Updated: Apr 4
In this article, we will learn about Functional Hypothalamic Amenorrhea (FHA), a condition where your period disappears due to chronic stress. We will explore why stress affects our periods, why periods are so important, and what you can do if you are trying to recover from FHA.
Hello reader! My name is Carly (she/her) and I am a researcher here at missINFORMED. This article is meant to be a resource for those who are (or know someone who is) struggling with Functional Hypothalamic Amenorrhea (FHA). I have had my own personal struggles with FHA, an experience that has influenced my perspective on the topic. I acknowledge that my experiences with this condition may not be the same as others and I do not intend to speak on behalf of anyone dealing with this condition. I am not a medical professional. It is important to speak with your doctor if you are struggling with FHA. With that being said, I also want to acknowledge my privilege as a white cis-woman with access to a post-secondary education as my position has shaped my experiences navigating through the healthcare system in Canada. My hope is to use my education and experiences as a researcher to provide scientifically-sound information that will empower others with a better understanding of their body and their health.
What is your relationship like with your period? I’m sure I am not alone in saying that periods can be unpleasant and annoying. Although it can be easy to dismiss as a monthly burden, the truth is that your period and the hormones that regulate it are vital to your overall health. There are multiple reasons why your period may become irregular or absent*. Some of these reasons are normal and likely not a cause for concern. However, a missing period can also be a sign of underlying suppression of your reproductive hormones. If ignored, this type of hormonal suppression can greatly impact your health. Here we’ll do a deep dive on Functional Hypothalamic Amenorrhea (FHA), a condition where your period disappears due to chronic stress. We will explore why stress affects our periods, why periods are so important, and what you can do if you are trying to recover from FHA.
*Certain types of hormonal birth control, medications, and medical conditions may cause your period to become absent or irregular as well. This can be totally normal and not a cause for concern The information in this piece is focused specifically on Functional Hypothalamic Amenorrhea and its impact on overall health. With that in mind, some of this information may not apply to you. If you are concerned about a missing or irregular period, please bring up these concerns with a healthcare practitioner who can evaluate your individual circumstances.
The Hypothalamic Pituitary (HPO) Axis
To understand why our periods may disappear, we first have to understand what normally keeps them around. Reproductive functions are controlled by a cyclical fluctuation of hormones (1). In the ovaries, these hormones support the growth and development of an egg, as well as the egg’s release (ovulation) (1). In the uterus, they support the thickening of the uterine lining and then its shedding if pregnancy does not occur (1). This shedding is what you experience as your period! As annoying as periods can be, they are a sign of a healthy body with a predictable cycle of reproductive hormones.
So what is maintaining this delicate balance of hormones? That is where the Hypothalamic-Pituitary-Ovarian (HPO) axis gets involved. There are three parts to this axis: the hypothalamus, the pituitary gland, and the ovaries (1). While these components of the axis are located in separate areas of the body, they can communicate with each other through hormones. Hormones are chemical messengers in the body. One organ/tissue will release a specific hormone into the bloodstream where it travels to its recipient. For the recipient organ/tissue, this hormone is a signal that instructs the cells of that organ/tissue to alter their function in some way. Let’s take a look at the components of the HPO axis and the hormones involved:
The hypothalamus. The hypothalamus is a brain region with a host of different functions, including hormone production (1). One of the hormones produced by the hypothalamus is Gonadotropin-releasing hormone (GnRH) (1).
The pituitary gland is a tiny gland at the base of the brain that responds to GnRH (1). GnRH causes the pituitary gland to release two other hormones: luteinizing hormone (LH) and follicle stimulating hormone (FSH) (1). These two hormones are released into the bloodstream where they travel across the body to the ovaries (1).
The ovaries respond to LH and FSH. At the ovaries, LH and FSH support the production of estrogen and progesterone (1). It is the interaction and coordination of FSH, LH, estrogen, and progesterone that control the reproductive cycle and keep our periods coming regularly* (1).
*For a more detailed breakdown of how these hormones control the menstrual cycle, check out our previous article.
Functional Hypothalamic Amenorrhea (FHA)
What is it? Functional Hypothalamic Amenorrhea (FHA) is a condition where someone loses their menstrual cycle for 3 or more consecutive cycles due to hormonal imbalances (2,3,4). These imbalances are caused by the suppression of the HPO axis. By suppressing the HPO axis, less GnRH is released(2,4). With less GnRH being released, levels of FSH, LH, estrogen, and progesterone also drop (2,4). Without the normal fluctuations of these hormones, the menstrual cycle and therefore our periods disappear (2,4).
What causes suppression of the HPO axis? When we consider what causes this suppression, there are three main culprits: over-exercise, under-nutrition (caloric restriction), and stress (1,2,4).
You may have heard about Olympic athletes or marathon runners who lost their period due to their extreme training schedule. Unfortunately this situation is far more common than you might expect. FHA occurs in 3-5% of menstruators and these rates are even higher in athletes of any kind (not just olympians) (5). FHA often occurs in circumstances of low energy availability (6). Imagine your body is like your bank account and energy is your currency. Consuming food gives you energy, which is like adding money to your bank account (6). At the same time, the body is constantly using energy (6). A significant amount of the energy your body “spends” powers the basic functions that keep you alive (digesting food, breathing, pumping the heart, etc) (6). On top of that expense, your body also spends energy on physical activities (walking your dog, playing a sport, going to the gym) (6). The more physically active you are, the more energy your body will use (6). Using up energy is like withdrawing money from a bank account. Low energy availability occurs when the body isn’t getting enough energy to support all of its energy expenses (6). An example of this might be if you begin an intense exercise regime without supporting the extra activity with food, or starting a restrictive diet (restricting calories or macronutrients like fats or carbohydrates) that does not provide you with enough energy to support your body’s day-to-day functioning.
While the media often tells us that our bodies should all fit a certain ideal (namely, small, abled, and white), the truth is that we come in many beautiful shapes and sizes. Trying to make yourself smaller, particularly when done with extreme diets and exercise, can actually move you away from being at your healthiest. When your body doesn’t have enough energy, it is forced to adapt. The menstrual cycle requires a lot of energy to maintain (6). While it is important to your overall health, it isn’t essential to keeping you alive. So when challenged with an energy deficit, the body conserves energy for vital functions and shuts down reproductive functions by suppressing the HPO axis (6,7). For this reason, it is common for people to lose their period while dieting, exercising strenuously, or after losing weight quickly (2,3,5,7).
A common misconception about FHA is that it only impacts folks who are underweight. While FHA is more common in people who are at a lower weight, this is not always the case (3,6). Everyone has different energy needs based on their lifestyle, genetics, and age (3,8). Similarly, everyone also has different susceptibility to an energy deficit (6). Your tolerance to an energy deficit can be influenced by your levels of psychological stress. Psychological stressors like the heartache felt after losing a loved one or the stress felt during a long exam season can also cause suppression of the HPO axis (2,3). Someone living with a great deal of consistent stress will be at a greater risk of developing FHA while in an energy deficit (2,3). More often, it is the combination of physical and emotional stressors that leads to developing FHA (2,3).Previous studies have reported that people of colour are at a greater risk of developing certain reproductive health conditions (9,10,11). This risk exists largely because of systemic racism, which among other inequities presents a significant deal of psychological stress (9,11). Currently, there is little to no data on if FHA disproportionately impacts people of colour, suggesting a lack of research attention to this important issue.
A key takeaway here is that people impacted by FHA don’t all look the same. You don’t have to be an Olympic athlete or any particular size to be impacted by FHA. Your susceptibility to developing FHA may be different based on your lifestyle and daily levels of stress.
Does it really matter?
Now you may be wondering, what’s the big deal about periods? Well, having a regular menstrual cycle* is a helpful indicator that our reproductive hormones are balanced (4,12). Without the normal cyclical fluctuations of these hormones, your body cannot ovulate regularly (1,2,5). This makes getting pregnant without medical intervention extremely difficult (2,5). For folks with FHA who do manage to become pregnant, there is a greater risk of pregnancy complications like miscarriage or preterm birth (5). While FHA can be resolved, it can have long-lasting impacts on fertility if it is ignored (5).
*This may not apply if you are on certain types of hormonal birth control which cause you to have irregular, infrequent, or no periods. We discuss this more at the end of the piece.
While our reproductive hormones are obviously necessary for fertility, their importance extends to many other processes in the body (1,2,5,12). One of the symptoms of FHA is low levels of estrogen. Estrogen is extremely important for a range of other health systems and body functions including:
Bone health (4,5,12,13,14). Estrogen is important for bone formation. Bones are constantly changing as new bony tissue is formed and old bony tissue is broken down (5,13). From the time you are born until you’re ~30 years old, your bones continue to grow/ thicken because bony tissue is formed (5,13). This causes your bone mass to increase until you reach your peak bone mass (maximum amount of bony tissue). As you age beyond your 30s, the speed at which bone is broken down surpasses the speed at which it is formed (5,13). This causes bone mass to decrease over time (5,13). Low estrogen levels, particularly during adolescence when substantial bone growth normally occurs, can prevent you from achieving your peak bone mass (5,13). This makes bone fractures more likely and it puts you at a higher risk of osteopenia and osteoporosis in your adulthood(5,6,13).
Cardiovascular health (2,5,14). Estrogen has protective effects on the cardiovascular system (5,14). Having FHA for a prolonged period increases your risk of developing cardiovascular disease (5,14).
Mental Health (5,14). Reproductive hormones, particularly estrogen, help to regulate mood (5). Low levels of estrogen can impact the balance of compounds in the brain that help to manage mood (5). As a result, it may be harder for you to cope with stress and you may experience greater levels of anxiety and depressive symptoms (5,14).
Sexual Function (15,16).FHA can lead to changes in the reproductive tract that can make penetrative sex painful (15). For example, a symptom of estrogen deficiency is reduced vaginal lubrication (15). It is also common for FHA to reduce your desire for sexual activity (absent libidio) (15).
What can you do about it?
How can you recognize FHA? The main sign of FHA is having an absent period for 3 or more consecutive cycles without any other anatomical or internal problems (2,3,4). If this occurs, your first step is to see your healthcare provider. There are a few other health conditions that can cause your cycle to become irregular or absent (2,3,5). FHA is a diagnosis by exclusion, meaning that your healthcare provider has to rule out other conditions first (3). Tracking your cycle (or lack thereof) can be really helpful for you and your healthcare provider. Tracking helps you understand your normal cycle, which makes it easier to notice if it becomes irregular. Having a history of your menstrual cycle can also help guide conversations with your healthcare provider. You can learn more about how to track your cycle here.
The current recommended treatment is to remove the underlying cause of HPO suppression (3):
If you are experiencing low energy availability, it is recommended that you fix the energy imbalance by increasing your energy consumption or decreasing your energy expenditure (3). This may include taking a break from strenuous exercise and/or consuming more calorically-dense foods. Often recovering your period can require weight gain even if you are at a body mass index (BMI)* or body weight that is classified as healthy (2,3,9). It can also be helpful to work with a registered dietician who can assess your specific nutritional needs and ensure they are being met (3).
*Although BMI is widely used in medical settings as an estimate of body mass, it is an imperfect measure (17). There are many factors, aside from your fat mass, that may influence a BMI measurement (17). People with a higher BMI are not necessarily unhealthy, underweight, overweight, or obese. Your BMI alone offers little information on your overall health.
If you are experiencing psychological stress, it is helpful to practice techniques that help you manage or alleviate stress where possible (12). There is no one way to manage stress, so what works for you will be personal! This may include mindful journaling, meditation, or picking up a creative hobby you enjoy doing. Even if journaling isn’t your thing, one universal strategy for managing stress is prioritizing rest. Getting enough sleep (7-9 hours per night) can help your body and mind manage stress (12).
For some, all of this advice is easier said than done. It is common for people struggling with FHA to have underlying mental health struggles, including eating disorders and body dysmorphia (3). For this reason cognitive behavioural therapy (CBT) is recommended as a tool to help address underlying behaviours that contribute to FHA (3,4). A psychiatrist/psychologist can also provide emotional support throughout your recovery journey (3,4).
Can’t you just use a birth control pill or intrauterine device to induce your period?
Certain types of hormonal birth control, including some birth control pills and intrauterine devices, can affect the regularity of your cycle (3). Some of these contraceptive tools may prevent you from getting a period or may decrease its frequency even if your reproductive system is functioning fine on its own – this is perfectly normal.
However, some types of contraceptives – specifically those containing estrogen – can cause you to have a period even when you have FHA (16). Using estrogen-containing birth control to induce your period when you have FHA is not recommended (3). The problem is that using birth control can mask an underlying hormonal imbalance in your body (3). This makes it difficult for you to know whether your body can ovulate and menstruate on its own. The levels of estrogen found in birth control are also not high enough to prevent bone loss in people with FHA (3). Depending on how long you have been without a period, there are short-term hormone replacement therapies (which supplement higher levels of estrogen than the birth control pill) that can help to protect your bones (2,3). The primary way of treating FHA is by addressing the underlying stressor(s) causing it; however, these short-term hormone replacement therapies can be a helpful tool that are preferred over hormonal birth control (2,3).
If you are someone struggling with FHA, know that you are not alone. The journey to recovery can be difficult and frustrating; but, there is light at the end of your journey. My hope is that this article has given you information that will help you feel empowered and encourage you (if you have not already) to set forth on the path to recovering your period.
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