Get your period back naturally with these 5 tips for Hypothalamic Amenorrhea recovery. Plus, how to know if you have HA and what causes it.
Note from Dena: This post was co-written with Olivia Ferrazza, Dietetic Intern, as part of a research partnership between Back To The Book Nutrition and post-graduate nutrition students from the University of Houston.
It’s been months, maybe years, since your last period. You’re desperate for answers. If you’ve stumbled on this page, chances are you might suspect- or know- that you have Hypothalamic Amenorrhea (HA). If you take anything away from this post, let it be these 3 things:
YOU ARE NOT ALONE!
HA is characterized by stress-induced missing periods for 3 months or longer, and is diagnosed by eliminating all other possible causes of amenorrhea. This condition is responsible for 30% of secondary amenorrhea (missing periods after having at least one initial period) (1). It’s even more common in very active women, with half of women who exercise regularly experiencing subtle menstrual disorders and one-third having amenorrhea (2).
ALTHOUGH IT’S COMMON, IT’S NOT NORMAL!
While periods may be inconvenient, they are vital to our health. Missing periods signify inadequate sex hormone production, which impacts your bone health, heart health, and mental health in addition to your fertility (3,4).
MOST CASES CAN BE REVERSED NATURALLY WITHOUT MEDICATION!
Luckily, most women can overcome HA by eating more and/or cutting back on exercise and other stress. Details below!
SYMPTOMS OF HYPOTHALAMIC AMENORRHEA (HA)
HA has several presenting symptoms, including:
- Irregular or missing periods
- Decreased sex drive
- Low energy
- History of rapid weight loss or chronically underweight
- Always feeling cold
- Increased hunger or loss of hunger signals
- Poor sleep
- Feeling weak or lightheaded
- Mood Changes (depression, anxiety, low motivation)
- Low metabolic markers (see next section)
METABOLIC MARKERS OF HA
These are common with HA, but they can also occur for other reasons as well. (8)
- Low Basal Body Temperature (BBT) – Test your temperature as soon as you wake up, while still lying in bed. With regular menstrual cycles, we expect to see lower temps (97-97.5 ℉) in the Follicular Phase (first half) of the cycle, and somewhat higher ones (>97.5 ℉) in the Luteal Phase (second half). But, if you’re not having periods, your temperature may not fluctuate much.
Temps consistently below 97. 5 (℉) are too low.
- Low Resting Heart Rate (pulse) – Test when seated after having been still for a few minutes. Place two fingers firmly on the side of your neck and count the beats for 6 seconds, then multiply by 10 to get your beats per minute (BPM).
<60 BPM is too low.
- Low Blood Pressure – Test when seated after having been still for a few minutes. If you have access to a blood pressure monitor (often free at pharmacies, or $20-40 for an at home monitor).
<90/60 is too low.
WHAT CAUSES HA?
In short, STRESS..
More specifically, the Hypothalamus-Pituitary-Adrenal (HPA) Axis is a hormone pathway between three endocrine glands (the hypothalamus and pituitary glands in the brain, and the adrenal glands that sit on top of the kidneys), and it is highly sensitive to stress. The hypothalamus is tasked with producing the hormone that triggers the start of the menstrual cycle (gonadotropin-releasing hormone, or GnRH). It also regulates sleep, hunger, and body temperature.
Women with HA are undereating, overexercising, or otherwise enduring some kind of stress. Stress triggers the hypothalamus to signal the pituitary, and then the adrenals to release stress hormones like adrenaline and cortisol. An increase in stress hormones will decrease the production of GnRH by the hypothalamus, which decreases LH and FSH from the pituitary, decreasing estrogen and progesterone from the ovaries.(3). Remember, your body’s main task is to keep you alive, and when resources are scarce, reproduction is one of the first processes to go, as it is not “essential” to your survival.
HPA AXIS AND THYROID
Being the major regulator of our metabolism, the thyroid is essentially the engine that keeps our bodies running. Unfortunately, stress on the HPA Axis decreases thyroid function in one or more of these ways (5,6):
- A drop in TSH production, which signals to the thyroid gland to make less thyroid hormone – this is called “Central Hypothyroidism” (you may see low-normal TSH and lower end T4 and/or T3 in your labs).
- Reduced conversion of T4 to T3, the active form of thyroid hormone that your body can actually use (you may see low-normal T3 in your labs).
- Deactivating of T4 and/or T3 into Reverse T3 and inactive T2 (if Reverse T3 is ordered, it may be high; T2 isn’t measured on lab work).
- Blocking T3 from entering the cells where it can act – usually due to high cortisol levels produced by the HPA Axis during stress – this is called “Cellular Hypothyroidism” (in some cases, they’re may be a higher than expected level of T3 compared to lower end TSH and T4 but usually this isn’t seen in labs).
Simply put, HPA Axis Dysfunction (HPA-D) can resemble hypothyroid symptoms.
OTHER CONDITIONS THAT MAY LOOK LIKE HA
Ruling out other conditions that cause amenorrhea or irregular cycles before diagnosing HA is important. Examples of these conditions include (1):
- Polycystic Ovarian Syndrome (PCOS)
- Premature Ovarian Insufficiency
- Uterine abnormalities
- Thyroid dysfunction, as discussed above
- Pituitary tumors/prolactinoma
- Trauma, brain injury, etc.
- Perimenopause (mostly mid-to-later stages)
Now that we’ve addressed the what, why, and how of HA, let’s go over what to do – and what not to do – about it.
HORMONAL BIRTH CONTROL & WHY IT DOESN’T FIX THE PROBLEM
The pill is the go-to treatment in conventional medicine for irregular or missing periods, but birth control doesn’t “bring back” periods. The pill or other hormonal birth control bleeds aren’t real periods – they’re bleeds that result from withdrawal of the medication.
Despite the fact that adding hormonal birth control does introduce estrogen (albeit synthetic), which can offset bone density losses from longer periods of amenorrhea, it masks the underlying problems and suppresses natural hormone production. This will delay the return of regular menstrual cycles that would result in higher estrogen levels and better bone density naturally (7).
Moreover, birth control further disrupts HPA Axis signaling and depletes B6, magnesium, zinc, and other nutrients that are critical for stress management and hormone balance. Birth control also has several side effects, which every woman should know.
How to Fix Hypothalamic Amenorrhea Naturally
1. Eat well (and more?)
Most women with HA aren’t eating enough.
- Gradually increase caloric intake
- Eat a balanced diet (sufficient carbs, fat, and protein) instead of diets with disproportional macros (keto, carnivore, vegan, etc.)
- Eat at consistent intervals throughout the day to promote stability in the HPA Axis and blood sugar
- Ideally, choose mostly whole, nutrient dense foods (unprocessed plant and animal/seafood, fewer refined foods)
2. Cut back on exercise
Overexercising is common in HA but can be a source of stress, especially longer duration and/or higher intensity exercises. Consider opting for gentler exercises like walking, gently yoga, and light strength training, and take rest days between workouts.
3. Gradually regain weight/body fat
If you’re too lean or underweight, your brain senses this as a threat. Different bodies will have different thresholds of what weight/body fat % they will tolerate. For most, at least 22% body fat is required for the maintenance of regular menstrual cycles – some will need to be higher.
In some cases, especially if HA has been going on for longer, you may need to slightly exceed your body’s preferred weight or body fat % for a time to fully convince the body of security (i.e., eating a bit more than you’d otherwise need and/or gaining a few more pounds than expected).
Be sure to increase food intake gradually (ideally, with the help of a nutrition professional!) to stoke the fire of your metabolism. If too much food is added too fast, you may feel unwell and it may take longer to restore balance.
4. Address other physical stressors
#1-3 are by far the most common drivers of HA, but be sure you’re seeing to any of these contributors you may be experiencing as well:
- Lack of sleep or sleep disturbance
- Poor blood sugar control
- Gut imbalances or overgrowths
- Toxic exposures
- Chronic illness
5. Reduce and Manage Mental/Emotional Stress
Tending to Mental & Emotional hurdles is just as important as addressing physical ones. Ideally, address these with support from trained mental health professionals.
- Body image
- Food relationship issues
- Trauma (past or current)
- Manage Stress (relational, financial, etc.)
Things to Remember When Your Period Comes Back
It’s important to remember that HA recovery is highly individual, so setting too many expectations can lead to disappointment. With that being said, there are a few things many women experience:
- The return of your period can take several months or even a year.
- Periods may start and stop over several months before becoming consistent OR monthly periods are consistent from the start. Usually, as long as monthly patterns are becoming more and more consistent over time, you’re moving in the right direction. When in doubt, reach out to a provider.
- Heavier periods the first few cycles (this is because the uterine lining is shedding for the first time in a while)
- PMS! It may take you by surprise if you haven’t felt it in a while. Hopefully it is mild, but give it a few months to level out before getting too concerned.
- Once your periods are consistent every month, ensure all signs are pointing to hormone balance. If you suspect hormone imbalance as your periods return, consider working with your provider or a practitioner like Dena 1:1 to consider whether more comprehensive hormone testing is helpful.
- Monitor for signs of ovulation in addition to your period bleed!
If healing from HA is taking longer than expected or symptoms are difficult to manage, supplements, vitamins, minerals, herbs, and/or glandular products may help.
With these steps, you can address the real root cause of your missing periods. Working with a functional or holistic practitioner like Dena to optimize your eating, supplements, and lifestyle (as well as hormone testing when needed) can help the process go even more smoothly!
About the Co-Author
Olivia Ferrazza is currently a dietetic intern at the University of Houston. She graduated from Miami University of Ohio in 2021 with a degree in nutrition and food sustainability. Prompted by her own nutrition-related challenges, Olivia’s passion continues to flourish in the areas of women’s health and environmentally friendly food systems. One day, she hopes to help others nourish themselves and align with their sustainable values, without compromise. Outside of “nerding out” on nutrition science, Olivia spends her time writing poetry, traveling with friends and family, hiking, and cooking.
Disclaimer: Information on this site is intended only for informational purposes and is not a substitute for medical advice. Always consult with a trusted healthcare provider before implementing significant dietary change. Read additional disclaimer info here.