There are common misconceptions about how someone can lose their period. “Everyone” seems to know that those who have eating disorders or are "Olympic-level athletes" commonly have no period. What is much less well-known, however, is that periods can go missing at much less extreme levels of calorie/food group restriction and exercise, and at a wide range of body sizes.
A big part of my book, No Period. Now What? is the survey of over 300 women that we completed, asking a variety of questions about factors leading to hypothalamic amenorrhea, steps taken to recover, and recovery success (as well as trying to get pregnant, pregnancy, and beyond.) From that survey we were able to get a much better picture of the range of women affected by missing periods.
Other terms that can be used for "no period" that all involve aspects of the same condition include:
female/male athlete triad
relative energy deficiency in sport
I'm offering a free download of both the first chapter of NPNW, which describes the basics of hypothalamic amenorrhea, as well as the information sheet (which is also the information below). Please feel free to share the files: for example with your doctors, others with HA, and friends or family members who might not understand why your periods are missing.
Factors leading to hypothalamic amenorrhea
There are multiple ways someone can lose their menstrual cycle, one of which is hypothalamic amenorrhea (HA). This condition is a component of relative energy deficiency in sport (RED-S), also known as the male/female athlete triad. Another name for it is hypogonadotropic hypogonadism.
In HA, signals that are supposed to be sent out by the brain’s hormonal control center, the hypothalamus, are suppressed. This means that no egg grows, no ovulation (egg release) occurs, and therefore there is no period.
In my experience there are five factors in acquiring HA, and I will discuss each in more detail below. References are included at the end of this post.
The good news is that HA is reversible in most cases.
1. Eating habits
Caloric and food group restriction are common in those with HA. We performed a survey of over 300 women who had HA at one time and found that the average planned caloric intake was 1481 calories a day which is a level usually recommended for weight loss.
Many of those with HA exercise what the average person would call “a lot” but not everyone. The graph below shows the range of exercise amounts in days per week and hours per day. It might be expected that someone exercising two hours a day, seven days a week will have HA. But there are plenty with HA who exercise much less than that. Each bubble below shows the number of people in my survey with the listed amount of exercise.
In addition, exercise intensity is often increased when someone has HA compared with when periods are more normal. Compare the green line below (before HA) with the red (exercise intensity during HA) - you can see that people were exercising at much more challenging levels! (Much more explanation of these graphs in No Period. Now What?)
3. Weight and Weight Loss
People think that only someone who is severely underweight will lose their period / experience symptoms of RED-S. While it is true that 33% of our survey respondents had a BMI less than 18.5 ("underweight"), we also had 7.5% with a BMI over 22 (well into the "normal" range). It has also been clear to me since publishing NPNW that there are many more people who fall into the category of larger bodies with missing periods; but so often there is misdiagnosis when people don't fit the myth for what a person with a missing period should look like.
Previous weight loss was a surprisingly common finding; 82% of our survey respondents had lost 10 or more pounds prior to acquiring HA.
It is common knowledge that an acutely stressful event like loss of a close family member can cause a missed period. However, the hormones that result from chronic stress are also known to shut down the hypothalamus and therefore, particularly in combination with some of the other factors, can cause periods to stop. It’s important to realize that many of us with hypothalamic amenorrhea deal with constant stress from trying to live up to the goals we set for ourselves, often including eating “perfectly” and daily exercise.
Mutations have been found in a number of proteins involved in regulation of the menstrual cycle in people with HA / RED-S. This suggests a potential susceptibility to loss of periods. This can explain why in two people with seemingly similar body composition, eating habits, etc., one might be missing a period and not the other. We each have our own genetic composition, and our own journey!
All in all, these are the factors that are commonly associated with missing periods due to hypothalamic amenorrhea. To learn more, you can download the first chapter of NPNW for free, or if you're ready to dive in and learn all about the #allin method for recovery, get the book now. You can also join my online support group to ask questions and chat with others going through the same thing, or book a time to speak directly with me for a personalized assessment of the factors at play in YOUR amenorrhea, and expert guidance on recovery.
In case you’re interested, references for the information sheet are listed below.
Causes of amenorrhea:
Liu JH, Patel B, Collins G. “Central Causes of Amenorrhea.” Endotext. Updated Mar. 1, 2016. http://www.endotext.org/chapter/central-causes-of-amenorrhea/4/
Effects of underfueling:
Wade GN, Jones JE. “Neuroendocrinology of Nutritional Infertility.” American Journal of Physiology: Regulatory, Integrative and Comparative Physiology. 287(6) 2004: R1277-1296. doi: 10.1152/ajpregu.00475.2004
“Balancing Calories to Manage Weight.” In Dietary Guidlines for Americans, 2010. 7th Edition ed. Washington, D.C.: U.S. Department of Agriculture and U.S. Department of Health and Human Services, 2010. http://www.fns.usda.gov/sites/default/files/Chapter2.pdf
Exercise (stress) and hypothalamic amenorrhea:
Hill EE, et al. “Exercise and Circulating Cortisol Levels: The Intensity Threshold Effect.” Journal of Endocrinological Investigation. 31(7) 2008: 587-91. doi: 10.1007/BF03345606
Loucks AB, et al. “Alterations in the Hypothalamic-Pituitary-Ovarian and the Hypothalamic-Pituitary-Adrenal Axes in Athletic Women.” The Journal of Clinical Endocrinology & Metabolism. 68(2) 1989: 402-11. doi: 10.1210/jcem-68-2-402
Mastorakos GM, et al. “Exercise and the Stress System.” Hormones. 4(2) 2005: 73-89. http://www.hormones.gr/57/article/article.html
Stress and hypothalamic amenorrhea:
Berga SL, et al. “Recovery of Ovarian Activity in Women with Functional Hypothalamic Amenorrhea Who Were Treated with Cognitive Behavior Therapy.” Fertility and Sterility. 80(4) 2003: 976-81. doi: 10.1016/S0015-0282(03)01124-5
Biller MK, et al. “Abnomal Cortisol Secretion and Responses to Corticotropin- Releasing Hormone in Women with Hypothalamic Amenorrhea.” Journal of Clinical Endocrinology & Metabolism. 70(2) 1990: 311-17. doi: 10.1210/jcem-70-2-311
Brundu B. “Increased Cortisol in the Cerebrospinal Fluid of Women with Functional Hypothalamic Amenorrhea.” Journal of Clinical Endocrinology & Metabolism. 91(4) 2006: 1561-565. doi: 10.1210/jc.2005-2422
Caronia LM, et al. “A Genetic Basis for Functional Hypothalamic Amenorrhea.” The New England Journal of Medicine. 364(3) 2011: 215-25. doi: 10.1056/ NEJMoa0911064
Gianetti E, et al. “When genetic load does not correlate with phenotypic spectrum: lessons from the GnRH receptor (GNRHR).” Journal of Clinical Endocrinology & Metabolism. 97(9) 2012: E1798-807. doi: 10.1210/jc.2012-1264