Eating Disorders Symptoms Eating Disorders and Hypothalamic Amenorrhea By Lauren Muhlheim, PsyD, CEDS Lauren Muhlheim, PsyD, CEDS Facebook LinkedIn Twitter Lauren Muhlheim, PsyD, is a certified eating disorders expert and clinical psychologist who provides cognitive behavioral psychotherapy. Learn about our editorial process Updated on January 30, 2023 Medically reviewed Verywell Mind articles are reviewed by board-certified physicians and mental healthcare professionals. Medical Reviewers confirm the content is thorough and accurate, reflecting the latest evidence-based research. Content is reviewed before publication and upon substantial updates. Learn more. by Anita Sadaty, MD Medically reviewed by Anita Sadaty, MD Facebook LinkedIn Anita Sadaty, MD, is a board-certified obstetrician-gynecologist at North Shore University Hospital and founder of Redefining Health Medical. Learn about our Medical Review Board Print Emilija Manevska / Getty Images Table of Contents View All Table of Contents Eating Disorders and Amenorrhea Contributing Factors Prevalence Consequences Treatment What to Do Treatment Outlook Hypothalamic amenorrhea is a condition in which the hypothalamus causes a person's period to stop. It often occurs due to undereating related to eating disorders, but it can also be caused by stress and excessive exercise. Hypothalamic amenorrhea is a common medical condition in women of childbearing age with eating disorders. The body enters survival mode, periods stop, and women cannot reproduce. Learn more about what causes it, the consequences, and how it is treated. The Connection Between Eating Disorders and Amenorrhea When an eating disorder is present, the most common cause of missing a period is hypothalamic amenorrhea (HA). The hypothalamus is an area of the brain that plays a central role in maintaining the balance of body systems. It receives input from throughout the body in the form of hormones and chemicals; it responds by secreting hormones that affect other organs including those involved in reproduction. When the hypothalamus receives a signal that something in the body is off-kilter and needs addressing, it rebalances the body by releasing hormones into the bloodstream. Sometimes, when things go wrong in the body, the hypothalamus can’t restore balance; such is the case with hypothalamic amenorrhea. An energy deficit occurs when a person eats too little compared with the energy they expend. A chronic energy deficit causes body mechanisms to conserve fuel for critical body processes. Less vital body functions are put on hold. This includes reproduction, which can actually be hazardous to survival—when energy is insufficient, energy and metabolic functions suppress the release of ovarian hormones by the hypothalamus. A diagnosis of HA is only made after other causes of amenorrhea are ruled out. However, in the case of an eating disorder, HA is a likely cause, even when weight is not extremely low. Contributing Factors The contributing factors to hypothalamic amenorrhea include energy imbalance, food restriction, weight loss, exercise, stress, and genetics. Each person expresses these factors differently, and each factor contributes in varying degrees to the development of HA. Energy Balance According to Nicola Rinaldi—a biologist who both experienced and ran an online forum for women who had HA—and colleagues, an energy deficit caused by undereating or overexercising is the primary driver of most cases of hypothalamic amenorrhea, regardless of the individual's body size. Simply put, our bodies need fuel to function optimally. Depriving the body of what it needs contributes to various problems, including loss of menses. Food Restriction Restricting the range of food eaten can contribute to the development of HA. Low-fat diets are a common culprit–our bodies need fat to function optimally. Weight Loss Low weight and body fat percentage, as well as a history of prior weight loss, can be contributing factors. It is important to point out that some women lose their period at higher weights than others. Each person’s body appears to have a different weight at which it will function optimally—it is reasonable to believe that as with anything else in the natural world, people’s bodies naturally come in different sizes and shapes. Losing a significant amount of weight (10 pounds or more)—even years in the past—increases the risk for HA. A common misconception is that one needs to be extremely emaciated to lose one’s period. However, hypothalamic amenorrhea can occur at higher BMIs as well. BMI Is an Imperfect Measure Body Mass Index (BMI) is a dated, biased measure that doesn’t account for several factors, such as body composition, ethnicity, race, gender, and age. Despite being a flawed measure, BMI is widely used today in the medical community because it is an inexpensive and quick method for analyzing potential health status and outcomes. Exercise Exercise contributes to HA by burning energy, leaving less available for body functions, and increasing stress hormones, including cortisol. Stress Chronic stress can lead to increased production of cortisol. High cortisol levels also appear to stop the hypothalamus from releasing reproductive hormones. Genetics There is genetic variability in the various factors that determine the sensitivity of our reproductive systems to energy deficits and stress. This explains why some people can continue to menstruate at relatively low weights while others will lose their period at a much higher weight. The Different Causes of Eating Disorders Prevalence of Hypothalamic Amenorrhea It is estimated that HA affects approximately 1.62 million women between the ages of 18 and 44 in the United States and 17.4 million women worldwide. The presence of secondary amenorrhea (defined as the cessation of regular menses for three months or the cessation of irregular menses for six months) used to be a diagnostic criterion for anorexia nervosa but was removed in the latest update of the "Diagnostic and Statistical Manual of Mental Disorders" (DSM-5-TR). While the prevalence of amenorrhea is high among adolescent and premenopausal women with anorexia, it has been removed as a criterion because: The predisposition to hormone dysregulation is variable—some women with very low weights continue to menstruate. This criterion is not useful across the broader spectrum of those susceptible to anorexia, including men and females who are premenarchal, post-menopausal, or taking birth control pills. Medical Consequences of Hypothalamic Amenorrhea HA results in estrogen deficiency and the cessation of the menstrual cycle in young premenopausal women. This, in turn, has significant effects on the body’s cardiac, skeletal, psychological, and reproductive system. These effects can mimic menopause and all the physical and psychological changes that it works on the body. Short-term consequences of amenorrhea include low estrogen, which then causes:Hair thinning or lossBrittle nailsSkin problemsLow libidoVagina dryness One difficulty is that many women with HA, due to lack of bothersome symptoms, often feel quite well. Thus, they may be reticent to seek treatment. Longer-term consequences include: Higher cardiovascular disease risk: Research has found that 69% of young women with coronary heart disease have low estrogen levels. This predominantly occurs among young women with hypothalamic amenorrhea caused by overexercising, undereating, and/or excess stress. Threatened bone health: Low estrogen suppresses bone production, leading to bone loss, osteopenia (loss of bone calcium), and increased risk of fractures. Amenorrhea can cause bone loss in as little as six months. Mental health concerns: HA is also implicated in increasing depression and anxiety. Infertility: HA can cause an absence of ovulation and infertility during a woman’s peak reproductive years. Treatment for Hypothalamic Amenorrhea The goal of treatment for HA is to reestablish a regular ovulatory menstrual cycle. Appropriate weight gain appears to be the most important predictor of menstrual resumption. Typically, all the contributing factors must be addressed: energy imbalance, food variety, excessive exercise, low weight, and stress. Birth Control Pills Are Not Recommended Many women with HA who present to a medical provider are prescribed birth control pills. This is unfortunate. While this estrogen replacement will provide a fake bleed, it does not solve the underlying problem or help the resumption of normal natural hormone activity. The underlying HA still needs to be addressed and birth control pills may only mask the problem. If you are already on birth control pills, be aware that the artificial period you get from birth control pills does not provide an accurate indicator of your health. You won’t be able to tell whether you’d menstruate on your own and whether HA is an issue for you until you go off them. “If you’re getting your period only because you are on birth control pills, it doesn’t count,” explains Nicola J. Rinaldi, PhD, author of "No Period. Now What?". Studies have shown that birth control pills do not help prevent further bone loss. Therefore, birth control pills should not be used as a treatment for HA. What to Do It should go without saying that if your HA accompanies an eating disorder, you should be getting help from a professional. Working with a therapist, dietitian, and medical doctor experienced with eating disorders can help you recover from HA. Eating disorder treatment will likely include the goals of eating more, exercising less, and learning to manage stress better. If you believe you are recovered from your eating disorder but your period has not yet resumed, you are encouraged to follow the recommendations below. Some women may think they are recovered, but still have more work to do in terms of increasing weight or food flexibility. Eat More Recovery requires eating enough—not only to adequately fuel current energy needs but to also to make up for the history of under-fueling. For most women with HA, recovery requires eating at least 2500 kcal per day. Eating a greater variety of foods, from all macronutrient groups, including fats and starches, seems to stimulate more hormone production. Full-fat dairy is particularly good for stimulating ovulation. You may not want to gain weight, thinking that you already feel healthy. However, your body disagrees with you if you are not menstruating due to HA. Try gaining 5 pounds and see what happens. You may be pleasantly surprised to see your cycles resume. Although healthy body weights vary greatly, most women with HA must obtain a BMI of 22 to 23 or higher to resume menses. Exercise Less Recovery is also facilitated by eliminating intense exercise. Faster recovery is associated with cutting exercise entirely. Slower recovery is achieved when exercise is reduced in intensity or duration or both. Running seems to be the exercise that makes it hardest to regain natural menstrual cycles. Excessive Exercise as an Eating Disorder Symptom Stress Management Research shows that reducing stress can help with recovering from HA. However, you might be managing your anxiety in ways that can contribute to HA—strenuous exercise or restrictive eating to deal with body image. Learning other coping skills such as relaxation, mindfulness, distress tolerance, and sedentary joyful activities can help complete the recovery puzzle. Treatment Outlook The length of time it takes to resume regular menses varies based on factors such as rate of weight gain, exercise level, stress level, age, and genetics. One survey of women with HA tracked how long it took for women to regain their cycle after making lifestyle changes and found that success rates increased over time: After three months: 24%After four months: 34%After six months: 57% A Word From Verywell If you’ve lost your period, you may think there’s no reason to be concerned with your health. However, the absence of regular cycles is not normal. You are encouraged to see a medical professional and ask about the possibility of a diagnosis of hypothalamic amenorrhea. You can reduce irreversible damage to your bones by seeking help and following the lifestyle change suggestions above. If you are on birth control pills and don’t know if you’d still menstruate without them, you are encouraged to speak to your treatment providers about whether you are truly at a healthy weight. Amenorrhea and Bone Health in Disordered Eating 9 Sources Verywell Mind uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles. Read our editorial process to learn more about how we fact-check and keep our content accurate, reliable, and trustworthy. Shufelt CL, Torbati T, Dutra E. Hypothalamic amenorrhea and the long-term health consequences. Semin Reprod Med. 2017;35(3):256-262. doi:10.1055/s-0037-1603581 Ryterska K, Kordek A, Załęska P. Has menstruation disappeared? Functional hypothalamic amenorrhea-What is this story about? Nutrients. 2021;13(8):2827. doi:10.3390/nu13082827 Rinaldi NJ, Buckler SG, Waddell LS. No Period, Now What? Waltham: Antica Press; 2019. Roberts RE, Farahani L, Webber L, Jayasena C. 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