Last time we talked about the first two factors in missing periods / hypothalamic amenorrhea. Today we’ll talk about the remaining three: 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.
3. Weight and weight loss
It is common to think of hypothalamic amenorrhea / missing periods as an issue for women who are super-skinny, but as we described earlier, 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.
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 totally surprised when we analyzed our data to find that 82% of our survey respondents 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):
You can see that there was significant weight loss even in women whose starting weight/BMI was “normal”. I was certainly in that category. 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 who are overweight or obese. 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.
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. 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 get HA. 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 absent cycles 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.)
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 every.single.day.
I am fairly sure that my hypothalamic amenorrhea came 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.
What’s your combination?