Missing Period? Understanding Hypothalamic Amenorrhea and How to Treat It

Jan 9

When I was 29 years old, my period disappeared. At first, I thought it was a fluke—something temporary that would resolve on its own. But no matter how much I told myself it was fine, my period didn’t return.

Finally, after three months, it came back. I felt relieved, thinking I had solved the issue. But then it vanished again—this time for six months.

At that point, I was still studying to become a functional nutritionist and didn’t yet have the knowledge I have now. Unfortunately, I also struggled to find a practitioner who could help me. No one had answers. Looking back, I’m shocked that no one asked me the most basic questions:

Are you eating enough? Are you eating often enough? What type of exercises are you engaging in and how often?

These were the root causes of my problem. I had hypothalamic amenorrhea (HA) due to over-exercising and under-eating. My body wasn’t properly fueled, which led to chronically elevated cortisol (our primary stress hormone). This sent a signal to my body to suppress hormone production in the hypothalamic-pituitary-ovarian (HPO) axis, effectively shutting down my reproductive system.

Let’s break this down further to understand the science behind it.

What Is Hypothalamic Amenorrhea (HA)?

Hypothalamic amenorrhea is the cessation of menstruation caused by disrupted signaling between the hypothalamus and the pituitary gland. This disruption is often due to insufficient pulsatile secretion of gonadotropin-releasing hormone (GnRH), which is essential for proper ovarian function. Without this signal, ovulation and menstruation cease.

HA is typically diagnosed by exclusion. This means ruling out other potential causes of missing periods, such as:

Pregnancy
Breastfeeding
Hypothyroidism (check with a full thyroid panel)
Hyperprolactinemia (measure prolactin levels)
Pituitary tumor (often associated with very high prolactin levels)
Polycystic Ovary Syndrome (PCOS)
Premature Ovarian Insufficiency (POI)

Labs to Consider

To confirm or rule out these conditions, I recommend working with a practitioner experienced in interpreting labs from an optimal range. Here are some labs to start with:

FSH and LH (on day 3 of your cycle if cycling, or anytime if not cycling)
Estradiol (same timing as above)
Progesterone (7 days post-ovulation if cycling)
AMH
Prolactin
Insulin
Full thyroid panel
Total testosterone

If these conditions are ruled out, hypothalamic amenorrhea is diagnosed based on symptoms, low estradiol levels, low/normal FSH and LH, and a causative factor like under-eating, excessive exercise, or significant weight loss.

Common Causes of Hypothalamic Amenorrhea

The most common causes of HA include:

Excessive exercise
Malnourishment or restrictive eating
Significant weight loss
Low body weight
Eating disorders
Psychological stress

Symptoms of Hypothalamic Amenorrhea

If you have HA, you might experience:

Irregular or missing periods
Very light periods
Low sex drive
Feeling cold frequently
Depression or anxiety
No rise in basal body temperature (typically seen after ovulation)
Difficulty sleeping
Increased hunger
Low energy

In many cases, signs of hormonal imbalance may appear before periods fully stop. These can include:

The above symptoms
Short luteal phases
Low basal body temperature pre-ovulation (below 97.3°F)
Fertility challenges

Tracking your menstrual cycle and ovulation can provide invaluable insights into your overall health. Ovulation isn’t just about fertility—it’s a critical indicator of hormonal balance, stress resilience, and overall wellness. If you’re seeing irregularities in your cycle or experiencing symptoms like these, it’s worth investigating.

The Role of Stress and the HPA Axis in Hormonal Health

The hypothalamic-pituitary-adrenal (HPA) axis is our body’s primary stress-response system. When we face chronic stress—whether from under-eating, over-exercising, or emotional factors—our HPA axis signals the adrenal glands to release cortisol. Elevated cortisol levels, especially over time, suppress the hypothalamic signals needed for proper ovarian function. This suppression impacts the HPO axis, leading to irregular or missing cycles.

From an evolutionary perspective, your body perceives high stress as an unsafe environment for reproduction. It shifts resources away from non-essential functions (like reproduction) to prioritize survival. This is why stress management is essential for restoring hormonal balance and regular cycles.

Treatment Approaches for Hypothalamic Amenorrhea

The good news? Hypothalamic amenorrhea is reversible with the right support and lifestyle changes. Here are some key steps:

Increase Caloric Intake: Work with a practitioner to ensure you’re eating enough to meet your body’s energy demands. This often means incorporating more nutrient-dense foods and reducing restrictive eating patterns.
Reduce Exercise Intensity: Switch from high-intensity workouts to gentler forms of movement like yoga, walking, or stretching. Prioritize rest and recovery.
Address Stress: Incorporate stress-reducing practices such as mindfulness, therapy, journaling, or restorative activities that bring you joy.
Support Hormones: Focus on balancing blood sugar with regular meals, healthy fats, and proteins. Ensure you’re getting enough micronutrients like magnesium, zinc, and B vitamins.
Seek Professional Guidance: For many women, food and weight can be emotionally sensitive topics. Working with a practitioner or therapist can provide the support needed to navigate these changes.

Next Steps

I know from personal experience that overcoming HA is possible. I’m deeply grateful to have found the knowledge and support I needed to heal, restore my cycle, and go on to have a healthy pregnancy and baby.

Now, as a practitioner, I specialize in helping women just like you recover from HA and improve pregnancy outcomes. Healing can feel overwhelming, but with the right guidance, it’s absolutely achievable.

If you’re ready to take the next step, book your free 30-minute Fertility Insights call here. Let’s work together to get your health and cycle back on track.

References

Roberts RE, Farahani L, Webber L, Jayasena C. Current understanding of hypothalamic amenorrhoea. Ther Adv Endocrinol Metab. 2020 Jul 30;11:2042018820945854. doi: 10.1177/2042018820945854. PMID: 32843957; PMCID: PMC7418467.

Saadedine M, Kapoor E, Shufelt C. Functional Hypothalamic Amenorrhea: Recognition and Management of a Challenging Diagnosis. Mayo Clin Proc. 2023 Sep;98(9):1376-1385. doi: 10.1016/j.mayocp.2023.05.027. PMID: 37661145; PMCID: PMC10491417.

Shufelt CL, Torbati T, Dutra E. Hypothalamic Amenorrhea and the Long-Term Health Consequences. Semin Reprod Med. 2017 May;35(3):256-262. doi: 10.1055/s-0037-1603581. Epub 2017 Jun 28. PMID: 28658709; PMCID: PMC6374026.

Olivia Moeller