Hypothalamic amenorrhea: causes and treatments

 

What is amenorrhoea?

Most women have a period approximately every 28 days. Some, however, experience problems with their monthly cycle, including missed or stopped periods – a condition known as amenorrhoea.
 

What are the two types of amenorrhoea?

There are two main types of amenorrhoea; primary and secondary: 

 

Primary amenorrhoea

 
This is when your periods don’t start in the first place (experts are divided on exactly at what point primary amenorrhoea should be diagnosed, but generally it’s considered a problem if your periods don’t start by the time you’re between 13 and 16 years old (i)).
 

Secondary amenorrhoea

 
This type of amenorrhoea occurs when you have already: started having regular, normal periods but they stop for three months or longer. There are different forms of secondary amenorrhoea, for example, hypothalamic amenorrhoea or ‘post-pill’ amenorrhoea.
 

Post-pill amenorrhoea

 
Sometimes your period may not come back straight away after you stop taking contraceptives. This is often referred to as post-pill amenorrhoea and is usually temporary. In most cases, periods return back to normal within a couple of months. However, if your period still hasn’t returned over three months since stopping the pill, you should consult with your GP to see if there is another underlying cause of your missing period.

 

Hypothalamic amenorrhea

Also called functional hypothalamic amenorrhoea or functional amenorrhoea, HA is a common form of secondary amenorrhoea. According to the National Institute of Health and Care Excellence (NICE), around three to four per cent of women of reproductive age are affected by secondary amenorrhoea – though this figure is much higher in athletes (up to 60 per cent) and ballet dancers (up to 44 per cent) (iii). Scientists writing in the journal Therapeutic Advances in Endocrinology and Metabolism, meanwhile, suggest around 30 per cent of cases of secondary amenorrhoea are caused by HA (iii).


Cases of HA, however, are on the rise. According to Patient UK experts are currently worried by the growing number of women who are losing their periods as a result of their lifestyle (iv). And while not having periods may not seem like a problem – in fact for some it could be quite the opposite – HA can lead to several health complications, including fertility problems, skin and hair problems and an increased risk of cardiovascular disease, osteoporosis (bone loss) and even mental health problems such as anxiety and loss of self-esteem. 
 

What causes hypothalamic amenorrhoea?

There are lots of different reasons why your periods might stop. For instance, it could be caused by another medical condition such as polycystic ovary syndrome (PCOS) or a problem with your thyroid gland. It can also be caused by genetic factors, with secondary amenorrhoea sometimes running in families or caused by a genetic health condition.
 
Lifestyle factors can cause amenorrhoea too, including stress, compulsive exercising, significant weight loss and poor or extremely extreme restrictive diets – or sometimes a combination of all four. These particular lifestyle factors are all linked to hypothalamic amenorrhea (HA).
 

What hormone causes hypothalamic amenorrhoea? 

As you may expect with problems that affect the menstrual cycle, hormone disturbances are at the heart of hypothalamic amenorrhoea.
 
Experts believe HA is caused by the suppression of a hormone called gonadotropin-releasing hormone (GnRH). This hormone is produced in the part of the brain called the hypothalamus, where it is released into tiny blood vessels and transported to the pituitary gland, a gland found at the base of the brain. While in the pituitary gland GnRH stimulates the production of two more hormones – follicle-stimulating hormone and luteinising hormone – which in turn control the levels of hormones produced by the ovaries in women, including oestrogen and progesterone.
 
Both follicle-stimulating hormone and luteinising hormone are important for your reproductive system, as one of the things they do is control the release of an egg each month during your menstrual cycle. But if you’re not producing much or any GnRH you may also not produce enough follicle-stimulating hormone, luteinising hormone and oestrogen – and low levels of these hormones will usually lead to the disappearance of your period. Indeed, some experts claim hypothalamic amonerrhoea is defined as when you don’t have a period for at least three consecutive months accompanied by low blood levels of oestrogen, follicle-stimulating hormone and luteinising hormone (v). 
 

Is hypothalamic amenorrhea caused by stress?

The lifestyle factors thought to cause HA also have various effects on these important hormones. For instance, experts believe stress increases levels of hormones called cortisol and corticotrophin-releasing hormone, both of which block the production of GnRH (iii). Extreme weight loss, dieting and exercise – all of which put the body under a lot of stress – trigger other processes that result in the suppression of GnRH too, which can lead to HA.
 

Other causes of hormone imbalance

Some medicines can also cause a hormone imbalance that can make your periods stop, such as:
 

• Chemotherapy and radiotherapy treatments

• Some antidepressants

• Some high blood pressure medicines 

• Some allergy medicines 

• Some anti-psychotic medicines 

 

What are the other signs of amenorrhea?

Not having your period is the main symptom, but some women with HA may experience other symptoms too, including:
 

• Sleep difficulties (insomnia) 

• Sexual dysfunction (low libido)

• Lack of energy  

• Depression 

• Anxiety 

• Appetite changes (usually increased hunger)

• Acne 

 

Does amenorrhea cause infertility?

Having amenorrhoea usually means you’re not ovulating, so you cannot become pregnant until your periods return. If you have amenorrhoea for a long time, it could be caused by a chronic condition that may also cause infertility.
 

How is hypothalamic amenorrhea treated?

If you’re not pregnant and you’ve missed more than three periods in a row, it’s a good idea to speak to your GP. Tests they may recommend will usually look to rule out other conditions such as pregnancy, thyroid problems or pituitary problems. Awareness of HA among the medical profession is growing, and some GPs may also suggest a test that measures your levels of GnRH to confirm whether or not you have HA.
 
Thankfully HA can usually be successfully treated and reversed – though it can take many months or longer for your body and your hormone balance to get back to normal. Some of the treatments consist of lifestyle changes to correct the behaviours that have contributed to your condition:
 

• Changing your diet may be necessary – for instance, if you have developed HA because you eat too little food and are underweight, your doctor may recommend ways of increasing how much food you eat to help you achieve a healthier weight. Your GP may also refer you to a dietitian if you need help with making your diet more nutritious.

• Therapies that can help you manage stress more effectively include yoga, meditation and mindfulness.

• Advice on over-exercising, including how to cut back on exercise and having longer rest periods between training sessions. You may also be referred to a sports physician if one is available in your area.

 
Other treatment options will also depend on what’s causing your HA and any other symptoms or complications you may be experiencing:
 

• Psychological treatments to treat stress, anxiety and depression include talking therapies such as cognitive behavioural therapy.

• Hormone replacement therapy may be an option if you’ve tried other treatments but your periods have still not returned after six to 12 months. This can help reduce your risk of developing osteoporosis, for instance (vitamin D and calcium supplements may also be recommended to combat bone loss).

• Infertility treatment may be offered to you if your body mass index (BMI) has returned to normal as a result of changing your diet and/or exercising less frequently, but you’re still having problems getting pregnant.

 
Meanwhile, several experimental treatments are being investigated for HA, including hormone treatments that are designed to help with weight gain – though it could be some time before these treatments are widely available.

 

What vitamins help with amenorrhea?

There are a few things you can do yourself if you’ve had a few missed periods – though it’s always advisable to see your GP if you think you may have amenorrhoea, as they can give you lots more advice and support. In the meantime, here’s how to help yourself:
 

• Eat a healthy, balanced diet: this is essential for healthy hormone production and to relieve the symptoms associated with HA. For general advice on healthy eating, check out Public Health England’s Eatwell Guide.

• Try nutritional supplements if your diet isn’t as healthy as it should be all of the time. A good-quality multivitamin and mineral supplement, for instance, can help make sure your body gets all the important nutrients it needs, even when you’re having an off day. Find out more about multivitamins and the various types available by reading our guide to multivitamins and daily requirements. 

 
Other supplements you may find useful include:
 

High-strength fish oils  

 
The omega-3 fatty acids found in oily fish such as salmon, herring and sardines are arguably best known for their heart, brain and eye health benefits. However many natural therapists also recommend omega-3 supplements for hormone balance support. There’s also some evidence that omega-3 supplements may help you cope better with stress by reducing your body’s level of the stress hormone cortisol (vi). Meanwhile, trials involving participants having chemotherapy treatment suggest omega-3 fatty acids may help with weight gain too (vii).
 
If you’re a vegetarian or vegan you can still benefit from an omega-3 supplement, thanks to the availability of products that contain the natural triglyceride (TG) form of omega-3, which is sourced from plant organisms called microalgae rather than fish oils.
 

Magnesium  

 
Many experts believe your body’s level of magnesium may be also lowered when you’re under a lot of pressure, with larger-than-normal levels excreted in urine during times of stress (viii). There’s also some evidence to suggest taking magnesium may help you sleep better if stress is keeping you awake at night (ix).
 

Vitamin D  

 
This nutrient is important for keeping your bones strong as it allows your body to absorb calcium. Indeed studies suggest taking vitamin D and calcium supplements reduce the risk of a bone fracture significantly (x). However many people are thought to be low in vitamin D, which is why Public Health England advises all adults and children over the age of 12 months to consider taking a daily 10mcg supplement of vitamin D, particularly during autumn and winter (xi).
 
Some people may need a vitamin D supplement throughout the year, including those who spend most of their time indoors and others whose skin is rarely directly exposed to the sun. People with dark skin from African, Afro-Caribbean and South Asian backgrounds should consider taking vitamin D all year round too, PHE advises.

The recommended form of vitamin D is vitamin D3 or cholecalciferol, as it’s the natural form of vitamin D that the body makes when it’s exposed to sunlight. Vitamin D3 supplements are available in tablet form, and now you can get them in veggie-friendly drops too. However, most vitamin D3 supplements are made from the fat of lamb’s wool, which means they’re unsuitable for vegans. Fortunately, vegan vitamin D3 supplements sourced from lichen are now more widely available.

 

Can you recover from amenorrhea?

Few women arguably look forward to having their period. But when your periods stop it can be a worry and lead to several potential health problems. When your lifestyle delays your period – when you eat too little, exercise too much or your life is too hectic – one of the results can be hypothalamic amenorrhoea. You could think of this as a sign that your body is putting itself on standby in protest


The good news, however, is that HA is reversible if you make healthier choices and lifestyle changes.
 

• Aim to achieve a normal BMI, which is between 18.5 - 25. If your BMI is lower, find out how to gain weight safely by reading our article What does it mean to be underweight?

• Exercise in moderation – if you’re aged between 19 and 64, the current recommendations state that you should do a minimum of 150 minutes of moderate activity each week (however the guidelines do not state how much exercise is too much).

• Make time for relaxation, as it can help reduce the impact stress has on your physical and mental health. How you spend that time is up to you – just do whatever helps make you feel calmer, whether that’s listening to music, reading a book or taking a long bath.

• Breathe deeply when you can’t avoid stress. Try the following deep breathing exercise whenever you need to feel more in control:

1. Lie on your back with your knees bent, your arms by your sides, and your weight sinking into the floor.

2. Take a breath in through your nose, feeling your upper chest rising slightly and then your stomach.

3. Exhale and feel your stomach and chest slowly lowering. 

4. Repeat for a few minutes or until you feel calmer and more relaxed.

 

Learn more about women's health

For more advice and information about lots of other health conditions, visit our pharmacy health library.
 

References:

1. Available online: https://cks.nice.org.uk/topics/amenorrhoea/background-information/definition/

2. Available online: https://cks.nice.org.uk/topics/amenorrhoea/background-information/prevalence/

3. Roberts, RE et al., Current understanding of hypothalamic amenorrhoea. Therapeutic Advances in Endocrinology and Metabolism. 2020 Jul 24;11:2042018820945854. Available online: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7418467/

4. Available online: https://patient.info/news-and-features/why-are-more-young-women-losing-their-periods-due-to-restrictive-diets-and-excessive-exercise

5. Shufelt, CL, Torbati T, Dutra E. Hypothalamic amenorrhoea and the Long-Term Health Consequences. Seminars in Reproductive Medicine. 2017 May;35(3):256-262. Available online: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6374026/

6. Madison, AA et al., Omega-3 supplementation and stress reactivity of cellular aging biomarkers: an ancillary substudy of a randomized, controlled trial in midlife adults. Molecular Psychiatry. 2021 Jul;26(7):3034-3042. Available online: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8510994/

7. Murphy, RA et al., Nutritional intervention with fish oil provides a benefit over standard of care for weight and skeletal muscle mass in patients with nonsmall cell lung cancer receiving chemotherapy. Cancer. 2011 Apr 15;117(8):1775-82.

8. Schlebusch, L., Bosch, B.A., Polglase, G., et al., A double-blind, placebo-controlled, double-centre study of the effects of an oral multivitamin-mineral combination on stress. South African Medical Journal. 2000 Nov 18;90:1216-1223.

9. Schlebusch, L., Bosch, B.A., Polglase, G., et al., A double-blind, placebo-controlled, double-centre study of the effects of an oral multivitamin-mineral combination on stress. South African Medical Journal. 2000 Nov 18;90:1216-1223.

10. Grases, G., Perez-Castello, J.A., et al., Anxiety and stress among science students. Study of calcium and magnesium alterations. Magnesium Research. 2006 Jun;19(2):102-6. Available online: http://www.eurostaga.com/pdf_estudios/tm/Mg_estres.pdf

11. Lips, P., van Shoor, N.M., The effect of vitamin D on bone and osteoporosis. Best Practice & Research Clinical Endocrinology & Metabolism. 2011 Aug;25(4):585-591. Available online: https://www.sciencedirect.com/science/article/abs/pii/S1521690X11000418?via=ihub

12. Available online: https://www.gov.uk/government/news/phe-publishes-new-advice-on-vitamin-d

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