- Losing periods from dieting, excessive exercise, and stress is called functional hypothalamic amenorrhea.
- It’s a rarely discussed but common side effect of getting lean, but also occurs at higher body weights.
- The condition is reversible though, and women can regain their health with lifestyle tweaks.
- Visit Insider’s homepage for more stories.
As a bikini competitor at her leanest in 2015, Hayley Madigan ate just 800 calories and worked out for 2.5 hours a day.
She admits she was in a dark place mentally, but her physical health massively suffered too – despite winning physique competitions and having a body idolized in fitness magazines, Madigan didn’t have a period for three years.
And the worst part of it all was that she was told by all the coaches and professionals in the fitness industry that not only was this normal, but it was OK.
Madigan, now a healthy personal trainer who helps women regain their menstrual cycles, had what’s known as functional hypothalamic amenorrhea (FHA), which is where you have no period for 90 days or more (or less than three in a year), generally due to stress, over-restrictive dieting, not having enough body fat, or over-exercising.
Often it’s a combination of all factors, according to consultant gynecologist Dr. Lisa Webber.
Not only does FHA mean you can’t have children, but it can also lead to osteoporosis and possibly a higher risk of cardiovascular disease.
There are 3 key factors that cause hypothalamic amenorrhea
FHA occurs when the pituitary gland in the brain doesn’t produce the hormones that signal a follicle (which contains the egg) to grow, meaning you don’t ovulate or have a period.
There are three key stressors that lead to FHA, according to Webber: Being too thin for your natural body, over-exercising, and stress. How much each of these is responsible depends on the individual.
“Think about it from an evolutionary perspective,” she said. “When we were all nomadic, if you were very lean, that usually meant it was a time of famine. If you were doing a lot of exercise, that usually meant you were either having to move a lot to find food or you were running away from a predator. And if you were stressed, it was probably because of these things.”
In each of these situations, the body shuts down all non-essential processes (such as the menstrual cycle) and knows you’re not in a position to reproduce.
Aside from being unable to have children, Webber said when estrogen isn’t stimulated, you’re at much higher risk of osteoporosis and thus many women with FHA break bones through minor injuries.
“I’ve looked after women who have fractured part of their pelvis just getting out of bed,” she said, adding that there’s emerging research suggesting a higher risk of cardiovascular disease too, although it’s thought this can be reversed when the menstrual cycle is regained.
It’s hard to know just how common FHA is, because many women don’t come forward and others don’t even know – hormonal contraception can mask FHA, and the menstrual cycle can be affected for other reasons like polycystic ovary syndrome.
It’s an unspoken side effect of being too lean
FHA has long been linked to being very lean, and it’s more common in women with lower body fat levels.
The threshold for leanness varies from woman to woman though: Madigan cites a bodybuilder friend who says she never lost her cycle despite getting as lean as 10% body fat for her competitions.
While being very lean is not necessarily the cause of FHA, the process of getting shredded generally involves the perfect cocktail of the three main stressors: too much intense exercise, extreme dieting, and both physical and mental stress.
Madigan believes it’s much more common than people let on.
Madigan said she looks at “ripped” women on fitness magazines but worries their physiques are due to restriction. “Why are we celebrating this low body fat percentage when it’s actually really unhealthy?” she said.
It’s true that we are all different, and an unhealthy body fat percentage for one woman may be healthy for another, but on the whole, women need more fat on their bodies than men.
“Women naturally carry a lot of easily metabolized fat around the abdomen, and the reason is that it’s stores so you are able to reproduce,” Dr. Frankie Jackson-Spence, an NHS doctor and personal trainer, told Insider.
Fitness culture on social media may contribute to hypothalamic amenorrhea
Webber says some people have a genetic predisposition to FHA, and the women she sees tend to be “type A” people who like to feel in control – often it occurs when people are anxious, so the one thing they think they can control is their diet and exercise.
A 2017 study concluded that patients with suspected FHA often had “perfectionism and high need for social approval; ambitions and expectations for self and others.” But this overachieving can lead to hypervigilance and stress, which can be dangerous.
Data on the prevalence of FHA is hard to collate because it’s often masked or undiagnosed, but it’s thought that 1.62 million women aged 18-44 in the US have the condition, and 17.4 million women worldwide.
Jackson-Spence told Insider she thinks the bodybuilding industry and fitness culture on social media have normalized being shredded and losing your cycle as a result. “It’s much more common in this sub-group than the general population,” she said.
Along with the rise of the fitness influencer, recent years have seen the soaring popularity of high-intensity interval training, but this means some people are doing too much, putting stress on their bodies, and not giving themselves time to recover.
You don’t need to be thin to lose your period
Although people associate losing a period with elite athletes like marathon runners, it can occur at higher body fat levels too. The majority of Webber’s patients are in the healthy-low bodyweight range and do not have an eating disorder as such, but have disordered eating habits.
If a woman isn’t eating enough and is too stressed (whether physically through over-exercising or mentally), she can develop FHA – Madigan cites a client who didn’t menstruate for 10 years due to over-exercising despite being around 25-30% body fat.
“People typically think of this with very thin girls with eating disorders, and actually it can be in someone who on the outside looks healthy but has a lot of internal stress,” said Jackson-Spence.
FHA can occur when a woman is in a gentle calorie deficit for a long time – even if it isn’t extreme, if the preoccupation is causing anxiety and stress, you can lose your menstrual cycle. However, the greater the calorie deficit, the higher the frequency of menstrual cycle dysfunction.
Research shows that low energy availability (ie. not consuming enough for your body and activity levels) is a key factor in developing FHA.
Studies also suggest that going full steam ahead into exercise rather than easing yourself into a new fitness regime gradually makes it more likely that your menstrual cycle will be disrupted, and if you are also restricting your calories it’s even more likely.
The issue is very complex because being overweight can also lead to the brain stopping production of estrogen due to the hormone being released by the body’s fat tissues, Jackson-Spence said.
FHA is generally reversible
Jackson-Spence stressed that every woman’s cycle is different so you shouldn’t diagnose yourself with hypothalamic amenorrhea, but if you’ve missed more than three periods in a row and have a negative pregnancy test, “you should speak to your GP rather than getting advice from social media.”
While doctors can prescribe medicines for inducing ovulation, a better approach is to focus on the underlying cause of FHA. But as these are so complex, the solutions are too – it can take months or over a year to get your cycle back, but it is possible.
Focusing on rest days and recovery is important, and Madigan has seen some women regain their cycles simply by taking out one workout a week and replacing it with something calming like yoga or meditation (and crucially, not feeling guilty about it).
It’s also important to ensure that not only are you eating enough, but you’re eating a balanced diet and specifically not cutting down on fat too much.
Madigan herself stopped taking part in bikini competitions in 2017 after speaking to the other women in the fitness industry (the vast majority of whom had no periods), having her concerns routinely dismissed by coaches, and realizing it just wasn’t right.
When did she finally get her period back? On a holiday in 2018. “I relaxed, I moved less, I ate more, it was amazing,” she said.