Period missing for 3 months or longer? It may be Functional Hypothalamic Amenorrhea (FHA)
Secondary amenorrhea, defined as the absence of menstruation for three months or longer, is common among athletic women of reproductive age
Losing a menstrual cycle is the body’s way of preserving energy in these high stress situations. If we break it down, it makes sense that the body doesn’t want to devote energy to making babies if it thinks you’re busy fighting a tiger of getting through a famine.
Stress is a powerful inhibitor of reproductive function
Now, “stress” is a pretty broad term. When we say stressors, we are referring to internal or external environmental challenges that cause a neuroendocrine response.
In cases of of FHA the Hypothalamus stops GnRH production, and so the pituitary gland doesn’t produce luteinizing hormone (LH) or follicle signal hormone (FSH), thus the ovaries don’t release an egg to be fertilized, and you don’t get a period.
What are some of the stressors that can contribute to Functional Hypothalamic Amenorrhea (FHA)?
Dieting, low body fat, over-exercise or low energy availability are most common causes of FHA , especially in the fitness space. Energy Availability is the amount of energy “available” to sustain all physiological functions, after accounting for energy expended through exercise. Low Energy Availability leads to impaired menstrual function such as FHA, among many other issues systematically.
In addition, infections, poor thyroid health, a history of birth control use and any underlying diseases can also be stressors contributing to hypothalamic amenorrhea.
Mental health is also a factor in an individual's total stress burden. Poor body image, perfectionism, lack of social support, anxiety, financial stress etc. can’t be overlooked in a female with a missing cycle. This is one reason why Cognitive Behavioral Therapy (CBT) has been utilized as a tool for amenorrhea recovery - to work on the behavioral and mindset piece of the equation.
How to Get Your Period Back
As you can infer, the solution for FHA and getting your period back is not always as simple as to eat more and move less.
When we factor in the mental health component, previous birth control use, each female’s unique health timeline, the intricacies of how all systems work together and overall allostatic load (or cumulative stress) you can start seeing how there may be more to address than just your calories and training.
Proper lab testing is a must if your period is missing in action because it allows for 1) proper diagnosis and 2) gives insight as to what other systems you might need to most support. A blood chemistry and complete blood count, a full thyroid panel, testing for nutrient deficiencies such as anemia and markers to assess adrenal health all can be warranted .
We generally suggest starting with serum labs for our clients but sometimes a GI Map to dive deeper into gut health or a DUTCH test to look at cortisol patterns can be helpful to put more pieces of the puzzle together.
Regardless of labs (and perhaps while you are waiting on testing) we suggest assessing and focusing on the following areas with FHA:
Calorie quality and quantity- ensuring you are eating enough calories and carbohydrates, and not in a state of low energy availability. Consuming a variety of plant and animal foods to ensure plentiful micronutrients is also of critical importance.
Sleep- Work on a routine to get enough sleep and enough quality sleep each night.
Exercise and movement- This is NOT us cosigning an an exercise addiction or over training. That said, we do feel if you want to continue to train (and you are medically stable) , you continue to do so. The key is to understand that while a good stressor, exercise is still a stress that the body must recover from. If we are also asking it to recover a menstrual cycle, ensuring the other "inputs" on this list are accounted for is critical. Intensity and volume of training may need to be adjusted from what you are currently doing.
Mental Health and fostering a positive stress perception. There’s a reason why CBT has been utilized as a tool for amenorrhea. Not only do we know mental stress can be a trigger for HA, but low estrogen/progesterone (due to not ovulating ) can make you feel down or anxious- a vicious cycle. Professional support and using mindfulness tools such as journaling, yoga, meditation or breathing exercises can be very helpful as you support your physical body in getting your cycle back.
Address gut health-Poor gut health can lead to nutrient deficiencies and be a source of inflammation, both of which impact fertility.
Blood sugar- Eating balanced meals every ~3-4 hours and being careful about any extending fasting is important in helping the body feel “safe,” and avoid riding a blood sugar roller coaster as well as remaining insulin sensitive.
Thyroid support- An under functioning thyroid is closely tied to amenorrhea due to the major role it plays in energy production and ovulation.
Spiritual and Emotional wellbeing - the more “woo” side of things for some, but in our experience having a grounding practice, affirmations, gratitude lists, getting in touch with your feminine energy can be powerful ways a female can support her fertile health and healing.
Liver support- Especially after oral birth control use, as the liver plays a pivotal role in regulating and detoxing hormones .
A final ingredient to recover your cycle is time. Depending on how long that brain/ovary communication has been turned “off” (whether from birth control, low energy availability or something else) and epigenetic factors, it can take some time to restore a cycle. Even when doing “all the right things.”
Finally, once you get your period back, supporting these systems is still important!
The goal is to have consistent ovulatory cycles in a female’s reproductive years to ensure proper hormonal balance. Fertile health is about a lot more than just making babies. By including the menstrual cycle as a vital sign, we highlight the importance of a hormonal axis that is working in harmony for our overall health and longevity.
If you’ve been missing your period for three months or longer, it’s time to take action. Addressing Functional Hypothalamic Amenorrhea requires a comprehensive approach, considering diet, exercise, mental health, and more.
Don’t navigate this journey alone— at Fortify Health Coaching, we can guide you through personalized strategies for recovery. Reach out today to schedule a consultation and take the first step towards restoring your menstrual health.
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