What to Know About Amenorrhea

There are a few health conditions that I find regularly infiltrate the health and wellness space for women.  One of these is amenorrhea (a.k.a. missing periods).  Here we will walk through the who, what, where, and why or amenorrhea and in a follow up post, we will address strategies and support for getting that period back!!

what is amenorrhea

What is amenorrhea?

Amenorrhea by definition simply means no menstruation or no periods. There are four categories in which amenorrhea is typically defined.

Primary amenorrhea: 

  • Menstrual periods have not begun by age 16 

Secondary amenorrhea: 

  • The absence of three or more periods in a row (3 months) by someone who has already started regular menstruation.  Hypothalamic underfunction accounts for more than 30 percent of secondary amenorrhea cases.   The hypothalamus is a portion of the brain that helps keep the body’s internal functions in balance regulating appetite, weight, body temperature, and other homeostatic support,  while playing an important role in hormone function.  Hypothalamic amenorrhea (HA) is often associated with perceived stress or weight loss, but isn’t clearly caused by a reproductive anatomical issue with a woman’s body.

RED-S, formerly called “Female Athlete Triad”:

  • A condition related to low energy availability (inadequate caloric intake), amenorrhea (lack of menstrual periods), and  low bone mineral density that can be a function of both poor nutrition or poorly matched nutrition and lifestyle support for athletic intensity.

Post Pill 

  • A type of secondary amenorrhea, where after discontinuing a form of birth control, your cycle does not resume in a 3 month time frame. 

What are typical root causes to amenorrhea?

I like to say that a missing period is information.  From your body’s perspective, having a healthy period is about being healthy and nourished enough to reproduce.  If the body suspects a threat to the safety of that reproduction, we start to see changes in sex hormones that will temporailiy halt menstruation. 

Factors that the body could perceive as unsafe include:

  • Undereating 
  • Overexercising 
  • Eating a too low carbohydrate diet 
  • High stress (high cortisol) 
  • Inadequate sleep 
  • Undernutrition 
  • Food restrictions (eliminating whole categories of food i.e. dairy, guten, nuts, grains) 
  • Emotional trauma 
  • Inflammation 
  • Fasting 

For each person experiencing HA, the combination and the level of each factor above is different.  Genetics may even play a role here too!

Today’s diet culture can make it very confusing when looking to best support your health needs.  It is not uncommon for a woman to experience amenorrhea after making diet and exercise modifications with the intention of simply improving their health.  Research suggests that women with HA tend to have “higher levels of perfectionism” than women without HA.  This could be in the space of health preoccupation or also focused around body image and even disordered eating tendencies. 

In some cases, certain health conditions may further motivate amenorrhea.  For example, undernutrition doesn’t simply relate to low nutrient availability; it could also relate to digestive conditions like SIBO, IBS, IBD where maldigestion is regularly present.  With maldigestion comes decreased nutrient absorption and increased stress to the body from a variety of pathways.  Additionally, environmental stressors like toxic mold exposure and environmental toxicants like air pollutants, parabens, and polybrominated biphenyls have also been found to negatively impact hormone health and increase autoimmunity and stress on the body.  

As always, consult with your doctor regarding other physiological factors related to your missing period including pituitary function, structural reproductive problems, genetic chromosomal abnormalities.

What’s the deal with post pill amenorrhea? 

Birth control pills provide synthetic hormones that stimulate an artificial period, which is not an accurate indicator of menstrual health.  Let me repeat, a withdrawal bleed (the technical term for your period on the pill) is NOT a real period.

The truth is that while taking the birth control pill, you can completely mask a missing menstrual cycle. Although post-pill amenorrhea is not an evidenced-supported diagnosis, looking to the root causes of amenorrhea and starting to explore support is an important part of recovering a missing period after birth control use. 

What are the risks associated with long term amenorrhea?

Many times I get feedback from women…

“I don’t get a period- it’s great!”

“My period is a nuisance- I wish I didn’t have it”

“I like being able to control my period with birth control”

The truth is, sex hormones have more roles in the body than just supporting one’s fertility.  

Let me explain by walking through ovulation quickly: The main event of your cycle is ovulation. Ovulation is the phase of the cycle where your body releases an egg to have the opportunity to be fertilized. It occurs after estrogen peaks and signals LH (Luteinizing Hormone) to release an egg from a mature follicle. The body then creates a temporary organ (uh, cool!), called the corpus luteum out of the follicle that produces progesterone. Ultimately when an egg is not fertilized by sperm, the built up lining sheds, your sex hormone levels drop, and menstruation begins. Without a period, ovulation is not occurring; there is no egg released and the temporary hormone that make progesterone does not develop.

When you are not getting your period, it means that your estrogen, progesterone and other sex hormone levels are low.  

So what’s the problem?

Sex hormone production is essential for hair, skin, and nail health (glowing skin!), balanced mood, strong bones, and quality sleep. It also supports sex drive, healthy energy levels, and anti-aging! 

When hormone levels are low, one may experience low libido, brittle nails, hair loss and hair thinning, brain fog, vaginal dryness, poor wound healing, missing periods, fertility challenges, and stress fractures.

Long term risk factors with low hormone levels include conditions osteopenia and osteoporosis, increased risk of cardiac disease, and increased risk of dementia and early cognitive decline. Risks also include infertility and, if you to become pregnant, challenges like preterm deliveries and low birth weight. 

What conditions might be associated with missing periods?

A missing period can also be a clue that other aspects of hormone imbalance are at play.  Polycystic Ovarian Syndrome (PCOS), adrenal disorders, and hypothyroidism may also be involved in the presentation of a missing period. 

So, what’s the bottom line on amenorrhea?

Missing periods are not uncommon, but oftentimes overlooked in our society. A healthy menstrual cycle is a key sign of a balanced and healthy body. It is important to know that many diet and lifestyle actions are root cause factors to a missing period.  With this information, know that getting back a missing period is not only very healthy, but also for many entirely possible with diet and lifestyle strategies. 

Stay tuned for a “Part 2” where we will dive into the what and how of getting your period back naturally!

Women's Health

About Olivia Wagner

Olivia is a Functional Dietitian (RDN) with a strong foundation in nutritional and exercise science, advanced training in integrative and functional medicine, and certificates in mindful/intuitive eating practices so she has a deep understanding of the relationship between food, body and mind. She specializes in helping women achieve holistic transformation without ruining their relationship with food. Olivia helps growth-focused women balance hormones, beat the bloat, and create confidence with an empowered mindset. She works with a variety of conditions including PCOS and hormonal imbalances, irregular cycles, gastrointestinal conditions and autoimmune disease.