deficiencies in estrogen contribute to secondary amenorrhea.
Problems arise when the hypothalamus stops secreting enough gonadotropin-releasing hormone. This occurs when the hypothalamus recognizes there is a stress within the body, signaling it is not an appropriate time for reproduction to occur. This can be due to weight loss, chronic stress, or an energy deficit due to inadequate caloric intake and excessive exercise.
How Common is Hypothalamic Amenorrhea?
Hypothalamic amenorrhea accounts for 25-35% of secondary amenorrhea cases. About 1.62 million women in the United States between the ages of 18-44 and 17.4 million women worldwide suffer from HA.
Statistics show an estimated 66-84% of women struggling with anorexia nervosa and 77% of women with bulimia nervosa who have a history of anorexia nervosa experience amenorrhea.
What Causes Hypothalamic Amenorrhea?
The hypothalamus is the control center for your brain and manages the release of important hormones that assist with regular menstruation.
When your hypothalamus receives a message that something is stressing your body, such as inadequate caloric intake from food restriction or chronic stress at work, it goes into survival mode and decides it is not a good time for the body to be reproducing.
It begins decreasing its secretion of gonadotropin-releasing hormone, which leads to inadequate amounts of FSH and LH. Without enough FSH and LH, menstruation stops.
Common Causes of Hypothalamic Amenorrhea:
1. Excessive exercise
A common misconception among female athletes is that loss of a menstrual cycle due to intense athletic training is normal. This is simply not true. While intense exercise alone does not cause imbalances in hormone levels seen in hypothalamic amenorrhea, it can significantly contribute to an energy imbalance. The combination of too much exercise and inadequate caloric intake are what lead to the loss of regular periods.
2. Inadequate caloric intake
One of the most common causes of hypothalamic amenorrhea is an imbalance between energy intake and energy expenditure. This can occur from caloric restriction and/or high energy expenditure via excessive exercise. When not enough energy is available for the body, it shuttles the small amount accessible to the most vital processes for maintaining life. Unfortunately, not enough calories are available to prevent diminished hormone levels, bone loss, and missing periods.
3. Dietary Restrictions
Studies show that women following certain dietary patterns, such as low-fat and low-calorie diets, tend to be more at risk for hypothalamic amenorrhea, even when maintaining a normal BMI.
4. Chronic stress
It has been shown that high levels of physical, emotional, and psychological stress can negatively impact normal reproduction by activating the hypothalamic-pituitary-adrenal (HPA) axis. Whether stress is coming from strenuous exercise, an energy imbalance, or low body weight, it is important to make a significant change towards a healthy lifestyle in order to manage stress and maintain normal hormone levels.
5. Eating disorders
Amenorrhea is no longer listed as a criterion in the Diagnostic and Statistical Manual of Mental Disorders, but many women struggling with anorexia nervosa still experience menstrual dysregulation. This is most often due to inadequate calorie intake, significant weight loss, and a low percentage of body fat.
Signs and Symptoms of Hypothalamic Amenorrhea:
The hallmark sign of hypothalamic amenorrhea is missing your period for 3 or more months when you are not pregnant. While this may be the sole issue for some women, many other signs and symptoms of hypothalamic amenorrhea may be present. These signs and symptoms include:
- Changes in basal body temperature – often feeling cold
- Increased bone loss
- Low sex drive
- Impaired immune system
- Hair thinning
- Infertility
- Low energy
- Vaginal dryness
- Anxiety and mood disorders
Evaluation for Hypothalamic Amenorrhea:
Hypothalamic amenorrhea is considered a “diagnosis of exclusion“, meaning it is diagnosed after all other potential medical conditions have been ruled out.
If you or someone you know may be experiencing symptoms of hypothalamic amenorrhea, it is important to reach out to a medical provider who can run tests to determine the correct diagnosis and design an appropriate treatment plan.
Your general practitioner may choose to run a variety of tests including:
- Pregnancy test
- Blood tests to check levels of estrogen, prolactin, follicle-stimulating hormone, and luteinizing hormone, thyroid functioning
- MRI of pituitary gland
- Complete blood count (CBC)
- Progestin challenge test
- Bone density testing
Hypothalamic amenorrhea recovery tips
The good news is that recovery from hypothalamic amenorrhea is possible. The human body is incredibly resistant and able to withstand an unbelievable amount of physical, emotional, and psychological stress.
The recovery process for treating hypothalamic amenorrhea will take time and hard work. It will include a variety of positive lifestyle changes such as increasing food intake, reaching and maintaining a healthy weight, reducing psychological stress, and avoiding excessive exercise.
For individuals struggling with eating disorders, making some of the recommended lifestyle changes can be extremely difficult due to concerns about weight gain and body image. The good news is working with a team of trained health care providers can offer guidance and support for your individual needs.
A registered dietitian plays an important role by providing appropriate nutritional recommendations to help get your eating back on the right track and correct any energy deficits caused by inadequate caloric intake or excessive exercise. It will be absolutely essential to ensure you are consuming enough food and enough calories to reach or maintain a healthy weight.
In addition to increasing your food intake, your hypothalamic amenorrhea recovery meal plan will include building a healthy relationship with food, avoiding low-fat diets, consuming a greater variety of foods, using energy dense options such as nut butters, and moderating your activity levels with gentle exercise.
When eating disorders and/or chronic psychological stress are contributing to missing periods, it is important to work with a psychologist or psychiatrist who can provide tools for managing stress levels. Managing mental health will be just as important as managing physical health when recovering from hypothalamic amenorrhea.
Some medical doctors may prescribe birth control pills to artificially induces a fake bleed. While this may cause blood to appear on toilet paper, it does not solve the underlying issue of the missed periods.
Signs of Recovery from Hypothalamic Amenorrhea:
1. Increased hunger and satiety regulation:
It is common for an individual struggling with an eating disorder to lose touch with their body’s innate hunger and fullness cues. This happens for a variety of reasons including changes in metabolism, hormone secretion, and digestive processes. Many individuals struggling with an eating disorder dread getting their hunger cues back due to fear they will engage in out of control overeating. It is important to remember that getting your hunger cues back on track and feeding your body appropriately will lead to increased satiety, decreased thoughts about food, and less chances of overeating. Increased hunger and satiety regulation are positive signs that hormone levels are regulating and regular periods are on their way.
2. Changes in mood:
Adequate amounts of estrogen are required for the brain to appropriately regulate levels of important neurotransmitters including serotonin, dopamine, epinephrine, and norepinephrine. Falling estrogen levels seen in hypothalamic amenorrhea can lead to an increase in mood swings, sadness, anxiety, depression, and more. One of the first signs of recovery many patients experience is positive changes in their mood and emotional well-being due to normalizing hormone levels and adequate caloric intake.
3. Increase in cervical mucus:
Cervical mucus is fluid produced from the cervix in response to rising estrogen levels. It is needed to help sperm move through the cervix to fertilize eggs during ovulation and help prevent sperm from entering the cervix. Changes in cervical mucus occur due to changes in hormone levels throughout your menstrual cycle. Prior to ovulation, rising levels of estrogen cause your cervix to produce mucus. After ovulation, estrogen levels drop and progesterone levels rise, leading to decreased cervical mucus and increased dryness. This is why noticing an increase in mucus is a good sign that your hormone levels are normalizing and your first period is on its way.
4. Normalized basal body temperature:
Tracking your basal body temperature (body temperature when you are fully at rest) first thing in the morning can be helpful in determining when you are about to ovulate. For women of childbearing age, basal body temperature will change throughout the time of ovulation due to changing levels of reproductive hormones.
Your average basal body temperature ranges between 97.0 – 97.5 degrees F. Immediately prior to ovulation, this temperature slightly drops.
After ovulation, your body experiences a sharp rise in temperature to around 97.6 – 98.6 degrees F and remains there until you get your period.
For women experiencing hypothalamic amenorrhea, their basal body temperature runs low, which is why they often complain of feeling very cold.
5. Increased sex drive and libido:
The sex hormones estrogen, testosterone, and progesterone are responsible for affecting sexual desire and arousal. Higher levels of estrogen correlate with higher amounts of sexual arousal while lower levels of estrogen, as seen in hypothalamic amenorrhea, lead to decreased sexual drive. This is one reason why experiencing an increase in sex drive and libido is a good sign that reproductive hormones are regulating and your are well on your way in your HA recovery journey.
Hang in There...
Getting your first period back during the eating disorder recovery process often brings up a mix of emotions. It takes a lot of hard work physically, mentally, and emotionally. A common misconception is that getting regular periods is a sign that one has achieved a healthy weight and weight gain can stop, but this is not necessarily true. The good news is that you are on the right track and continuing on through the eating disorder recovery process will help speed up your HA recovery journey.
