Yep, you read that title right. Today we’re dropping the P bomb, that is, we’re talking about periods.
The glorious part of womanhood we love to hate. But when our reliable monthly guest stops visiting as often, it can cause some concern—and rightly so!
Not getting a period is not normal, sure it may seem convenient at the time, but that doesn’t make it good.
It’s like this, the other week our fluffy 12 lb dog Appa who runs pretty wild on our land out in the country went missing. He didn’t come back for three whole days! I tend to complain about his general smelliness, the messes he makes, and his annoying habit of eating my clothes, but when he was gone, I was worried sick! We have coyotes and I suspect, big cats, roaming around on our land who would eat him for lunch (lions and tigers and bears, oh my)!
You can imagine my relief when he finally showed up back home, smelling awful, but totally unscathed. I found out later that our neighbor lady’s dog was in heat - and all the pieces started falling together, which brings me back to the topic at hand: periods.
An absent period is a symptom of something else going on in the body
Not getting your period is a warning sign that something is amiss.
Our bodies tend to downplay our reproductive system as a way to shift precious energy towards more pressing matters, like illness, injury or meeting basic survival needs.
And no, just getting off of birth control a few months ago is not necessarily an excuse for not getting your period. Most women, if their hormonal cycles were healthy to begin with, will resume normal menstruation soon after stopping birth control. If, however, birth control was prescribed as a bandaid for menstrual irregularity in the first place (as is often the case), it’s unlikely that the problem will be fixed without lifestyle or other appropriate interventions once birth control is stopped.
An absent or irregular period, defined as amenorrhea, may be caused by a number of conditions. This post will focus on functional hypothalamic amenorrhea (FHA) because it is one of the most common causes of an absent period. According to the American Society of Reproductive Medicine, FHA is responsible for 20–35 % of secondary amenorrhea cases and 3% of primary amenorrhea cases (1).
Secondary amenorrhea is an absence or irregularity in your period that occurs after you’ve already started cycling, while primary amenorrhea is a delay in starting normal menstruation.
Of course there are a number of conditions that cause absent or irregular periods including anatomical irregularities, PCOS, and more. It’s important to consult your healthcare provider to rule these out and confirm your diagnosis.
***On that note this blog post is not meant to serve as a substitution for diagnosis or treatment by your healthcare team. Read my site disclaimer here.**
FHA is caused by a disruption in the hypothalamic pituitary ovarian axis.
Unless you avoid health articles like the plague (sometimes me), you’ve probably heard the term HPA axis floating around the internet coupled with the phrase “adrenal fatigue.” For the purposes of this blog post that’s kind of** similar to what we’re talking about here. While the adrenal gland is separate from the ovaries, the whole hormonal and regulatory system of the body is interrelated.
**Note I have a hard time even writing the term adrenal fatigue as it is not a defined, researched, or validated condition, it’s just a popular buzz phrase that many people have co-opted and used for their own purposes. It’s become something like an umbrella term for every condition and symptom under the sun. Heavy dose of critical science consumerism is needed when reading anything with those words. Okay, Ted talk over now.
Understanding the hormone cascade and the causes of FHA
Anyways, a disruption in this system causes our hypothalamus (the control center in our brain responsible for regulating reproduction) to reduce or stop producing gonadatropin releasing hormone (GnRh for short).
Under normal conditions GnRh is responsible for signaling the production of FSH and LH from the pituitary gland. FSH and LH are needed to help mature eggs and signal ovulation.
Normally these two hormones would signal the ovaries to produce estrogen and progesterone. Estrogen aids in fertility (among other things) by thinning the cervical mucus and together with progesterone, preparing the uterus for a fertilized egg.
The normal rise and fall in FSH, LH, estrogen and progesterone are what signal to the body no pregnancy has occurred and menstruation can begin. If a disruption in this system happens at the hypothalamic level, then the whole hormonal cascade is affected, resulting in low FSH, low LH and low estrogen.
Okay, if you’re still with me through all that hormone chatter, here’s where we talk about what causes a disruption in the hypothalamus.
There are thought to be three root causes of FHA: stress, under-eating, and over-exercising. And really, we could just chalk it all up to stress, because under-eating and over-exercising are stress inducing to the body.
For this reason, we often see high circulating levels of cortisol (the stress hormone) in women with FHA. And while we’re on the clinical indicators discussion, in addition to low FSH, LH and estrogen, we tend to see low serum insulin, low insulin growth factor, high grehlin (the appetite stimulating hormone), and low T4 (thyroid hormone) with FHA.
We need our periods for a reason…or reasons
Why should we care about all of this? I mean isn’t not getting your period a blessing? If this is you, I totally understand.
I used to think it was completely normal and convenient that I didn’t have a regular period. But the truth is there are health risks associated with FHA, and I’m not just talking about infertility (although that can be a concern).
Even if you have no plans of getting pregnant, ever, the low estrogen that characterizes FHA is linked to an increased risk of bone disease (osteopenia and osteoporosis), increased risk of heart disease, low libido, vaginal dryness, moodiness and issues with glucose metabolism (1). FHA itself is associate with increased rates of depression and anxiety (1).
We were designed to function at our best with regular hormonal cycles.
Now before this blog post becomes all gloom and doom, let me say this: for the most part, FHA is completely reversible, and often with lifestyle interventions only!
With that said, every one is different, the amount of time it takes to get your period back could range from 2 months to 2 years. It depends on your situation and how aggressively you’re able to work on recovery right now.
As I mentioned, the primary driver for FHA is thought to be stress, whether that’s mental, social, and emotional stress, or physical stress from lack of sleep, over-exercising and under-eating.
While a lower BMI and recent weight loss are risk factors for FHA, you do not have to be underweight or have an eating disorder to lose your period from under-nourishment. In fact, many athletes lose their period by putting there body at a slight, persistent energy deficit—oftentimes unknowingly. This is called relative energy deficiency syndrome or REDs for short. I write more about REDs and my experience with it here.
Depending on what the primary driver is for your absent period: stress, over-exercising, nutrition, or all of the above, there are some very important foundational interventions to try first.
Here I have them broken down by category, but please realize that for many, working on several of these areas is necessary to restore menstruation.
Stress Management (non exercise and food related)
Getting good quality sleep is one way to reduce our body’s stress load. Of course, don’t let fitting in a certain number of zzz’s every night drive you bonkers, but if this is an issue for you, here are a few simple hacks I’ve found that work.
Turn off the phone, TV, ipad, etc. at least an hour or two before bed.
Try reading before bed on an actual book or backlit e-reader
Take a shower before going to bed and turn the temperature down in your house to help cool your body off for sleep.
Invest in black out curtains and keep electronic lights out of the bedroom
Eat a bedtime snack with a small amount of protein and fat and some slow releasing carbs ( I love a bowl of warm oatmeal for this or just good old fashioned cereal and milk).
Don’t engage in any sort of serious discussion or work right before bed if you can help it. If you do have anxious thoughts running through your head, try journaling them, so they are written down and hopefully out of your mind.
Try a short restorative yoga or stretching routine in the evenings to help you wind down.
This one is probably a no-brainer BUT i’m totally guilty of it: back off the coffee after 2ish pm…or whenever you notice it effects your sleep. I hate arbitrary time rules because some people can slug back caffeine at 8 pm and zonk out one hour later — only you know you!
Cognitive behavioral therapy
CBT for short. This popular form of therapy has been shown to be effective in reducing stress levels and aiding with the restoration of periods (2). It’s certainly ideal to work with your own therapist, however if that isn’t feasible for you right now, there are a plethora of books available that walk you through practicing CBT on yourself. Here is a list of 30 from positivepsychology.com
Minimize excess, spark all the joy
How many times can I reference Marie Kondo on the blog? I’ve lost track, but seriously we all have clutter in our lives, and I’m not talking about material clutter only. We have tasks and activities we’re involved in that mainly serve to stress us out. I’d encourage you to work with a coach, with a therapist, or on your own to determine what your 5 core values are as a person. Then, start filtering your life through the lens of those values. If something doesn’t fit, and it’s possible to cut it out of your life, do it —or take steps to reduce its impact.
Put together a self-care tool box
I got this idea from several someones somewhere on the internet, and I’m not 100% sure who they were, but it’s genius. Your self-care toolbox can look like a list of items and activities that you go to in order to recharge and recenter, or it can be a physical box containing items you use in your self-care routine.
My self-care tool box is more of a list of activities. These include: prayer journaling, reading, coffee with friends, walking outside and shopping at book stores, among other things. I’ve known clients who’ve kept a literal box filled with books, journals, nail polish, colored pencils, etc. The most important thing is that you tailor your self-care tool box to you!
Ditch the high intensity stuff for now
High intensity exercise increases stress on the body. In an ideal situation where this is only happening a few times a week and everything else in your life contributes to recovery, this can be a good thing.
For example, professional athletes get better at their sports by progressively overloading their bodies with the view that recovery will allow them to adapt and improved. The reality is that most professional athletes do nothing BUT train and recover. When they aren’t working out they’re sleeping, stretching, eating, and doing everything they can to promote body healing.
For the majority of us, this is NOT the life we live. Trying to train like a pro and living the 9-5 life often isn’t conducive to health.
If you are experiencing an absent period, its a sign that your stress levels are already elevated. High intensity and even moderate intensity exercise will likely lead to a more depleted, stressed-out system as opposed to aiding in health.
So what do I mean by high/moderate intensity exercise? Again this is individual for each person, but in general working out at a level where it’s hard to breathe and talk is higher intensity, logging 30 min to an hour of long endurance exercise, even at a moderate intensity can also equate to high intensity training. This includes most running, interval training, spin classes, and lots of group workout classes.
Again, you will need to determine what decreasing exercise means for you, but know that many times (not always) the more radically a person decreases exercise, the sooner they see a return in their period.
Practice complete rest OR focus on low intensity movement less often
Building off the last point, it may be best to practice complete rest for now. Aside from light stretching to help your body feel good, resting from movement can be so restorative to our systems.
If you are a very active person and you want to incorporate some movement, I suggest lower intensity, lower impact movement fewer times a week. I love yoga, barre, and light walking outside.
A caveat: even walking when done for extended periods of time can inhibit progress here in certain individuals.
You may enjoy something other than what I’ve mentioned, like swimming or house-cleaning (if so, come on over please ;)). Find something that provides refreshment and energy, but doesn’t cause you to fatigue or stress.
There is no exact weight range or body fat percentage that guarantees a normal period. We are each unique as far as what body size and composition allows for optimal health. And by the way, having a period does not guarantee you are fully weight-restored or at your healthy weight. Again, we are all different! That being said, there are some key nutritional interventions that have been shown to help in restoring a normal menstrual cycle in those with FHA.
Ramp up the calories
One of the main risk factors for developing FHA is being at an energy deficit either by eating too littler calories or burning too much in activity. A big deficit isn’t required for some people to stop menstruating.
Try including more calorically dense foods at meal and snack time. Increase the frequency of eating, adding snacks throughout the day with the goal to eat 3 meals and 2-3 snacks per day.
If you’re stuck, work with a non-diet dietitian to help determine your energy needs and to provide you with creative options for meeting those needs.
Focus on fat
Aside from meeting your calorie needs, it’s imperative for normal menstruation that you eat adequate amounts of dietary fat. Fat is involved in regulating appetite hormones and producing the sex hormones we need for a normal period.
Try switching to full fat dairy options like full fat yogurt, whole milk, and full fat cheeses. There is some evidence to suggest that full fat dairy consumption is positively associated with fertility in women with anovulatory conditions (of which FHA is one) whereas low fat dairy consumption may increase the risk of infertility in these women (3).
Aside from dairy, you can find find dietary fat in fatty meat and fish, nuts, seeds and nut butters, coconut oil, avocados, olive oil, and sesame oil (to name a few). If you aren’t already doing it, try cooking any vegetables you eat in fat. On the one hand it makes them taste about 10X better (IMO) and on the other hand, it aids in nutrient-absorption and may increase your progress towards restoring your period—what’s to lose?
Please eat the carbs!
Finally, please eat the carbs, all the carbs. Your body doesn’t really care if it comes from bread, rice, beans, or potatoes (unless of course you have celiac disease or a true food allergy). Your body just needs glucose (the smallest chemical unit of carbohydrates). Your brain alone consumes 8-9 servings of carbohydrates each day, the equivalent of about 9 slices of bread or 3 cups of pasta (4). That doesn’t account for the glucose needed by your muscles, your red blood cells and your organs for everyday functioning.
Carbohydrate restriction may serve to ramp up the stress hormone cortisol, which in turn adds to the total stress load of the body, signaling to the hypothalamus to continue suppressing reproduction.
In addition, restricting any food, especially whole macronutrient groups like carbohydrates often makes us feel more out of control and stressed around food, leading to more mental stress and an unhealthy relationship with food.
If you aren’t allowing yourself to have carbohydrates at meals and snacks, start adding them back in, focus on starchy foods like bread, pasta, and other grain products in combination with beans and starchy vegetables like potatoes, peas and corn. While fruit does contain carbohydrates it doesn’t offer the same calorie benefit, so I recommend using it as your carb at snack times or in addition to a starch with meals. On top of this, try adding a fun food to your meals like ice cream or cookies, chocolate, you name it.
Work on your relationship with food, exercise and your body
If the thought of adding fun foods, or carbs, or fat, or calories for that matter scares you, reach out! Often (not always) there are some unhelpful beliefs around food, exercise and our bodies that lead us to under-eat and over-exercise. If you’re going to be able to follow any of the above recommendations, it’s imperative to work on your relationship with food and your body first. This is probably the most important step in the process for most of us.
Reach out to a non-diet dietitian for nutrition counseling. You do not have to be suffering from a diagnosable eating disorder to warrant help. You do not have to be a certain body size. You do not even need to have an absent period. If food and body concerns are stealing your peace, your energy, and your focus, you deserve help.
It’s not uncommon for clients see normal menstrual function return, almost unintentionally, as they work through the principles of disordered eating recovery and intuitive eating.
Last on the list of nutrition interventions are some basic supplement recommendations. Note: supplements are by and far secondary to the above interventions. It’s imperative that we’re honest with ourselves about whether we’re eating and resting enough, and whether we’re dealing with stress in a healthy way. If we’re doing the work to care for our bodies and gaining weight as needed (often needed), then we can take some basic vitamins to help support our health.
Supplements will not make up for not doing the work, BUT it’s a good idea to consider a consuming a basic calcium/magnesium supplement to support bone health, since low estrogen is associated with poorer bone density. In addition you may talk with your doctor and dietitian about a vitamin D supplement and a good multi.
Herbs and other supplements
On the topic of supplements, your doctor or dietitian may recommend alternative supplements that may help increase your ability to handle stress. These can range from specific adaptogenic herbal supplements to anti-inflammatory supplements such as omega-3 fatty acids. It’s important to speak with your medical team about whether or not these are a good fit for you.
Another alternative therapy which is thought to help improve hormonal imbalances and may stimulate ovulation is acupuncture (5). I encourage you to dig into the scientific research yourself concerning this topic and determine whether this may be an option for you with your health care provider.
Summing it up
FHA is a multifaceted condition wherein the hypothalamus decides it’s protective to shut down the reproductive hormonal cascade. It’s a sign that healing needs to occur in one or several areas of our body.
I know it can be frustrating when we’re not getting our period. It can feel like we’re doing everything to “be healthy” and still our bodies aren’t working for us. But honestly, it’s just another example of our body protecting us. Reproductive health is secondary to meeting our basic energy needs. And carrying a baby in an undernourished or stressed out state isn’t ideal for us or baby.
Sometimes what we view as healthy isn’t actually helping us but may be causing harm, things like, strict food rules, stress, under-eating, overexercising, micromanaging our weight.
Restoring your period can be a process that brings long term healing to your relationship with food and your body. It’s yet another opportunity to learn to trust our bodies, to know that they truly have our best interests at heart.
If you’ve walked through restoring your period after FHA, I’d love to hear your feedback. What worked for you?
Until then, stay nourished, body, soul and spirit.
Meczekalski, B., Katulski, K., Czyzyk, A., Podfigurna-Stopa, A., & Maciejewska-Jeske, M. (2014). Functional hypothalamic amenorrhea and its influence on women's health. Journal of endocrinological investigation, 37(11), 1049-56.
Berga, S.L., Marcus, M.D., Loucks, T.L., Hlastala S., Ringham R., Krohn M.A. (2003). Recovery of ovarian activity in women with functional hypothalamic amenorrhea who were treated with cognitive behavior therapy. Fertility and Sterility , 80(4) , 976 - 98.
Chavarro J.E., Rich-Edwards J.W., Rosner B., Willett W.C. (2007). A prospective study of dairy foods intake and anovulatory infertility. Human Reproduction, 22(5):1340-7. Epub 2007 Feb 28.
Slavin, J., & Carlson, J. (2014). Carbohydrates. Advances in nutrition (Bethesda, Md.), 5(6), 760-1. doi:10.3945/an.114.006163
Chen, B.Y. (1997). Acupuncture normalizes dysfunction of hypothalamic-pituitary-ovarian axis. Acupunct Electrother Res, 22(2):97-108.