Getting Periods Again Postpartum

One thing many women who have experienced hypothalamic amenorrhea / no periods want to know is … will I get my periods again after I have a baby, and if so, WHEN??

We discuss this in depth in No Period. Now What? and here’s a cool graph that shows when my survey respondents started cycling again in relation to weaning (because breastfeeding increases levels of the hormone prolactin, which suppresses the reproductive system – to different levels in different women).

One of the key factors I found in my research around cycle resumption was an article that suggested a small weight gain was helpful in cycle resumption; this makes sense as it signals the body that energy is plentiful and reproduction is once again “safe” – just as with resuming cycles after hypothalamic amenorrhea in the first place. I was recently listening to the Period Podcast with Kate Clancy and was pleased to hear the expert she interviewed back this hypothesis up. Which turns out makes a lot of sense because it was Dr. Claudia Valeggia, who wrote the article I referenced. ๐Ÿ™‚

Anyway, Laurel who is in my facebook support group agreed to share her story, including postpartum cycle resumption – she hoped to continue breastfeeding but wanted to try and get pregnant again.

“I was a heavy teen and young adult. I went on oral contraceptives early to lessen my acne. I lost weight quickly when I was 23 years old and got into running. I never really noticed my cycle until I got married at 28 and went off the pill. I didn’t regain a cycle after 6 months, and started looking for reasons. Everything about HA resonated with me, and I found the support of the Fertile Thoughts board [genesis of No Period. Now What?] around the same time I met with a reproductive endocrinologist. Two rounds of injectables and 20 pounds later, I still didn’t have a period and wasn’t responding well to meds. I was “all in” in name only, but not mentally all in, as I was already resigned to doing IVF. We did one very easy (probably because I had gained weight!) round of IVF in May 2014 and I conceived my son. He was born in February 2015.

I breastfed my son and he was very needy, never sleeping more than an hour at a time. He nursed constantly. I started running again at 6 weeks postpartum and slowly lost weight. I settled at about 10 lbs. above my HA weight and was running what I thought was a reasonable 4 times a week, definitely not as much as before pregnancy. I wasn’t worried when I didn’t get my period for the first year, then 18 months, then 2 years postpartum. When my son turned 2 I started wondering. He still nursed all the time and I was still running. We weren’t trying to conceive, but I was worried about my bone density and heart health long-term. After running a disappointing race in October 2017, I quit running and vowed to give “all in” a better try. If I didn’t get my period in a few months, I’d try to start the weaning process with my son.
I looked at my diet and although I wasn’t restricting, I went 12+ hours without eating overnight and was nursing multiple times during that time, so my caloric deficit was high for several hours. I had just read an article on Nico’s blog about hours in energy deficit, so I added in a big pre-dinner snack and amped up my breakfast. I ate and ate. Twenty+ pounds and 3 months later, I noticed funny symptoms. I randomly took an ovulation test and it was positive! Eleven days later, I got my first non-medication (BCP or fertility medication) period since I was 17! It was amazing. My husband and I thought that since I was cycling, we might as well try to have a baby naturally. My second cycle was long, and I didn’t ovulate until cycle day 38. I was excited to have a second cycle, and even more excited when I started getting positive pregnancy tests 10 days later!
I’m very happy I didn’t have to wean to conceive again, because extended breastfeeding was important to me. Figuring out that the energy expended overnight was an important part of the equation, for me, was great. I also had to be comfortable getting to a weight I hadn’t seen since my overweight teens. It’s worth it for another baby and for my long term health.

If you’re in this situation, or might be in the future, I hope that it helps you to know that 84% of women in my survey resumed natural cycles after pregnancy (in those who wanted to conceive again), and 94% had resumed cycles at the time I performed my survey, after they were done having children. I do need to update those numbers, I do believe that a few years out the final cycle resumption number is higher ๐Ÿ™‚

Many of those who resumed cycles had not restored periods prior to pregnancy – but they maintained a weight at which their body was happy, fully fueled any exercise they were participating in, and did resume cycles after having a baby. For those who didn’t, many were anxious to conceive again and didn’t want to wait – hence the higher rate of recovery after families were complete.

Anyway if you’re interested in more data and information on this topic, please do check out our book!



Energy Balance and No Period…

Why is it that some women have no period, where others, in seemingly the same situation with exercise and energy consumption continue to menstruate regularly?

A possible explanation for this difference was recently offered by researchers in Sweden. Instead of looking at energy balance or availability for a whole day, as is the standard in energetic research, they computed energy balance on an hourly basis.

Before we get into the meat of the paper, it’s results, and my analysis, a few terms that might be helpful to understand:

  • energy balance: Total energy intake (kcal) minus total energy expenditure, i.e., resting metabolism + daily living + exercise.
  • resting metabolism: calories burned to fuel involuntary processes: pumping blood, fueling brain, building muscle and bone
  • glycogen: stores energy in the liver for short term use, ~300 kcal worth (Farenholtz et. al, 2017)
  • kcal: short for kilocalorie, measure of energy. In the US we usually say “calorie” instead.
  • negative energy balance: more calories expended than consumed; during small deficits, liver glycogen can make up the difference. During larger deficits (e.g., < -300 kcal), fuel is obtained from other body stores, for example, fat and muscle (called catabolism).

Alright – getting back to the paper. The findings were remarkable; the average time with a negative energy balance of < -300 kcal for athletes with regular periods was 17.6 hours (Interquartile range (IQR) 3.9 โ€“ 20.8 hours), versus 21.8 hours in athletes with no periods (IQR 17.8 โ€“ 22.4). Athletes with no periods were in a catabolic state (negative energy balance) for four more hours per day than athletes with regular periods.

What I found really interesting was a diagram the researchers included, illustrating how hourly energy balance was calculated. This example shows a period of significant energy deficit at night, with no positive energy balance until the middle of the day (presumably lunchtime). Thinking of energy balance on an hourly basis like this rather than simply the amount of energy consumed in a day leads me to wonder if this might be part of the reason some women can be โ€œall inโ€ for 6+ months without period restoration, where others resume cycles within just 6-12 weeks. Continue reading

Factors in a Missing Period / No Period, Part 2

Today we’ll talk about three additional factors that play a part in missing periods / no periods: weight and weight loss, stress, and genetics. In a way you can think of these factors as spokes in a wheel. One broken spoke (one factor taken to extreme) could make a wheel non-functional. Or, multiple cracked but not yet broken spokes (multiple factors in play but none to an extreme) could end up having the same effect of a non-working wheel. (Click here for more information on the role of exercise and eating when one has no period due to hypothalamic amenorrhea. )

3. Weight and weight loss

It is common to think of no periods / missing periods as an issue for women who are super-skinny, but in fact it is very possible to have HA at a higher weight. However, that said, a BMI under about 21-22 is for many women hard to maintain without some level of food restriction, and particularly at a BMI under 20 it is likely that weight and bodyfat are not high enough to support a functional reproductive system. This is particularly true in combination with other factors.

Here’s a graph that shows the BMI of our survey respondents when they were diagnosed with hypothalamic amenorrhea.Range of BMI when women had hypothalamic amenorrhea
The median BMI when HA was diagnosed was 19.0, 33% were “underweight” with a BMI of 18.5 or less, and 7.5% had a BMI of 22 or more.

The next part to this particular issue is weight loss. We were surprised when we analyzed our data to find that 82% of our survey respondents with no periods had lost more than 10 pounds at some point in the past. Weight loss and the caloric restriction that lead to that loss certainly played a part in my missing periods. Here’s the graph of that weight loss (each line represents 10% of the 272 women who provided these data):
Weight loss and hypothalamic amenorrhea
You can see that there was significant weight loss even in women whose starting weight/BMI was “normal”. This was true for me – I thought I was being so healthy by losing weight in preparation for a healthy pregnancy – I didn’t take into account that the recommendations to try and lose weight in order to increase chances of pregnancy are meant for women in larger bodies (and are likely unhelpful in those cases as well). I really thought I was doing everything right. It took me a long time to come around to the fact that my body didn’t agree with my mind that I needed to be thinner. (No period was sign I was unwilling to recognize for a while)

4. Stress

Thee next factor is stress, and by that we really mean psychological stress. Exercise can also be seen as a form of stress by our brains but for now let’s examine the effects of purely mental stress. I’m sure you’ve heard stories of women skipping a period after the death of a loved one, or while going through a divorce. So mental stress alone can mess up a normal cycle.

I experienced the effects on my cycle of mental stress when my youngest was almost two. His leg broke while going down a slide with his father – they went over a bump and Cam’s leg got caught underneath Dad. (Side note, never ever do this, it is actually a common source of toddler injury). With two older children and a toddler with 2-year-old desires but now the physical abilities of a newborn, it was an incredibly stressful time for me. I was tracking my cycles and found that the stress manifested in a luteal phase (the time between ovulation and getting a period) that was about five days shorter than had been my norm. I imagine that had the stress continued for longer my cycle might have stopped altogether, but fortunately Cam started walking again three weeks after his cast came off.

So those are some of the effects of acute stress. But what about chronic stress? Perhaps from a family situation, maybe from work, or sometimes, just the stress of constantly trying to live up to the high ideals and goals we set for ourselves.ย  And the real kicker is that often those stress-inducing goals include maintaining a strict, “healthy” way of eating, and a daily or weekly exercise plan. Another irony is that worrying constantly about not getting a period can be felt by the body in exactly the same way, as chronic stress.

When you mix this stress together with caloric or food group restriction, you are even more likely to lose periods. A study in monkeys found that stress alone (of moving to a different cage) disrupted menstrual cycles in a couple of sensitive monkeys. But when food restriction and exercise was layered on top of the stress, the mixture caused no period in a large majority (but not all – those “lucky*” women who can be thin, run marathons, and get pregnant at the drop of a hat.)

5. Genetics

The last piece of the puzzle in getting to hypothalamic amenorrhea is likely to lie in our genes. A few recent studies have found mutations (small changes) in women with HA in the proteins along the pathways that are involved in control of the menstrual cycle. This suggests that some women have a greater predisposition to loss of periods than others.

This might feel unfair, but I have come to thank my lucky stars for having been so predisposed; missing my period gave me the challenge and reasons to change my ways which I thought were healthy but now realize had crossed the line of health and were creeping into obsessive territory.

I have found upon recovery, as have many, many others, that I do not need to be nearly as strict with myself in order to maintain a healthy weight. I have found a place where my exercise is in balance with the rest of my life and I am no longer compelled to work out

I am fairly sure part of why I had no period stemmed from genetics (I have a naturally short luteal phase which given the interconnectedness of all the hormones involved with our menstrual cycles leads me to believe that I am likely to have some mutations), severe caloric restriction leading to rapid weight loss, a low-for-me BMI of 19, and low bodyfat (16%) , along with overexercising. I kinda went gangbusters and just broke all my spokes at the same time – it’s no wonder my wheel was broken.

This post includes a quick information sheet on hypothalamic amenorrhea as well as a free download of the first chapter of No Period. Now What?. Check it out for a LOT more info!

* These women are not in fact “lucky”- they remain stuck in the prison of calorie counting and feeling like they must exercise… please follow me on instagram and/or join my facebook support group to read about how much women gain from recovery.

What’s your combination?

Factors in a missing period / no period, Part 1

There are five factors that play into when a woman stops ovulating and has no period due to hypothalamic amenorrhea, aka HA. The most common combination is undereating/underfueling, and overexercising/overtraining. But… that is far from the only way to get HA. Stress alone can cause one to miss a period; add in a little bit of food restriction or increase in exercise, and that one missed period turns into many. Or perhaps you were in a larger body at one point and lost more than 10 lb to get to a “normal” weight… that alone can cause missing periods in some, but add that weight loss to food group restriction, like a low-carb or low-fat diet, and boom. No periods. (There are other reasons behind no periods, of course, one of the most common being PCOS… all of this is discussed in more detail in our book).

Let’s go through the factors one by one, and I’ll share some more data from our survey respondents with you.

1. Exercise

The first factor we’ll consider is exercise.ย  I shared last week that the amount of exercise can vary widely among women with HA, although we do tend to exercise more than four days a week and for an hour or more at a time. What’s interesting, though, is when you look at exercise intensity. That is another part of the equation. We asked our survey respondents about the intensity of their exercise when their periods were missing versus prior to that, when periods were normal.

Average exercise intensity when women experience hypothalamic amenorrhea versus prior

The two lines show exercise intensity on a scale where 0 is sitting, 5 is moderate exercise like a fast walk or slow jog, heartrate in the 140-149 range; 10 is a personal record pace, heartrate 190+. Each point shows the percentage of 278 women who described the average intensity of exercise they performed prior to having hypothalamic amenorrhea compared with the average intensity when their periods were missing. You can clearly see a shift to the right, denoting higher exercise intensity when periods disappeared. With normal periods, the average intensity was between 4-6; when periods were absent, average intensity was more like 6-8.

2. Eating

The second factor is eating. In my case, I started limiting myself to 1500 calories a day, because that’s what my (male) coworkers were doing in an attempt to lose weight. I thought, hey, that should work for me, as a woman I need fewer calories than my guy friends, but I exercise more, so sure, let’s go with 1500.ย  I made myself an Excel file in which I tracked every morsel that passed my lips, and if I didn’t know the exact number of calories I would overestimate so I didn’t “eat too much.”

Not all our survey respondents tracked how many calories they were eating, but among those who did, my experience was fairly typical. The average consumption when our survey respondents had hypothalamic amenorrhea was 1481 calories a day.

Number of calories eaten per day for women with hypothalamic amenorrhea

This is something that many doctors don’t even ask about when a woman is missing her period. They look at the woman and her physique/BMI, and if she “looks” normal, they don’t dig any further. But many of us are severely restricting the amount of food we eat, mostly in order to maintain/attain the societal idea of thinness.ย  Never mind the cost.

If we’re not restricting the amount of food, there is often a feeling of wanting to avoid “unhealthy” food, whatever that might mean to you. For some it’s fat, for some carbs, for some cooked food… regardless, the mindset that you have to watch what you eat can cause inadvertent calorie restriction, and also mental stress (see tomorrow’s post!)

Were you exercising more or more intensely when you had hypothalamic amenorrhea than before or afterwards? Did you track and restrict calories, or avoid certain food groups?

Factors in a missing period / no period, part 2


P.S. Feel free to download and share any of the graphs from these posts!