Is missing a period really a big deal?
For many women, their menstrual cycle is something they associate with uncomfortable symptoms – think heavy, painful periods, bloating, fluid retention, mood swings and cravings – so it’s little wonder we’ve come to view periods as an irritating inconvenience. However, continuous missed periods isn’t normal and a sign something is amiss. “Missing a single period is rarely of significance, but if you miss six consecutive periods, or have three missed periods in long or irregular cycles, you could be suffering from what’s known as hypothalamic amenorrhoea (HA),” explains obstetrician and gynaecologist Dr Tara Hughes.
Can you tell us more about HA?
As Tara explains: “Your menstrual cycle starts in your brain, specifically in your hypothalamus. Your hypothalamus is responsible for stimulating the nearby pituitary gland, which in turn sends hormone signals to the ovaries to trigger ovulation and the production of oestrogen and progesterone, both of which are important female sex hormones.” Tara also says HA is surprisingly common, affecting one in 100 women. “This may seem like a rare condition, but given the average gynaecologist sees 100 women in a week, it is something we see on a regular basis.”
Why might it happen in the first place?
In a nutshell, your body’s number one priority is survival, so when it feels under threat, your reproductive system is often the first thing to take a hit. As Tara clarifies: “There are believed to be four main causes of HA: stress, under-eating, over-exercising and dramatic weight loss.” All four of these factors put the body under a huge amount of strain, telling the brain it isn’t the time to prioritise fertility. “Stress, depression and anxiety can all result in HA, but the most common cause is weight loss. If your BMI is less than 19 or your body fat percentage is less than 22%, you are more at risk. Women who exercise intensely for more than one hour every day are also at risk – interestingly, 65% of professional long distance runners and 79% of ballerinas suffer from HA. Women with complex nutritional deficiencies due to a chronic disease such as inflammatory bowel disease or coeliac disease may also struggle to maintain an appropriate calorie intake and are also at risk.”
What if you’ve just come off the pill?
“If you’ve just come off the contraceptive pill, your period should come back between one to three months, regardless how long you were taking it.” explains Tara. “If you’ve come off contraception and you’re periods haven’t returned after three months, it’s a good idea to take a pregnancy test and see a doctor to rule out any other causes of amenorrhoea.”
What are the risks of missing periods?
Fertility aside, HA is a serious health issue, primarily due to the lack of oestrogen produced by the body. “The main concern is long-term low oestrogen levels can cause osteoporosis, and there is no way of knowing you have osteoporosis until you do a bone scan, so missed periods are one of the only signs. In extreme cases, women can suffer from stress fractures due to low oestrogen,” Tara says. Missed periods have also been linked with dry hair and skin, digestive issues, exhaustion, poor sleep and a decreased sex drive. If your missed periods have been triggered by calorie restriction, then there’s also the impact of missing out on certain nutrients, which can trigger deficiencies and conditions like anaemia.
Can you get tested for HA?
“Your doctor can absolutely help if you think you are suffering from HA,” says Tara. “They will look to rule out common causes of lost periods such as polycystic ovarian syndrome or rarer causes such as benign pituitary gland tumours or adrenal glands disorders. This will usually involve blood tests to check hormone levels and an ultrasound scan. Women with HA will present with low FSH/LH hormone levels and low oestrogen, while a scan should appear normal with no apparent irregularities.”
How does HA affect fertility?
“Sometimes HA may only be diagnosed in a woman when she is trying but unable to get pregnant. Unfortunately, an absent menstrual cycle means there is no egg released each month to be fertilised, i.e. no ovulation. Without a menstrual cycle and ovulation your chance of pregnancy is extremely unlikely. Fortunately, if lifestyle issues are corrected then periods should return along with the chance of falling pregnant naturally. If recognised and treated early, there is no likely long-term impact on fertility.
Some women with HA want to know if they can use Clomid to induce ovulation. Clomid, or clomiphene citrate, is a drug only used by fertility doctors. It tricks the body into thinking the ovaries aren’t producing enough oestrogen. The brain then has a reflex reaction to over-produce FSH and LH (two key hormones linked to reproduction) to stimulate the ovaries. This results in more egg follicles being recruited in a month and the LH triggers ovulation. As HA is a problem connected to brain hormones, women with HA usually do not respond to Clomid or other ovulation induction drugs. The problem needs to be treated by mimicking brain hormones, which usually involves injections rather than oral medication. Again, only fertility doctors have the expertise to use these medications so it’s best to be seen in a specialist fertility clinic to discuss options."
Is there anything you can do to get your period back?
First, avoid going on the pill, as the period you get when you’re on oral contraceptives is a placebo. “Inducing periods with the pill isn’t recommended if you have HA as it’s merely masking the problem and not addressing the low oestrogen levels associated with low body weight or high intensity exercise,” Tara advises. She also recommends a diet rich in antioxidants, packed with fruits and vegetables and healthy fats, which are the building blocks of female sex hormones – and be sure to eat plenty of essential fatty acids such as avocados, olive and flaxseed oils. It could also be worth focusing on reducing stress levels, trying things like as yoga and meditation, especially if you use intense exercise as your primary method of stress reduction. Acupuncture could also be worth a try, according to Tara: “Acupuncture has been shown to reduce stress levels and have a calming influence, even after just one session. If other causes of HA have been ruled out and stress is the issue, acupuncture is worth a shot.”
How long will it take for your period to come back?
Understanding why you aren’t having a regular period is vital, as this will determine what changes
will be most beneficial for you. How long it takes to get your period back can vary, but don’t be
surprised if it takes a few months.
For more information, visit NHS.uk