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What is Hypothalamic Amenorrhoea?

*** Be warned – I can get a bit 'ranty' on this topic! Through my own life experiences this has become a passion of mine, to help prevent people being led astray and to learn how to harness our hormones and cycle for good.

Amenorrhoea is the term used to describe the absence of a menstrual cycle for 3 or more months. There are 2 types of amenorrhoea, primary and secondary. Primary amenorrhoea occurs when a female never develops a menstrual cycle by the age of 16 and this may be due to a variety of reasons. These can include absence of reproductive organs, genetic anomalies or may be due to the functioning of the hypothalamus, pituitary gland or ovaries.

Secondary amenorrhoea occurs when a female has started menstruation in puberty and cycled somewhat ‘regularly’ for a period of time and then menstruation ceases. A woman who begun menstruating in puberty and then stops menstruating before the age of 40 and is not pregnant will need to be assessed for various causes. Certain causes need to be eliminated prior to treating hypothalamic amenorrhoea (HA) or as I see in clinic and have experienced first-hand, functional hypothalamic amenorrhoea (FHA).

Things that will need to be eliminated as potential causes of HA before we can treat FHA include –

· Asherman’s syndrome – the presence of adhesions and scars on the uterine wall. Can occur following certain gynaecological procedures such as a D&C. Please note this is rare and is a risk factor your surgeon would discuss with you if you were needing a D&C.

· Cervical stenosis – obstructed menstrual flow due to narrowing or closure of the cervix. May follow infection or poor surgery.

· Chronic renal and liver failure

· Certain medications and drugs may increase your prolactin levels and disrupt the menstrual cycle.

· Post-pill amenorrhoea – a small percentage of women may develop long-term amenorrhoea when stopping the contraceptive pill. The majority of women resume menstruating 3months after coming off the pill. MANY WOMEN ARE TOLD THE PILL ‘REGULATES’ THEIR CYCLE; THIS IS NOT TRUE. THE PILL SIMPLY ‘FLATLINES’ YOUR HORMONES TO PREVENT OVULATION SO YOU DON’T HAVE A CYCLE. The bleed you experience whilst on the sugar pills is a withdrawal bleed.

· Phantom pregnancy

· PCOS – causes failure to ovulate amongst a number of other things. You can be tested for PCOS and treatment will include dietary, supplement and lifestyle measures depending on the cause of PCOS. It is important to find out what is driving your PCOS.

· Premature ovarian failure.

What we see clinically, and the most common causes of FHA are generally lifestyle induced

· High and prolonged stress. Increases cortisol and adrenaline and decreases oestrogen, inhibiting ovulation. Stress can be anything that increases your cortisol levels and your sympathetic nervous system. It is mental, physical, emotional, trauma, untreated trauma, lack of food availability, poor diet, alcohol and drug abuse, anxiety, depression. Anything that alters our normal hormonal balance and internal stress modulating and processing ability. Stress is perceived differently for everyone. Some may find after a period of chronic stress their tolerance lowers and what used to be water off a ducks back now sets them on a downward spiral of stress.

· Low body weight. This does not need to be underweight, but low for your bodies ‘set-point’ and even if body fat drops below 25%. It’s important to highlight that we make hormones from fat, this initiates the hormonal cascade. Hence why in times of famine the body shuts down the reproductive system because it was not an ideal time to bring children into the world.

· Over-exercising. Gonadotrophin-releasing hormone (GnRH) is negatively impacted by prolonged strenuous exercise. GnRH is secreted by the hypothalamus, in the brain, which then does not signal to the pituitary gland and the ovaries to signal initiating of hormones (oestrogen, progesterone, follicle stimulating hormone, luteinising hormone).

· Under-eating for your daily requirements. The idea that women should live on 1200calories per day has served to harm many women and sadly some long-term. Remember what you see on social media isn’t always true. Just to function, most adult humans should be consuming at least 1800-2000calories per day, and then more on top of this if you exercise, are pregnant, lactating, and so on. Everyone is individual and no one set caloric ideal exists.

· Most commonly - A combination of all of the above!!!

When treating HA/FHA we need to look at the drivers of the HA. Are they an athlete that is not eating enough for the level of training, are they not allowing enough recovery time, is body fat percentage to low. Has someone else been under prolonged severe stress – whether that be from work, relationships, isolation – particularly prevalent now due to COVID-19 and enforced lockdowns, and so on. Does this person have an unhealthy relationship with food such as disordered eating and orthorexia, often misdiagnosed or missed because people can justify it has having a healthy diet. However, if any way of eating causes you to be consumed with the thought of food and what you can and cannot eat and prevents you from enjoying the rituals and social aspects of food it is not healthy. It is more detrimental to your health. Moderation is key. (Please note I’m obviously not talking about people with allergies or short term FODMAP diets etc)….

So how do we work to regain cycles? You’ll find this and more in part 2


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