Functional hypothalamic amenorrhea is a condition where the menstrual cycle has stopped. Amenorrhoea is the absence of a menstrual cycle. Hypothalamic refers to the hypothalamus, which is a section in the brain that produces a number of hormones.
The menstrual cycle provides key insight into the body’s hormonal balance. So when someone loses their period outside of menopause, the effects of contraception, or another diagnosed condition, it may be a sign that something is wrong. Nonetheless, if the menstrual cycle has stopped, it can be a sign that the body is under a lot of stress.
The concept of not having a period is probably pretty appealing for anyone with a uterus, but losing your period due to FHA can have serious health consequences.
What Is Functional Hypothalamic Amenorrhea?
FHA specifically occurs when the body is under a lot of stress. This stress can be from a variety of factors including:
- Psychological and emotional stress
- Lack of sleep
- Over training and/or undereating
- Low energy availability
- Being too lean
- Disordered or restrictive eating patterns
Typically there are several factors at play in FHA and the causes will dictate the management.
As previously mentioned, this stress on the body has an effect on the hypothalamus.
This leads to the suppression of gonadotropin-releasing hormone (GnRH) in the hypothalamus. Which has a cascading effect on several other hormones including a reduction in estrogen. Resulting in a lack of endometrial thickening leading to the loss of a menstrual cycle.
Think of FHA as your body’s “battery saver mode”.
When we consider the human body’s hierarchy of functions that are essential for life, the reproductive cycle is not one. So to conserve energy for more important things, the hypothalamus will shut down the reproductive hormonal cascade.
The diagnosis of FHA is a process of exclusion. Clinicians will need to rule out all other possibilities for why the menstrual cycle has stopped before diagnosing a person with FHA. A diagnosis means ruling out things like pregnancy and other conditions such as endometriosis and medications that can halt menstruation.
Hypothalamic Amenorrhea & Birth Control
Like a lot of things in women’s health, hormonal birth control can complicate matters.
Sometimes contraception can hide the existence of FHA. For example, someone who is on the oral contraceptive pill who is having regular withdrawal bleeds. These bleeds are not a ‘regular’ period so FHA can be present whilst continuing to have these bleeds on the placebo pills.
On the other hand, methods such as the Depo shot, Implanon, and Mirena can all cease menstruation completely making it almost impossible to recognize the signs of FHA which can still be present.
Furthermore, if birth control was prescribed to regulate an already irregular or absent period, it is unlikely to have fixed the problem. While the use of estrogen replacement in the form of birth control will provide a withdrawal bleed, it is simply a band-aid solution for a more complicated problem.
It should also be noted that for people who had a regular menstrual cycle prior to birth control, periods should return to normal not long after they stop using hormonal contraception.
Why Is It Important To Address Hypothalamic Amenorrhea
Hypothalamic Amenorrhea & Fertility
When the body has to go into ‘battery saver mode’, the reproductive system is one of the main things that gets downregulated to conserve energy.
The ability to reproduce is not essential to human life and therefore is not considered important when the body is under stress and has to prioritize what functions will receive the limited energy available in the system.
The loss of a menstrual cycle associated with FHA does reduce fertility and is often not addressed until a person is wanting to become pregnant.
However, even if you have no plans of getting pregnant now or in the future, the hormonal imbalances associated with FHA have negative impacts beyond reduced fertility.
Hypothalamic Amenorrhea & Bone Health
Low estrogen levels in women are associated with increased bone resorption. This is when the tissue in the bones is broken down and the minerals are released into the bloodstream.
There is also a reduction in calcium absorption in the intestinal tract.
Usually, we associate this with menopause and this is why post-menopausal women have much higher calcium requirements than pre-menopausal women.
However, there is also a reduction in estrogen levels seen in FHA can lead to premature bone thinning. This can result in conditions like osteoporosis and osteopenia.
Furthermore, the high cortisol levels associated with FHA can also reduce the intestinal absorption of calcium AND are associated with an imbalance in vitamin D absorption. Further adding to FHA’s impact on bone health.
Our bone mass peaks around the age of 25-30 years old and after this age it is mostly about damage control and reducing bone loss over time. So if someone has had periods of FHA throughout their young adulthood, it is very difficult to undo the damage to bone health once they reach their late 20s and early 30s.
Hypothalamic Amenorrhea & Cardiovascular Health
We have known the impact of low estrogen levels on bone health for quite some time now but another function of estrogen is actually as a potent vasodilator.
The research on low estrogen, FHA, and cardiovascular impact is limited. However, some of the study findings we have currently would suggest that FHA may increase the long-term risk of heart attack. Potentially even when it is not an ongoing issue during later life.
Research from the Nurses’ Health Study of over 82,000 women that self-reported menstrual cycle history demonstrated that the more irregular the menstrual cycle in young women the greater the risk for future cardiovascular events.
This was up to a 50% increase in risk!
Stress on the body can come in many forms. It can be physiological from over-training or it can even be psychological and emotional distress. Having this type of excess stress in your life can lead to or contribute to FHA.
Most women can relate to going through a period of high stress, grief or depression and experiencing a loss or irregularity of their menstrual cycle.
People with FHA have significantly higher depression scores, greater anxiety, and increased difficulty coping with daily stress.
So whilst it can contribute to the presence of FHA, FHA may also worsen mental health outcomes.
How To Restore Your Period With Hypothalamic Amenorrhea
Increasing Food & Calorie Intake
One of the most common causes of FHA is a large discrepancy in energy intake and energy expenditure.
Meaning someone is eating too few calories for how many calories their body is burning on a daily basis to point that their overall energy availability is very low.
For example, FHA is more common amongst people with restrictive eating disorders, those who are dieting aggressively, and athletes who consistently under fuel (whether intentionally or not).
However, to reverse FHA it often doesn’t take a major increase in daily calorie intake to make an impact.
The REFUEL study found that an increase of just 300-360 calories per day is enough for many people with FHA to resume their period. That could be just one extra decently sized snack in someone’s day.
Have Enough Fats In Your Diet
Very low-fat diets can also lead to hypothalamic amenorrhoea.
Dietary fats play an important role in the production of hormones including estrogen.
So when fat intake is very low, hormone production is interrupted.
A general recommendation could be aiming for at least 0.6g of fat per kilo body weight per day in your diet. However, depending on one someone’s body composition, in regards to their body fat percentage, this target could be slightly shifted.
So another recommendation would be to get at least 20% of your daily calories from fat when eating at maintenance calories or in a small surplus.
Aim to include a wide variety of foods rich in healthy fats including nuts, seeds and avocado.
Oily fish such as salmon and sardines are also a great thing to include regularly as they are sources of omega-3.
You May Need To Increase Your Body Weight
Being too ‘lean’ or having a body fat percentage below what your body is comfortable maintaining is another potential risk factor for FHA.
Having a very low amount of body fat can result in the downregulation of the reproductive system.
In the athletic world, we see this a lot amongst bodybuilders or bikini competitors when they are heading into the competition. It is also common amongst gymnasts, dancers particularly ballerinas, and those in weight making sports such as lightweight rowing
Increasing body fat does not always have to be part of the process of regaining your period. However, if you are currently very lean or you are maintaining a lighter bodyweight, it may be a very important part of solving the issue.
If you increase your calorie intake to a reasonable level and start to gain weight, it is highly likely that you were excessively lean.
Reduce Your Exercise
Reducing the overall stress on your body coming from exercise or training could also be a piece of the puzzle when it comes to treating FHA.
If you are doing too much exercise, whether that is in intensity, volume or both and not allowing yourself sufficient recovery time, your body is going to start shutting down less important processes. Like your menstrual cycle.
This accumulation of fatigue and lack of sufficient recovery may also present as chronic fatigue, poor performance, muscle soreness, and being injury prone.
Reducing exercise for FHA treatment will likely look different for each individual. Some practitioners recommend taking a break from training altogether for the fastest results, whilst others recommend simply reducing intensity and frequency to a more moderate level.
Focus On Stress Management
Stress is stress. Whether it is overtraining and undereating or going through a hard time with your mental health.
FHA can result from psychological and emotional stress.
As previously mentioned, most women have had the experience of losing a period due to this kind of stress alone.
Due to this link, cognitive behavioral therapy (CBT) has been found to be an effective treatment option for many people with FHA.
In one study, women who had FHA that received 16 sessions of CBT had a 75% higher rate of resuming their period than those who did not receive the sessions.
In another study from 2003, on CBT in 16 people with FHA found that 87% resumed ovarian activity over 20 weeks – whereas only 12.5% in the control group did.
So obviously, mental health and stress can play a big role in all of this.
Hypothalamic amenorrhea is a warning sign that the body is under too much stress. It is the ‘battery saver mode’ that your body uses to protect more important physiological functions.
The existence of FHA as a condition is actually a good thing since it’s a protective measure our bodies have been able to develop through evolution.
However, having FHA should not be brushed off or left untreated if it occurs.
Having FHA can impact bone health, heart health, mental health, and of course fertility. So it should not be taken lightly. It is far from an optimal state for the body to be in.
Treatment of FHA is going to look different for everyone and will be dependent on what is likely causing the absence of a period in the first place.
Although it could include increasing calorie intake, weight gain, reducing or stopping exercise and training, and reducing general emotional and psychological stress. The research is pretty promising on the use of CBT in managing FHA so that should be a consideration also.