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Hypothalamic Amenorrhea and Missed Periods (health.clevelandclinic.org)

Raise your hand if you LOVE having your period. That was a
trick question: Menstruation is something few — if any — women get excited
about. You might even think being period-free (called amenorrhea in medical
speak) is something to celebrate, especially if you’re hoping for a baby. But
menstruation is a barometer for more than just pregnancy.

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For many women, the cause of irregular or absent menstruation is functional hypothalamic amenorrhea (FHA). FHA is a hormonal imbalance related to stress, exercising too much or consuming too few calories (like with an eating disorder). Here’s what you need to know about FHA from endocrinologist Ula Abed Alwahab, MD:

Q. How does hypothalamic amenorrhea cause the body to skip periods?

A. Physical and emotional stress affect the functioning of the hypothalamus, which connects the brain to the endocrine system. When under stress, the hypothalamus goes to sleep, halting the production of gonadotropin-releasing hormone (GnRH). GnRH signals the ovaries to produce estrogen, among other things. Without estrogen, ovulation and menstruation stop.

When a woman eats too little or exercises too much, the body perceives this as stress. We often think about lack of menstruation in elite athletes, but we also see it in adolescents who are exercising hard in preparation for an upcoming sporting event. But athletes aren’t the only people affected — stress from work or home can also cause the hypothalamus to hibernate.

Q. Why would it be problematic to miss periods or have irregular periods?

A. The most obvious concern is that women aren’t able to conceive without a menstrual period. Even more important: women with FHA prematurely experience all of the problems that happen ten years after menopause including declining bone health and skin and hair problems.

Fortunately, all of these concerns are reversible once we get the estrogen flow back and support the diet with extra calcium and vitamin D.

Q. How does a woman know if hypothalamic amenorrhea is causing her period problems?

A. Usually irregular periods or total absence of menstruation for more than three months will trigger a woman to see a specialist. Sometimes, the diagnosis happens when a woman experiences a bone break from a trauma that wouldn’t normally cause one. In trying to determine why the break occurred, a specialist may diagnose estrogen deficiency; FHA is one of the possible culprits.

We confirm hypothalamic amenorrhea by ruling out other
possible diagnoses. Conditions such as pregnancy, benign tumors of the
pituitary gland or thyroid gland disorders are a few that may cause missed
periods. To rule these out, we use a history and physical, plus screening lab
tests and, in some cases, a bone mineral density test or MRI.

Q. What are the treatments for missed periods caused by hypothalamic amenorrhea?

A. Treatments that focus on mental and behavioral health are most effective. It can be challenging to break the “healthy” habits that lead to the condition, particularly if a woman is in denial that they are the cause.

In addition to an endocrinologist and gynecologist, these
providers join our care team:

  • Dietitian: Dietitians help women understand
    the balance between caloric intake and exercise. They also help them understand
    how to improve nutrition.
  • Psychiatrist/psychologist: Mental health
    and eating disorder specialists can use cognitive behavioral therapy and
    medications to help break bad habits that cause FHA or to support a woman who
    has an eating disorder.

Q. Do you offer fertility treatments for women with FHA who can’t conceive?

A. Because it is hard to maintain a pregnancy if your body isn’t functioning correctly, we need to help a woman resume a normal cycle rather than treat infertility. More often than not, fertility will follow naturally.

The most important point women need to understand is that a lack of menstruation is not normal. Whether or not you’re hoping to conceive, you should seek medical help if amenorrhea lasts more than three months.

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