I had just finished a marathon, was newly married, and was about to start graduate school—from the outside, I looked like a “healthy” and “successful” 25-year-old woman. But one thing was missing—my period—a vital sign of a woman’s health. In fact, my gynecologist said I had reproductive lab values of a menopausal woman.
At that point, I was living in what I now consider quasi-recovery from an eating disorder. While I wasn’t engaging in eating disorder behaviors and thought it was all behind me, my missing period said otherwise. After several tests to rule out other potential causes like polycystic ovarian syndrome or brain abnormalities, I was diagnosed with functional hypothalamic amenorrhea (HA).
The good news is that HA is reversible—I know from my own healing journey and those of my clients as an eating disorder dietitian. Ample research also supports that hypothalamic amenorrhea is a treatable condition. If you think you might be experiencing it, know you’re not alone. HA affects over 1.5 million women and people assigned female at birth in the U.S. Here’s what you need to know about HA, and the steps you can take to get your period back.
What is Hypothalamic Amenorrhea, exactly?
With hypothalamic amenorrhea, periods are absent for more than three months, hence the descriptor “hypothalamic”. HA occurs when the hypothalamus—the control center of your brain—is not working properly.
Ordinarily, the hypothalamus is in communication with your ovaries via what’s called the hypothalamic-pituitary-ovarian (HPO) axis. HA occurs after the HPO is disrupted, leading to hormonal imbalance, anovulation (ovulation doesn’t happen), and no periods.
Let’s break down the process known as the hypothalamic-pituitary-ovarian (HPO) axis:.
- The almond-sized hypothalamus releases the reproductive hormone gonadotropin-releasing hormone (GnRH).
- In turn, GnRH regulates key hormones in your menstrual cycle: follicle-stimulating hormone (FSH), and luteinizing hormone (LH).
- FSH and LH prompt the ovaries to produce estrogen, and estrogen causes a uterine lining to form each month eventually resulting in a period.
“Excessive exercise, disordered eating, and high levels of stress can cause the hypothalamus to secrete an abnormal amount of GnRH, which causes a reduction of LH and FSH,” explains Equip dietitian Gabriela Cohen, MS, RD, LDN. “When there is not an increase in LH production in the menstrual cycle, there’ll be a lack of follicular development, the body won’t be able to ovulate, and there’ll be a low level of estrogen. Ultimately, this results in a lack of a period.”
What are the risks of HA?
As you might guess, functional hypothalamic amenorrhea can lead to infertility, since ovulation is necessary for natural conception. But you might be surprised to learn how many other aspects of your health can be impacted.
“Beyond the reproduction effects, HA is a critical warning sign that the hypothalamus is overstressed and lacks the energy for proper functioning,” says Erin Decker, RD. Decker explains that “An improperly functioning hypothalamus means not only problems for the reproductive system, but also for many other body systems such as the gastrointestinal, psychological, metabolic, and immunological systems.”
Decker explains that hypothalamic amenorrhea manifests across said systems in several ways, including the following symptoms:
- Low resting heart rate
- Low bone density and increased risk for fractures
- Increased susceptibility to illness
- Low sex drive
- Disconnected hunger cues
- Poor sleep quality
- Food and body obsession
- Anxiety or depression.
Decker also advises, “Keep in mind that these symptoms and an overstressed hypothalamus can show up in a person of any sex and age—not just those who menstruate.”
When it comes to bone health, chronic hypothalamic amenorrhea “can lead to bone loss and decreased bone mineral density, and eventually osteoporosis,” according to pediatrician Katherine Hill, MD, and Vice President of Medical Affairs and Care Delivery at Equip.
Plus, HA can negatively impact your heart since normal estrogen levels help protect it.
Why is hypothalamic amenorrhea a side effect of eating disorders?
Several symptoms and behaviors of eating disorders, such as food restriction, anxiety, depression, emotional stress, excessive exercise, energy (calorie) imbalance, and malnutrition are associated with HA development, according to The Journal of Clinical Endocrinology & Metabolism.
Decker says weight loss “below someone’s expected weight for their body” can also contribute to HA. “Though keep in mind this might not present in the stereotypical ‘thin’ body you might expect.” We know that people of all body sizes experience eating disorders, and the same goes for HA, including those who appear underweight, “healthy,” or who live in a larger body.
Furthermore, research shows that attitudes common in people with eating disorders are linked to hypothalamic amenorrhea. One 2023 review showed disordered beliefs like hyperfocus on diet, excessive exercise, and fear of weight gain in patients with HA, but not in control groups without HA. Another 2020 study showed common eating disorder traits, like dietary rigidity, need for social approval, and drive for thinness, were also more apparent in women with hypothalamic amenorrhea.
In my practice, I often observe the cause of HA to be an energy deficit driven by restriction, overexercise, and stress. However, sometimes it only takes one of these factors to signal to the body that there’s not enough energy for reproduction. If the body is in an energy deficit (which happens often with eating disorders), it goes into survival mode, including the hypothalamus. “The body is going to have to put certain processes on hold, such as ovulation,” Cohen explains, “in order to focus on more important ones for survival, like breathing and heart pumping.”
Both eating disorder and functional hypothalamic amenorrhea recovery go hand in hand. “If HA isn’t resolved, it often indicates that you haven’t completed full weight restoration. And physical, emotional, and mental recovery is almost impossible to achieve without full weight restoration,” Cohen says.
Regular periods are a sign that there’s a healthy energy balance in your body, and according to Hill, restoring balance is essential “so that the hypothalamus is able to produce all the necessary hormones again.”
Here’s what needs to happen to get your period back
HA is usually reversible through making lifestyle adjustments, however—just like eating disorder recovery—it takes commitment and hard work. It can be frustrating, so practice patience and gentleness towards yourself, and consider taking these steps towards healing:
Clarify the source
First, work with a doctor or dietitian to pinpoint the source of your HA, so you know where to put your focus. Maybe it’s across all three categories (stress, exercise, and food) or maybe it’s one or two of them. According to a 2020 review, addressing the underlying factors (like inadequate food intake or overexercise) is the best approach to reversing hypothalamic amenorrhea.
Make sure you have a team
Healing from HA requires professional support from a team, often including a gynecologist, dietitian, and therapist, ideally with HA experience. Your doctor will help you understand your hormone lab values and provide any necessary procedures, like ultrasounds. Your dietitian can help you understand and work towards meeting your nutrition needs and address eating disorder thoughts or beliefs. Your therapist can help you through the inevitable uncomfortable emotions that come with making necessary changes. In fact, scientific evidence shows cognitive behavioral therapy could help restore periods.
For those who experience gender dysphoria, HA can be more complicated, and Decker recommends finding a team that “can meet you where you're at, understand and validate how menstruating might make you feel, and be able to have those difficult conversations around risks versus benefits with you,” she says.
Eat enough, especially carbs and fat
My clients with HA are usually not eating enough food to support all bodily functions, including ovulation and menstruation. Unsurprisingly, the two macronutrient groups that are typically lacking most are carbohydrates and fat, both of which diet culture demonizes. Without enough calories, fat, protein, and carbohydrates, the hypothalamus can’t do its job.
Since calorie and nutrient needs are never one-size-fits all, I suggest working with your dietitian to develop a flexible meal structure of meals and snacks (that includes all food groups) and take steps towards meeting it daily. Chances are, it’s going to require more food than you think to get your period back, especially if undereating drives your HA. Work with your dietitian and therapist through obstacles and struggles that arise and trust that it’ll be worth it.
Assess your exercise
Often, scaling back or stopping exercise for an extended period is necessary to restore energy balance. I had to take an honest look at my relationship to exercise and significantly decrease the frequency and intensity of my workouts to get my period back. Although it was hard, it pushed me to develop more coping skills and treat my body with more respect. Healing from hypothalamic amenorrhea eventually allowed me to transform my rigid, obsessive relationship with exercise into a free, joyful one.
If exercise is part of your HA puzzle, a therapist and dietitian can help you figure out what needs to change and support you through discomfort that comes with it.
Check on your stress
Since one of the causes of hypothalamic amenorrhea can be stress, take an inventory of your life stressors and ask yourself a few questions: Is everything on my plate right now completely necessary? Is there anything I can let go of for now? How can I put my self-care first? Simplifying and prioritizing may be necessary to lower your stress levels.
A 2021 review article concluded that healing from HA should include working on daily stress, along with addressing food and exercise. Researchers suggest trying relaxation techniques (such as meditation or breathing practices) and to prioritize adequate and high-quality sleep. If your sleep is lagging, try a sleep hygiene routine to help your nervous system slow down, such as a warm shower, reading a book, and a bedtime meditation or yoga nidra practice.
Work towards your body’s healthy weight
Decker points out that eating more and scaling back on exercise when healing HA may result in weight gain (and the Endocrine Society agrees). “This is a sign to me that weight gain was necessary for this person. Bodies come in different sizes and often aren’t what our culture (or even medical community) want or expect them to be,” Decker explains.
Despite what diet culture says, the BMI scale doesn’t determine your healthy weight. Instead, your healthy weight is whatever weight your body needs to be to support your health and well-being, which includes a regular cycle.
“Sometimes, patients may get their menstrual period occasionally before being fully weight restored, but they often need to meet their full target weight range in order for consistent, regular periods to return,” Cohen adds. Weight gain can be difficult since we’re conditioned to believe it’s always a negative outcome, but it’s often necessary to get your period back. Your team can help you determine your healthy weight range, challenge weight stigmatizing beliefs, and work through weight gain discomfort.
Healing from hypothalamic amenorrhea was what took me from quasi- to full recovery from my eating disorder. “Many think of eating disorder recovery as being the achievement of a ‘normal’ body weight or absence of disordered eating behaviors,” Decker adds. “While this is a step in the right direction, there are multiple other factors that could still require healing that we can’t necessarily see, and HA is one of them.”