April/May 2022 Issue
By Joanna Foley, RD
Vol. 24, No. 4, P. 38
This underdiagnosed condition can harm a woman’s health, but RDs can suggest diet and nutrition strategies to help get clients back on track.
Having a menstrual cycle is one of the most unique and important aspects of a woman's health. While not getting a period may sound appealing to some women, not having it may indicate potentially serious health problems—namely hypothalamic amenorrhea.
Hypothalamic amenorrhea is an underrecognized condition that causes the loss of a menstrual cycle and negatively impacts many aspects of a woman's health. The good news is RDs can play a crucial role in helping to recognize and treat this condition.
What Is Hypothalamic Amenorrhea?
Hypothalamic amenorrhea is a medical term for not having a menstrual cycle. It’s not a disease but a disorder that can be a symptom of other issues going on in a woman's body. There are two types of amenorrhea: primary and secondary. Primary amenorrhea occurs when a menstrual cycle hasn’t started by age 15 in a healthy adolescent girl.1 Hypothalamic amenorrhea, however, is a type of secondary amenorrhea in which the menstrual cycle may stop for several months after previously having one and in the absence of pregnancy. This occurs due to certain hormonal changes and results from a problem with a part of the brain called the hypothalamus.
The hypothalamus controls many parts of the body, including reproduction.2 It produces gonadotropin-releasing hormone (GnRH), which helps tell the body to produce a period if a woman isn’t pregnant.3 “GnRH acts on the pituitary gland of the brain, resulting in release of follicle-stimulating hormone (FSH) and luteinizing hormone (LH). FSH and LH then communicate to the ovary to release the hormones progesterone and estrogen to allow for regular menstruation,” says Lauren Papanos, MS, RD, CSSD, founder of Functional Fueling Nutrition, a nutrition business that provides functional medicine nutrition counseling and coaching services in Los Angeles.
In hypothalamic amenorrhea, the hypothalamus either stops producing GnRH or produces too little, which causes the loss of menstruation. Women with hypothalamic amenorrhea also have other hormonal imbalances, including increased levels of the stress hormone cortisol.
What makes hypothalamic amenorrhea serious are the health problems that can occur if it goes untreated.4 These include infertility, bone loss and osteoporosis, and increased risk of CVD. Each of these conditions can have short- and long-term consequences on health. In addition to a missed period, symptoms of hypothalamic amenorrhea include vaginal dryness, mood disorders, low libido, and frequently feeling cold.
Diagnosing hypothalamic amenorrhea can be complex since it’s a diagnosis of exclusion, meaning it’s usually identified only after other possible causes of a missed period have been ruled out. It’s estimated that about 3% to 5% of adult women lose their period without being pregnant, and about 20% to 35% of those women may have hypothalamic amenorrhea.5 It’s believed to affect 1.6 million American women between the ages of 18 and 44.4
Several factors may lead to the development of hypothalamic amenorrhea, including stress, excessive exercise, and low body weight. “Hypothalamic amenorrhea occurs when there are abrupt changes to the cumulative burden of chronic stress and life events. This can include emotional stressors, increased physical activity, low energy availability, and significant changes to body weight in a short period of time. When any or all of these events occur, the hypothalamus releases too little GnRH,” Papanos says.4,6
Genetics may play a role in how susceptible someone is to developing hypothalamic amenorrhea, but some factors can place a woman at greater risk, such as being an athlete, having a low BMI and low body fat percentage under 22%, strict dieting, eating disorders, and living a highly stressful lifestyle.7
The silver lining is that it’s possible for women to recover from hypothalamic amenorrhea with the right treatment. How long this takes depends on the root cause of the condition and how treatment is addressed.
Treatment may include a combination of approaches; however, the following four areas are the most important to focus on.
It’s important for RDs to evaluate their female clients’ daily caloric intake to ensure they’re eating enough food. “The body needs adequate calories from food to function optimally at baseline. Many women dealing with [hypothalamic amenorrhea] may not even realize they're undereating, so it's important to address this first to make sure that the body has enough fuel,” says Jillian Greaves, MPH, RD, LDN, an integrative and functional medicine expert, women's health specialist, and owner of Jillian Greaves Functional Nutrition and Wellness, a nutrition business that focuses on women’s hormonal and digestive wellness in Boston.
This includes at least three balanced meals each day with snacks in between as needed. “I recommend clients dealing with [hypothalamic amenorrhea] prioritize eating breakfast within one to two hours of waking and eating consistent meals and snacks every three to four hours throughout the day after that. Eating consistently to support stable blood sugar and taking in enough energy from food are two of the most effective ways to reduce stress on the body at baseline,” Greaves says.
Moreover, eating enough fat is crucial to achieve or maintain enough body fat, since research shows that body fat must compose at least 22% of body weight to maintain a monthly menstrual cycle.8 Healthful fats such as olive oil, avocados and avocado oil, nuts, seeds, and nut butters can provide important nutrients including magnesium and vitamin E. Coconut products, cheeses, and other full-fat dairy foods also can contribute to achieving enough calories from fat. And “emphasizing other macronutrient needs like high-quality animal proteins such as fish and eggs, [and] nutrient-dense starches like potatoes, beans, oats, and whole fruit are also a great place to start,” Greaves says. “Key micronutrients to prioritize for period recovery include zinc, vitamin A, vitamin D, vitamin K2, magnesium, calcium, B vitamins, and iodine.”
According to Papanos, “testing to identify micronutrient status, gut dysbiosis, and absorption can be beneficial. Through this testing there may be targeted supplementation that can further support cycle recovery.”
Of course, engaging in regular exercise benefits overall health. Yet, when female clients are underfed, poorly rested, or highly stressed, exercise can put additional stress on their bodies and interfere with hormones. For people with hormonal disorders such as hypothalamic amenorrhea, less intense exercises of shorter duration, including yoga, walking or other light cardio, or resistance training, are better than intense exercise of longer duration (eg, running, heavy weight training).
Clients should do these exercises only when they’re well rested and properly fed, and always follow up with a balanced recovery meal or snack.
Stress causes an increase in the hormone cortisol, which can interfere with many other hormones when levels are frequently too high.9 For some clients, high stress and anxiety can contribute to hypothalamic amenorrhea, so stress management is key.
It’s important to keep in mind that stress management involves clients’ mental, emotional, and physical well-being. Managing stress may involve seeing a therapist, scheduling time for relaxation and self-care, prioritizing more sleep, changing an exercise routine, setting boundaries regarding daily duties and relationships, and asking for help—each of which can go a long way in improving overall health.
Relationship With Food
Eating disorders such as anorexia nervosa and bulimia nervosa can cause imbalances in estrogen and progesterone, which can interfere with metabolism, fertility, and pregnancy outcomes.10 These effects can occur in women who haven’t been diagnosed with an eating disorder but have disordered eating habits or other risk factors, including low body fat, high stress, and malnutrition.
Disordered eating habits can negatively impact hormones even if clients are eating enough calories but are doing so irregularly or in an imbalanced manner. This may include following strict food rules, fad diets, calorie counting, and fearing weight gain, which can prevent female clients from resuming their regular monthly cycles. However, individuals can work on resolving unhealthful relationships with food with a trained dietitian and therapist to help them adopt intuitive and mindful eating practices.
Counseling Strategies for RDs
When counseling clients with hypothalamic amenorrhea, RDs need to provide individualized recommendations and perform a patient evaluation. “Any dietary approach should always be customized to the individual, and it's important to meet clients where they are at,” Greaves says.
According to Papanos, RDs should perform a “thorough evaluation” from the time the client ceased menstruating to the present. She says, “This will help identify any abrupt changes in stress, exercise and nutrition habits, or weight, which could have caused the loss of their menstrual cycle.”
Moreover, Papanos says RDs should screen patients for disordered eating since many of them may be restricting food or engaging in orthorexia nervosa behaviors. In many cases, talking about calorie needs may do more harm than good. Calorie needs vary greatly among individuals and also can fluctuate day to day depending on a variety of factors. Therefore, it’s important for dietitians to look at the bigger picture and focus on nutrient needs rather than on calories.
“I recommend being cautious with using tools like food tracking apps,” Greaves says. “Food tracking can be really helpful and even necessary for understanding gaps in nutrition contributing to [hypothalamic amenorrhea], but we also want to make sure that these tools are supporting a client's health physically and mentally and not creating more stress or contributing to disordered eating.”
In addition, Greaves says, “clients with [hypothalamic amenorrhea] should always receive support in an environment that’s nonjudgmental and empathetic. I recommend providing clients with ample education on the ‘why’ behind your recommendations, so they can feel informed and confident navigating the changes you suggest. I recommend taking things slowly and being methodical with dietary changes to avoid [overwhelming them] and minimize unpleasant symptoms that can arise from moving too quickly.”
Not having regular periods can be damaging to a woman's health. Women should be attentive to any unusual changes in their menstrual cycles and communicate such with their doctors to determine whether they may have hypothalamic amenorrhea. Working with a trained dietitian or therapist can provide a detailed lifestyle evaluation and offer further support to help individuals resume monthly menstrual cycles.
— Joanna Foley, RD, is a freelance writer and author of two cookbooks based in San Diego. Learn more about her writing services at joannafoleynutrition.com/press.
1. Nawaz G, Rogol AD. Amenorrhea. Treasure Island, FL: StatPearls Publishing; 2022. https://www.ncbi.nlm.nih.gov/books/NBK482168/
2. Kenealy BP, Terasawa E. Hypothalamic control of female reproduction [published online May 24, 2017]. Oxford Research Encyclopedia of Neuroscience. https://doi.org/10.1093/acrefore/9780190264086.013.59
3. National Institutes of Health Clinical Center. The effect of Gnrh on pituitary hormones in menstrual-cycle mood related disorders. In: ClinicalTrials.gov. Bethesda, MD: National Library of Medicine. https://clinicaltrials.gov/ct2/show/NCT00001232. Updated March 4, 2008.
4. Shufelt CL, Torbati T, Dutra E. Hypothalamic amenorrhea and the long-term health consequences. Semin Reprod Med. 2017;35(3):256-262.
5. Meczekalski B, Katulski K, Czyzyk A, Podfigurna-Stopa A, Maciejewska-Jeske M. Functional hypothalamic amenorrhea and its influence on women’s health. J Endocrinol Invest. 2014;37(11):1049-1056.
6. Nakamura Y, Yoshimura Y, Oda T, Kamei K, Iizuka R. Amenorrhea due to weight loss. Nihon Sanka Fujinka Gakkai Zasshi. 1984;36(5):727-735.
7. What causes amenorrhea? Eunice Kennedy Shriver National Institute of Child Health and Human Development website. https://www.nichd.nih.gov/health/topics/amenorrhea/conditioninfo/causes. Updated January 31, 2017
8. Baker ER. Body weight and the initiation of puberty. Clin Obstet Gynecol. 1985;28(3):573-579.
9. Ranabir S, Reetu K. Stress and hormones. Indian J Endocrinol Metab. 2011;15(1):18-22.
10. Eating disorders and hormones. You and Your Hormones website. https://www.yourhormones.info/topical-issues/eating-disorders-and-hormones/. Updated December 2016. Accessed February 4, 2022.