What is Hypothalamic Amenorrhea (HA)?

Written by Elle Kelly, Specialist Dietitian

The loss of the menstrual cycle is known as hypothalamic amenorrhea (HA), and although it’s common, particularly in active individuals (1), it is not normal and carries consequences for both health and performance that go beyond fertility.

Amenorrhea can be either primary, where a female hasn’t had a period by the age of 15 (2, 3) or secondary, which is when someone who has previously had a period loses it for 3 consecutive cycles, or has not had one for 6 months or more in those with irregular cycles (4).

Secondary amenorrhea can occur naturally during phases in a woman's life such as during pregnancy. Hypothalamic amenorrhea is a “diagnosis by exclusion”, meaning other conditions that could lead to the loss of the menstrual cycle need to be ruled out, and an assessment of lifestyle factors can help in identifying it.

You can learn more about period recovery on the Food is Food podcast, where Elle and Talia chat about: HA, RED-S and disordered eating.

What is Hypothalamic Amenorrhea?

The reason ‘hypothalamic’ amenorrhea gets its name is because the hypothalamus plays a vital role in the production of sex hormones which can lead to ovulation and menstruation stopping under certain conditions. The hypothalamus is a part of the brain that acts as the “control centre” and is responsible for regulating the production of hormones and other bodily processes such as your temperature and heart rate. 

It communicates with the pituitary gland which interacts with the ovaries, and this system is referred to as the hypothalamic-pituitary-ovarian (HPO) axis. This system is highly sensitive to change and any sign that the body is under stress can disrupt the system. Stress can be both physical and psychological, and this could look like sudden or extreme weight loss, severely restricting intake, excessive exercise, psychological stress or a combination of all of these factors (5, 6).

The hypothalamus stops producing gonadotropin releasing-hormone (GnRH), which influences the production of other hormones, such as follicle-stimulating hormone (FSH) and luteinizing hormone (LH). FSH and LH influence the levels of oestrogen and progesterone, which can lead to ovulation and menstruation stopping.

Why Does This Happen?

Excessive exercise and restricting dietary intake, or a combination of both of these, can lead to a state of low energy availability (LEA) which is the most common cause of HA.

LEA which describes the state where the body does not have enough fuel to carry out physiological functions to promote optimal health after the cost of movement is covered.  When there is not enough energy to support all physiological functions as well as performance, the body will prioritise functions that are essential to health. This means that systems such as the immune, digestive, reproductive and thermoregulation systems become down-regulated.

Amenorrhea is one symptom of a complexity of inter-related symptoms that may occur as a result of LEA, and so, not having a period carries more implications for both health and performance than just fertility.

Consequences of Hypothalamic Amenorrhea

Increased risk of cardiovascular related events

Oestrogen is considered cardioprotective as it helps to relax and dilate blood vessels which enhances blood flow and it is also linked with a favourable blood lipid profile (7), which can influence the risk of the development of cardiovascular disease (CVD) (8, 9).

Low oestrogen levels are associated with an increased risk of cardiovascular related events such as stroke (10, 11), which is why women have an increased risk of CVD post-menopause. However, research has shown that those with HA have an increased risk of cardiovascular related events too (12), with one study suggesting there is up to a 50% increased in the risk of cardiovascular disease in women with irregular and missing menstrual cycles in comparison to those with a regular cycle (10).

Increased risk of depression & anxiety

Evidence has shown that women with HA have significantly higher depression scores, anxiety and difficulty dealing with daily stress (13, 14). The link between HA and mood is complex, and expected to be related to higher cortisol levels, the impact of the reduction of sex hormones on mood, and also the relationship that an individual with HA may have with food (14).

Reduced bone density

Oestrogen plays an important role in the development and maintenance of bone density. Bone health can also be influenced by cortisol levels, which are usually high among those with LEA (15) and by calcium and vitamin D intake, which an individual may not be getting enough of if they are following a restrictive diet.

The rate of loss of bone density has been observed to be up to 2.5% per year in those without a menstrual cycle (16, 17.), and this can increase the risk of bone disease like osteopenia and osteoporosis, which can affect women from an earlier age than most people think. This also poses an increased risk of stress fractures and injury for those who are active.

Delayed recovery from training & reduced performance

Recovery time from exercise can be influenced by training load, nutrition and rest, but not HA can also impact performance and recovery. A study has shown that women with HA were 2.1 times more likely to experience longer recovery times and had decreased endurance performance in comparison to those with a regular menstrual cycle (18). 

Evidence has also shown that HA can have a negative impact on neuromuscular performance, which relates to the ability to execute movements in sports, as those with HA have slower reaction times and reduced muscle strength compared to those with a regular cycle  (19,  20, 21).

Recovery from Hypothalamic Amenorrhea

HA is a serious clinical condition that requires management by a multidisciplinary team, with clinical guidelines recommending the referral to a dietitian, psychologist and/or a sports physician if it is suspected that HA is related to weight loss, excessive exercise and a disordered relationship with food.

HA carries consequences on both physical and mental health, but these effects are reversible and it is possible to recover from HA. A long-term study found that over 70% of women with HA recovered (22). However, the recovery from HA looks different for everyone and is heavily influenced by the reasons for the development of HA.

A study in 2020 found that almost 50% of women with HA reported eating disordered behaviours and scored significantly higher in behaviours associated with dieting (23), which means that the solution lies in healing their relationship with food. 

You Don't Have to Navigate This Alone

If you would benefit from specialist dietetic support through your period recovery journey, the TCN team would love to hear from you. You can book a free 20 minute discovery call with one of the dietitians to talk about how we can help.

Elle also facilitates an incredible 12 week program: Refuel & Revive, which support you to recovery your period, restore your health and repair your relationship with food and exercise.

And if you haven't listened to the Food is Food episode with Elle Kelly and Talia Cecchele (TCN Founder) 'Get Your Period Back: HA, RED-S And Disordered Eating' yet, head over to the podcast page.

Elle Kelly

Registered Dietitian

https://eknutrition.com/

@ellekellynutrition

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Talia Cecchele Nutrition is a team of registered dietitians that specialise in eating disorder recovery, disordered eating, digestive issues and sports nutrition. We aim to bring balance back to nutrition, help you to break free from food rules and find food freedom. We offer virtual consultations and group programs so whether you are based in London, the United Kingdom or around the world we would love to support you. To enquire about a private consultation please fill out a contact form.

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3. Rebar, R. (2015). Evaluation of amenorrhea, anovulation, and abnormal bleeding. Retrieved from: https://www.ncbi.nlm.nih.gov/books/NBK279144/

4. NICE. (2024). Clinical Knowledge Summaries: Amenorrhea. Retrieved from: https://cks.nice.org.uk/topics/amenorrhoea/

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6. Gordon, C. M., Ackerman, K. E., Berga, S. L., Kaplan, J. R., Mastorakos, G., Misra, M., ... & Warren, M. P. (2017). Functional hypothalamic amenorrhea: an endocrine society clinical practice guideline. The Journal of Clinical Endocrinology & Metabolism, 102(5), 1413-1439

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9. Peters, S. A., Singhateh, Y., Mackay, D., Huxley, R. R., & Woodward, M. (2016). Total cholesterol as a risk factor for coronary heart disease and stroke in women compared with men: A systematic review and meta-analysis. Atherosclerosis, 248, 123-131.

10. Solomon, C. G., Hu, F. B., Dunaif, A., Rich-Edwards, J. E., Stampfer, M. J., Willett, W. C., ... & Manson, J. E. (2002). Menstrual cycle irregularity and risk for future cardiovascular disease. The Journal of Clinical Endocrinology & Metabolism, 87(5), 2013-2017

11. O’Donnell, E., Goodman, J.M. and Harvey, P.J. (2011) “Cardiovascular consequences of ovarian disruption: A focus on functional hypothalamic amenorrhea in physically active women,” The Journal of Clinical Endocrinology & Metabolism, 96(12), pp. 3638–3648.

12. Grosman-Rimon L, Wright E, Freedman D, Kachel E, Hui S, Epstein I, Gutterman D, Eilat-Adar S. (2019). Can improvement in hormonal and energy balance reverse cardiovascular risk factors in athletes with amenorrhea? Am J Physiol Heart Circ Physiol. 1;317(3):H487-H495. doi: 10.1152/ajpheart.00242.2019

13. Marcus MD, Loucks TL, Berga SL.  (2001)Psychological correlates of functional hypothalamic amenorrhea. Fertil Steril;76(2):310-6. doi: 10.1016/s0015-0282(01)01921-5. PMID: 11476778

14. Lawson, E. A., Donoho, D., Miller, K. K., Misra, M., Meenaghan, E., Lydecker, J., ... & Klibanski, A. (2009). Hypercortisolemia is associated with severity of bone loss and depression in hypothalamic amenorrhea and anorexia nervosa. The Journal of Clinical Endocrinology & Metabolism, 94(12), 4710-4716.

15. Melin, A., Tornberg, Å. B., Skouby, S., Møller, S. S., Sundgot‐Borgen, J., Faber, J., ... & Sjödin, A. (2015). Energy availability and the female athlete triad in elite endurance athletes. Scandinavian journal of medicine & science in sports, 25(5), 610-622

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19. Tornberg ÅB, Melin AK, Koivula FM, et al. (2017). Reduced Neuromuscular Performance in Amenorrheic Elite Endurance Athletes. Med Sci Sports Exerc.;49(12):2478-2485. doi:10.1249/MSS.0000000000001383

20. Hansen M, Kjaer M. (2014). Influence of sex and estrogen on musculotendinous protein turnover at rest and after exercis). Exerc Sport Sci Rev. 2014;42(4):183-192. doi:10.1249/JES.0000000000000026

21. Kitajima Y, Ono Y (2016). Estrogens maintain skeletal muscle and satellite cell functions. J Endocrinol;229(3):267-75.

22. Leopoldo Falsetti, Alessandro Gambera, Lorena Barbetti, Cristina Specchia. (2002). Long-Term Follow-Up of Functional Hypothalamic Amenorrhea and Prognostic Factors, The Journal of Clinical Endocrinology & Metabolism, Volume 87, Issue 2, 1 February 2002, Pages 500–505, https://doi.org/10.1210/jcem.87.2.8195

23. Tranoulis, A., Soldatou, A., Georgiou, D., Mavrogianni, D., Loutradis, D., & Michala, L. (2020). Adolescents and young women with functional hypothalamic amenorrhoea: is it time to move beyond the hormonal profile?. Archives of Gynecology and Obstetrics, 301, 1095-1101