Ask An Adult: I'm Not Pregnant So Where The Hell Is My Period?
The Debrief: Hypothalamic amenorrhea is one reason your flow goes MIA with no explanation. Here's what could be going on...
Illustration by Marylou Faure
Coming off the pill was meant to be the easy bit. I'd ridden the wave of Microgynon-induced mania, weathered the steadier storms of Loestrin 20 and was ready to let my body and brain revert to default. But without a daily hormonal boost, my menstrual gears appeared to grind to a halt - at 23. Cue panic. It's a feeling that 26-year-old holistic health coach Madeleine Shaw knows all too well. 'I didn't get my period for a year after I stopped taking the pill,' she tells me. 'It's not like I wanted to have a baby anytime soon, but I knew that I did in the future. It was really scary', she adds. Shaw's missing periods were likely linked to her Polycystic Ovary Syndrome (PCOS). Mine - after many conversations, blood tests and trans-vaginal scans (yep, as fun as they sound) - was put down to something called hypothalamic amenorrhea.
What is hypothalamic amenorrhea?
Never heard of it? I hadn’t either. Dr Channa Jayasena, reproductive endocrinologist at Imperial College London explains: ‘It’s the most common cause of period loss in young women who are otherwise healthy – around one in ten women who report period loss have it. The brain orchestrates your periods through hormonal signals and put simply, in hypothalamic amenorrhea, a variety of reasons cause that signal to go to sleep. It is not dangerous or irreversible - but it is an under-recognised problem.’ And it's not just the spectre of infertility; the condition - which you are genetically predisposed to develop - is linked to osteoporosis, anxiety and depression, according to a 2014 report in the Journal of Endocrinological Investigation.
What's going on?
The chain of hormonal signals that need to occur for you to have a period is a bit like a Mexican wave: if one element misses their beat, then the whole thing is screwed. Dr Jayasena breaks it down: 'In order to have a period, your pituitary gland (a pea-sized organ, attached to the base of the brain) makes two hormones: lutenising hormone (LH) and follicle stimulating hormone (FSH). In order for this to happen, a part of the brain called the hypothalamus releases gonadotropin-releasing hormone (GNRH). This triggers the pituitary gland to release LH and FSH, which then circulate around the blood and stimulate your ovaries. In hypothalamic amenorrhea, it’s this signal that goes to sleep,’ he explains.
Why does it happen?
We’re used to the idea that professional athletes and eating disorder sufferers lose their periods. But that stereotype doesn’t fit the patients at Dr. Jayasena’s London clinic.‘These are slim women in their 20s: on paper they are the healthiest people in society,’ he says. Stress is a very real factor - as shown by a report in the Journal of Clinical Endocrinology & Metabolism, which found that women who did not ovulate had excessive levels of the stress hormone cortisol in their brain fluid. 'If you ask someone “Are you stressed?” they will often say no. But beneath the surface, they are dealing with a lot,’ he adds. Mounting debts plus insecure employment and a revolving door flatshare are enough to make anyone part ways with their chill. Working up a sweat can be one of healthier ways to deal. Annoyingly for people predisposed to flighty cycles, adding physical to psychological stress can make things worse. One animal study from The University of Pittsburgh found that, when stressed alone, 10 per cent of monkeys stopped ovulating. But when stressed, with added exercise and restricted food intake, 75 per cent of the monkeys lost their periods.
Should I see a doctor?
Missing a period isn’t always a big deal, but if yours have been absent for six months, Dr. Jayasena suggests making an appointment. You’ll be asked about your menstrual history (so come armed with dates and details), and will be given blood tests to check your hormone levels and test for other causes of unexplained period loss such as PCOS and thyroid abnormalities. Just don't expect your GP to have all the answers. Dr. Jayasena explains: 'In hypothalamic amenorrhea the hormone levels will all be low. But GP's who don't have the condition on their radar will look at that and be reassured, thinking that they are just the normal, low levels for the start of your cycle. Sadly, this condition isn't taught in medical school and as a result, the level of knowledge amongst GP’s is quite limited. So don’t be afraid to ask “Is this hypothalamic amenorrhea? Do you think I need more tests?”,’ suggests Dr Jayasena.
What will they say?
‘The condition often reverses after a couple of years. That's why it's crucial to get in front of a specialist who can reassure you,' says Dr. Jayasena. If you're not looking to get pregnant any time soon, your gynaecologist will likely offer you hormone replacement to induce regular periods - not always a satisfying solution. ‘In doing so we're not able to tell patients the important things that they want to know, like “Will I be able to have children”,’ says Dr. Jayasena. The only way to tell that is to get your cycles back in order. And the only way to do that is to look at your routine, and lessen the stress. A busy NHS hospital is never going to be the number one destination for inspiring lifestyle advice. And after being told that going on long runs was making the problem worse, the suggestion to ‘try walking instead’ was of little comfort. The principle of sacrificing something I loved right now at the altar of future fertility was a little depressing, too.
Can I still work out?
What I didn’t know is that there are a number of ways that you can exercise a body in a stressed state. Enter Pip Black, co-founder of London fitness studio chain, Frame. ‘Instead of doing lots of high intensity exercise, try lifting heavy weights and doing low reps. You're still working hard but your body is under a different kind of strain. It's not always about how sweaty you are,’ says Black. Want something to calm your mind but can’t deal with yoga? ‘Pilates is so specific that you have to really concentrate on your body. It's slow and controlled but you really feel it the next day,' says Black.
Think: what’s motivating you?
In the age of #StrongNotSkinny we risk upgrading one unattainable body type for another. ‘You see an Instagram feed full of intensely toned bodies and think that is normal. But behind the scenes these girls are training a good few hours a day,' agrees Black. Blogger Celia Learmonth (@LondonFitnessGuide) is a case in point that leaner doesn't always mean healthier – she revealed that her intense exercise schedule sent her periods AWOL last year. 'If you're a female and you're training for the Olympics then yes, you might have a six pack. But for the rest of us, body fat shouldn't be that low,' explains Black. Resetting your body goalposts is tough - but fostering acceptance of what her body looks like at its natural place was crucial for Shaw in getting back in balance: 'I used to really smash it in the gym but now I'm doing more resistance training, yoga and walking. We think it is all about being lean but as a woman you're meant to have a bit of extra body fat in order for your body to work properly,' she says. Quite; a healthy body doesn’t have to be perfect, but it should be working. And if you’re not having regular periods, it isn’t.
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