By: Jessica Long, MS, RD, LDN

 

Today’s article on hypothalamic amenorrhea is the third installment in our Period Talk series. If you missed the first two, check out Part 1, Periods are a Vital Sign of Health, and Part 2, Trusting our Bodies again with PCOS. 

 

In this third article, we’ll be discussing hypothalamic amenorrhea (HA), including what it is, how it’s diagnosed, and how it’s treated. 

 

What Does Hypothalamic Amenorrhea Mean?

 

Hypothalamic refers to the hypothalamus, and amenorrhea means the absence of menstruation (typically for three months or longer). Hypothalamic amenorrhea, therefore, means the lack of a period due to hypothalamic dysfunction. 

The hypothalamus is often referred to as the body’s “thermostat”. It regulates our body temperature, our breathing, and in the case of hypothalamic amenorrhea, the hypothalamus controls the release of hormones from the pituitary gland that are necessary for menstruation. When our hypothalamus senses that our body would not be healthy enough to carry a pregnancy, it interrupts that hormonal cascade, and our period ceases. 

 

Why Does This Happen?

 

Menstruation (and even more so pregnancy!) are huge energy demands on the body. When the body senses an energy deficit, it offloads systems it deems not absolutely necessary for survival. For some, this energy imbalance comes from under-eating. For others, it’s a result of overexercise, and for many, it’s a combination of both. 

 

A Brief Note on RED-S

 

You might have heard of the term Female Athlete Triad, which was characterized by three conditions: low bone density, amenorrhea, and disordered eating. Expanded upon and later replaced by the more comprehensive term Relative Energy Deficiency in Sport (RED-S) in 2014, RED-S is a result of a mismatch between calories consumed and calories burned in sport. 

 

You might be thinking, but Jessica, I’m not an athlete! Well, I’m here to tell you that you certainly don’t need to be a professional athlete to find yourself in an energy deficit. Perhaps you joined a new gym or decided to train for a race. However, those who exercise at high intensities or play a sport with a focus on leanness are at a higher risk for developing RED-S (and, therefore, hypothalamic amenorrhea). 

 

How is Hypothalamic Amenorrhea Diagnosed?

 

The telltale sign of HA is low estrogen levels. LH (luteinizing hormone) and FSH (follicle-stimulating hormone) are also often low, but they can be in the normal range. If you think back to our first Period Talk article, in which we reviewed the functions of the various hormones involved in menstruation, these lab abnormalities make sense. Estrogen is responsible for stimulating growth of the ovarian follicle, thickening of the uterine lining, and triggering LH (thereby triggering ovulation). In HA, none of these mechanisms are happening, and, as a result, the hormone levels are quite low. An additional sign of low estrogen is breakthrough bleeding. When estrogen is low, the endometrium (the tissue lining the uterus) is quite thin, resulting in spotting between periods. 

 

It’s important to note that a hypothalamic amenorrhea diagnosis does not require the individual to be underweight. It’s entirely possible to be at a “normal” or “overweight” BMI and still develop HA. If your period has been absent for more than a cycle or two, it’s important to ask yourself, “Have I changed how I eat lately?” “Am I exercising any differently?” If you’re a provider whose patient is coming to you and reporting that their period is absent, these questions are a great place to start, too. 

 

Is Hypothalamic Amenorrhea a Problem?

 

In the first article on periods, we noted how a regular menstrual cycle is a proxy for positive health outcomes. An irregular or absent menstrual cycle can cause serious problems if not addressed:  

  • Increased risk of certain cancers.
  • Low estrogen (as seen in HA) can lead to loss of bone density.
  • Ovulating irregularly (or not at all) increases the risk of hypertension, diabetes, and cardiovascular disease. 

Can Hypothalamic Amenorrhea Be Solved?

 

The answer to this question is a resounding YES! For many with HA, period return can be expected within 3-6 months, but it is not uncommon for it to take longer, especially if the period has been missing for an extended period of time. 

  • Increase your intake of carbohydrates and fats. Research has found that those with HA tend to eat less carbohydrates and fats (but more protein and fiber) than their menstruating counterparts. 
    • Add an extra serving of grains to your plate. Toss all grains with butter or olive oil, too!
    • Say goodbye to open-faced sandwiches and use two pieces of hearty (not “lite”) sandwich bread. Slather on extra mayo, avocado, or peanut butter, too. 
    • Reach for the bread basket when out to eat. Bonus points if you add butter or dip it in olive oil!
    • Switch to full fat dairy products. 
  • Decrease your exercise.
    • Some in HA recovery will need to completely abstain from exercise in order to regain their period, whereas others may be able to continue some level of activity. 
      • For my HA patients, this may be the most frustrating part of HA recovery: how some are able to get their periods back relatively quickly and others need much more time, healing, and rest. I think this dichotomy is best explained by Dr. Gaudiani’s “survivor genetics” vs. “sensitive genetics”. 
    • Explore new ways to move your body, like (non-heated) gentle yoga or pilates.
    • Finding yourself struggling to cope without your former exercise routine? Explore a new hobby, like pottery, painting, or drawing. My clients and I love this coloring book.

 

Need Personalized Help? 

 

Working with a Registered Dietitian allows for individualized, targeted nutrition advice to help guide you towards period resumption and subsequent period regularity! The team of Registered Dietitians at Lutz, Alexander & Associates Nutrition Therapy would love to be a part of your healing journey. We specialize in eating disorders and disordered eating in Raleigh, Durham, Chapel Hill, and Cary, NC, and we’d love to help!

Contact us today.

 

References: 

Dobranowska K, Plińska S, Dobosz A. Dietary and Lifestyle Management of Functional Hypothalamic Amenorrhea: A Comprehensive Review. Nutrients. 2024;16(17):2967. Published 2024 Sep 3. doi:10.3390/nu16172967