What is Hypothalamic Amenorrhea?
The following article serves as an introduction on the causes and complexity of Hypothalamic Amenorrhea. This article does not outline treatment, as will be a focus in a separate post.
In the subsequent posts I will share my current plan and journey, previously attempted treatments and their outcomes and hopefully a tool to help you recognise what part you need to work on with some suggested strategies. It needs to be mentioned that the right ‘plan’ also depends on your ‘stage’ in readiness to change.
Positive progress can be just moving to the next stage in your acceptance, readiness and actioning, rather than viewing success as only getting your period back.
We all differ in our readiness and an effective plan needs to be matched to this. ‘I don’t have a problem’ (pre contemplation) to, ‘maybe I have a problem, but I am not ready to do anything’ (contemplation), to ‘taking some initial conservative steps but may result in 1 step forward and 1 step back’ (preparation), to being ‘fully committed and ready to make whatever change is necessary’ (action) is the direction of progress in tackling this complex issue.
For progress from the first stage of ‘pre-contemplation’ or ‘unawareness or denial of a problem’ to recognising there is a problem (contemplation) first requires education. I hope this article provides this awareness and then proceeds with taking some action!
For more information on the Theoretical Model of Behaviour Change click here.
What is Amenorrhea?
Amenorrhea is the term used when a woman or adolescent girl is not having menstrual periods. There are two types of Amenorrhea:
- Primary Amenorrhea: when a girl has not started having periods by age 15 (or within 5 years of the first signs of puberty)
- Secondary Amenorrhea: when a girl or woman has been having periods but then stops having them for at least 3 months
There are many causes for Amenorrhea, and it should be noted it is not normal, something isn’t right. Finding out the root cause and a treatment plan is essential!
Hypothalamic Amenorrhea (HA):
Hypothalamic Amenorrhea is a condition characterised by the absence of menses due to the suppression of the hypothalamic–pituitary–ovarian axis, in which no anatomical or organic disease is identified. Adolescents or young women with this condition typically present with amenorrhea of 6 months’ duration or longer. (Gordon, 2010)
The Endocrine Society’s new (2017) clinical practice guidelines released on treating patients with functional Hypothalamic Amenorrhea highlights the complexity of condition and the need for a multidisciplinary approach to treatment. (Gordon, et al., 2017)
It is common for some patients to be reluctant to undertake certain lifestyle changes recommended from their clinician such as to reduce exercise, eat more or gain weight to overcome HA. It is difficult to help someone who is not willing which provides a whole other set of challenges.
Hypothalamic Amenorrhea is ultimately a diagnosis of exclusion but should only be diagnosed by a specialist after all necessary information is collected and analysed including from blood tests (hormones and general biochemical markers of health), a pelvic ultrasound and a physical examination including taking a lifestyle history to investigate lifestyle stresses, family history, exercise patterns, weight history and information around current and past nutritional status as well as behaviours and attitudes around food.
Patients with HA characteristically have a low level of serum estradiol and low or low-to-normal levels of luteinizing hormone and follicle-stimulating hormone, whereas the gonadotropin response to GnRH stimulation is preserved. In a patient with presumed HA, the measurement of follicle-stimulating hormone alone generally provides adequate information to rule out ovarian insufficiency. (Gordon, 2010)
To put it simple the cause of HA is stress.
Three main types of functional Hypothalamic Amenorrhea have been recognised, associated with stress, weight loss, or exercise. Women who are either underweight or of normal weight may be affected, but often all three factors are present. An energy deficit (which can occur independently of body weight) appears to be the critical factor in both weight-loss and exercise-induced forms of Hypothalamic Amenorrhea. (Gordon, 2010)
Underweight or insufficient body fat:
Weight loss results from an energy deficit. Inadequate fat stores, especially in women can cause havoc. Although many strive for a ‘lean physique’, falling below a ‘healthy range’ for body fat is as dangerous if not more dangerous than sitting above healthy fat ranges. Many are aware of the negative side affects of carrying too much fat, especially around their vital organs, especially when it comes to cardiovascular risk, but what is often neglected is the bodies need for fat to function.
The female’s reproductive system is designed to produce and carry a baby throughout pregnancy and be the soul source of nutrition for the first part of the baby’s life. In many ways during the pregnancy the mother’s health comes second as it prioritises its nutrition to the developing foetus. It does this my depleting the mothers nutritional stores of certain nutrients including iron in preference to support the baby. In this way we can understand the power, intelligence and beauty of the human body.
Interestingly, a women’s energy requirements are increased around the time of her cycle and ceasing this cycle preserves energy. There is conflicting conclusions as to how the body turns off the mensural cycle as there are so many factors at play and also individuality but most high quality literature and research agree that both a method to conserve energy and also to prevent an unhealthy pregnancy are very probable purposes.
We know body fat is a significant source of estrogen therefore it is important to maintain an optimal level of body fat for fertility. A study conducted on 141 healthy women in southern Poland with self-assessed regular periods (between 25 and 35 days) as part of the recruitment criteria concluded that having less than 22% body fat correlates with low estrogen levels, resulting in issues with menstruation and fertility. (Ziomkiewicz, Ellison, Lipson, Thune, & Jasienska, 2008)
Although there is no BMI or body fat percentage number that is definitive for everyone to when your mensural cycle will stop, around 20 % body fat seems to be a number that much high-quality research agree on. As discussed there are many other factors at play along with individual sensitivity. Although below 20% body fat is commonly seen in athletes this doesn’t necessary mean that their general health is optimum. Apart from amenorrhea, which is commonly masked from the pill, biochemical markers of kidney, liver and heart function can be outside healthy ranges in lean athletes who may also be over training. You can be fit, fast, powerful and strong but this doesn’t always mean you are at your most health state and can have long term health and fertility consequences.
Exercise, what’s too much?
Exercise induced energy deficit:
Your body requires a certain amount of energy, fat and protein to maintain normal bodily functions including the preference to direct energy to the heart and lungs. When exercise results in expending more energy that is available the body is in a state of stress and tries to adapt in response to survive. The hypothalamus is like the master gland of the body. When there is a major energy low, the hormonal signals from the hypothalamus to the pituitary and then to the ovaries are shut down and the energy is directed to other organs, like the heart and lungs. The hormones produced by the pituitary gland, luteinizing hormone (LH) and follicle stimulating hormone (FSH) and ovarian hormones estrogen and progesterone become extremely low resulting in little or no ovulation and few if any periods (oligomenorrhea).
Exercise can impact mensural cycles even when energy needs are met and even in an individual sitting within a healthy range for body fat. (Mastorakos, Pavlatou, Diamanti-Kandarkis, & Chrousos, 2005)
Stress, as the chief cause of Hypothalamic Amenorrhea can be contributed to by intense exercise and or high volumes when there is insufficient recovery. This is common in people with weight loss goals, those who only use exercise to manage stress, athletes from recreational to elite, meaning they don’t have to have exceptional fitness results and those who are addicted to exercise. Often we are all too familiar with the benefits and importance of exercise, even with national guidelines to aim to achieve but little are we aware of the consequence of doing too much or overdosing!
When exercise becomes too much for the body, it puts the body into a state of “stress”. This results in the stress hormone cortisol being released in excessive amounts resulting in shunting the release of important hormones including gonadotropin-releasing hormone (GnRH), follicular stimulating hormone (FSH) and luteinizing hormone (LH) (Mastorakos, Pavlatou, Diamanti-Kandarkis, & Chrousos, 2005)
This leads to a decrease in circulating estradiol, a precursor to estrogen that is needed to stimulate the ovaries. The result is a cease in ovulation.
Today there are many who depend on apps, online calculators and equations to tell them how much energy their body needs and nutritional information panels (NIPS) to tell them how much energy their body is absorbing.
Exact individual energy requirements are almost impossible to determine, unless you have access to someone trained to perform direct calorimetry or the doubly labeled water technique, which also brings with it high costs.
Estimated energy requirements are just that, estimates. These include estimated energy equations and added stress or activity factors that are most commonly used by health and fitness professionals and through apps and online calculators. A Dietitian has the understanding that they are only ‘estimates’ and that if the client is not responding to the treatment plan and if all other factors are ruled out then adjustments are made.
These tools are of course great but must be used with caution. NIP’s are based on nutrition databases, so again based on ‘averages ‘ and often NIP’s found on food products are created via a widely accessible website. They are not tested in their lab on their exact food. I know because I have had to create these for projects I have been involved in an even with my nutrition composition knowledge I can still make small errors.
There and many potential areas for error here including incorrectly entering the weight of an ingredient and factoring in moisture and nutrient losses during cooking.
Sometimes we need to step back and look at the big picture. If you are losing weight you are in an energy deficit, this could be due to an increased metabolic rate due to illness or increased exercise or purely just not eating enough energy to match output. If you are weight stable, you are meeting your energy needs. If you are gaining weight, with your current metabolic rate and health status you are consuming more energy than your body requires. There is the exception when it comes to fluid losses and gain. Fluid balance can be poorly regulated in certain disease types such liver and kidney disease but if out of scope for this blog and if you are gaining or losing large amounts of weight unintentionally you should seek medical advice.
Female Athlete Triad:
Hypothalamic Amenorrhea fits within the Female Athlete Triad syndrome. Understanding this relationship is helpful to understand how sometimes too much of a good thing can be dangerous when referring to healthy eating, exercise and a strive for a lean physique, especially in females.
The Female Athlete Triad is a syndrome of three interrelated conditions that exist on a continuum of severity, including:
- Energy Deficiency with or without Disordered Eating
- Menstrual Disturbances/Amenorrhea
- Bone Loss/Osteoporosis
Energy deficiency with or without Disordered Eating
A chronic energy deficit is main cause of the Female Athlete Triad. An energy deficit is created when inadequate energy is consumed to meet one’s energy needs. As athletes typical expend more energy than the average person with increased training it is important that they meet these addional fuel needs by consuming more energy from food.
Failure to meet energy needs can be both unintentional and intentional. A lack of knowledge in nutrition for training and in what foods provide greater nutritional and energy value, conflicting messages from the media, social environment or coaches, lack of appetite after intense training, food availability and access to healthy and safe food, financial situation, lack of skills in food preparation and purchasing and a general lack of self-care or interest.
Intentional inadequate fuelling is also common in aim to achieve or maintain a lean physique. Many sports due to a believed overall performance benefit or just aesthetics favour a lean physique which encourage athletes to strive for low body fat levels, often below healthy ranges. Weight loss or fat loss is a result of an energy deficit and in fact an absolute requirement for it to occur. Here we start to understand that a lack of knowledge on the long-term impacts of a negative energy balance can be dangerous.
At the end of the spectrum is full blown eating disorders including anorexia and bulimia. These illnesses are multifaceted and require much greater support than just education. These are psychiatric illness that require input from a multidisciplinary team including a psychologist and or psychiatrist, dietitian who specialise in this area and their general practitioner. More information on eating disorders, warning signs and symptoms as well as fact sheets and support services in Victoria can be found here . More information on Disordered Eating will be provided in further blogs.
Menstrual disturbances & Amenorrhea
Secondary Amenorrhea is defined as no menstrual period for 3 months or more. Athletes can be more susceptible to irregular mensural cycles due to the physical stress from exercise and other psychological stresses around competition including anxiety.
Bone loss & Osteoporosis
Women with the Triad are at higher risk for low bone mass leading to weakened bones, called Osteoporosis in its most severe form. A decrease in bone mass increases ones risk for a bone fracture. Insufficient energy to meet the bodies demands as well as a lack of estrogen being produced during amenorrhea are the primary causes of weakened bones and consequential fractures. Unlike the bodies fat and muscle stores, bones are not as easily restored.
- Gordon, C. M. (2010). Functional Hypothalamic Amenorrhea. The New England Journal of Medicine , 365-71.
- Gordon, C. M., Ackerman, K. E., Berga, S. L., Kaplan, J. R., Mastorakos, G., Mirsa, M., . . . Warren, M. P. (2017). Functional Hypothalamic Amenorrhea: An Endocrine Society Clinical Practice Guideline. The Journal of Clinical Endocrinology & Metabolism, 105(5), 1-27.
- Mastorakos, G., Pavlatou, M., Diamanti-Kandarkis, E., & Chrousos, G. P. (2005). Exercise and the Stress System. Hormones, 4(2), 73-89.
- Ziomkiewicz, A., Ellison, P. T., Lipson, S. F., Thune, I., & Jasienska, G. (2008). Body fat, energy balance and estradiol levels: a study based on hormonal proﬁles from complete menstrual cycles. Human Reproduction, 23(11), 2555-2563.