Hypothalamic Amenorrhea Part 3: How do I heal from HA?
Disclaimer: This is not intended to substitute medical advice & should not be taken as such. Please refer to your qualified healthcare provider when recovering from HA when discussing your treatment plan that is specific to your individual needs.
The treatment of HA is to regain normal ovulation and menstruation, and this will involve addressing the underlying root cause/s of HA. The treatment will differ based on the individual and these may include addressing psychological stress, disordered eating or dieting, achieving a healthy body mass index and reducing excessive, strenuous exercise.
Also please note, the treatment will also depend on the individual’s readiness to change. Treating HA is a big, scary change and I would recommend doing what feels right to the individual whether that is going “all in” (consuming a minimum of 2500 calories, cutting out all high-intensity exercise) to making gradual, slower changes. This is intended to inform readers and provide awareness of hypothalamic amenorrhea.
1. Find support
A multidisciplinary team is recommended to support the individual to heal from HA. These may include a general practitioner, naturopath, nutritionist, dietician, endocrinologist and psychologist. Additional therapeutic options include group therapy, eating disorder counselling individual therapy with a psychologist and/or psychiatrist if disordered eating habits are suspected/diagnosed.
Furthermore, with any big lifestyle change, a support network is vitally important. Having a support network will help you cope with the ‘bad’ days & help keep you accountable for your goals. I found having a multidisciplinary team who supported my goals in addition to having support from friends, family & the NPNW group to be so incredibly helpful. A “No Period Now What” Facebook group is a private group that is designed to support women and girls in recovering from their periods, learning to be positive about their bodies, and reclaiming their "life worth living”. It’s a great group to join as all of the members will emphasise your HA recovery & it’s a great place to ask questions in a safe, body-positive and non-judgemental environment.
2. Nutrition
Often individuals with HA present with orthorexia/disordered eating habits and will be underfeeding for their needs. The general guidelines are to consume a minimum of 2500 calories and 200g of carbohydrates daily (although this can be a gradual build-up depending on the individual’s readiness), listen to your hunger signals (these include both mental and physical hunger) and eat regularly and often. To heal from HA, the body and brain must feel as if they are no longer in an energy deficit and food is readily available.
Carbohydrates are often demonised, but they are important for numerous reasons including providing energy, fuelling the muscles and brain, promoting digestive health (fibre), improving mood and providing essential nutrients. Glucose (the storage form of carbohydrates) will increase the firing rate of GnRH nerve cells which in turn increases the release of FSH and LH to trigger ovulation.
Some individuals will experience ‘extreme hunger and this is due to the disrupted hunger signals that occur during HA (decreased leptin levels and increased ghrelin levels). Please don’t be alarmed, feeding your body regularly and often will help regulate hunger levels. Note, for those who are severely underweight and malnourished, the refeeding syndrome is a potential risk and will require medical assistance.
How to increase caloric intake:
- Add more nutrient and calorically dense foods such as nut butter, seeds, fatty fish, tahini, potatoes, olive oil, dark chocolate and avocado (delicious)
- Eat more frequently and add snacks (yoghurt, hummus, peanut butter, dates, protein bars) as consuming large meals may be difficult and cause discomfort initially. Do not fast.
- Increase liquid calories such as smoothies, juices, protein shakes, coconut water, whole milk
- Consume more starchy vegetables (e.g. yam, sweet potato, corn) over non-starchy vegetables (e.g. leafy greens, cucumbers, tomatoes)
- Add toppings to meals such as sesame seeds on stir-fries, coconut flakes and crushed nuts on smoothies, almond butter and maple syrup drizzled on oatmeal, tahini topped on toast
If consuming less nutrient-dense ‘fun foods’ such as pizza, ice cream and doughnuts are causing discomfort or fear then consulting with an eating disorder specialist, dietician, or psychologist is recommended to unlearn unhelpful beliefs around food that are rooted in diet culture. Food should not be labelled as ‘bad’ or ‘a cheat meal’ as food does not have a moral value.
3. Movement
Exercise is important and so beneficial for our health but often too much of a good thing can have detrimental effects. Intense, prolonged exercise (HIIT, 90-minute hot yoga classes, 1-hour-long plyometric workouts, CrossFit, running, etc) is taxing on our bodies and to heal from HA they should be stopped or at least reduced.
Intense or excessive exercise produces opioids that inhibit GnRH secretion. GnRH induces the releases of FSH & LH which then triggers ovulation. Finally, exercises increase cortisol which will reduce the release of GnRH, FSH & LH resulting in a decrease in estrogen and anovulation. Whilst it is true exercise has health-benefiting effects, the benefits are outweighed by the adverse effects of insufficient estrogen.
Furthermore, often these high-intensity activities are calorically taxing and use up a lot of our body’s energy stores. When there is an energy imbalance (output by exercise VS input through food), the hypothalamus (the master gland) will “switch off” signals and the hypothalamic-pituitary-ovarian (HPO) axis will shut down.
Other gentle exercises such as yin yoga, walks and stretching are recommended. Cutting out exercise may be very difficult, but it is temporary and many will be able to include other forms of exercise after 3 consecutive cycles (although not excessive or prolonged). Also, think of all the extra time you’ll have! Less laundry too!
4. Psychological stress
Stress will cause the body to send messages to the hypothalamus in the brain to stop producing female sex hormones. Cognitive behavioural therapy (CBT) has been shown to help improve cortisol levels (stress hormone), increase leptin, female sex hormones, and TSH and recover ovulation. Focusing on the individual’s perceptions and attitudes on diet, self-care, exercise, stress and body image during CBT has shown to be helpful during HA recovery.
If exercise has been your method of choice to reduce stress, it is imperative to seek other stress-reducing activities. Some options may include journaling, spending quality time with family and friends, painting, reading books, watching movies, singing, gardening, listening to music, taking care of a plant, baking, playing an instrument, learning a new language & volunteering.
5. Weight restoration
When recovering from HA, you may need to gain weight and how much is completely individualised to your own needs and your own homeostatic ‘set point’. Women need a lot more body fat than males to be healthy. Generally, we need at least 17% body fat although this will be dependent on the individual. Having a healthy level of body fat is so important for females for our health especially if we want healthy periods.
Whilst many are aware of the negative consequences associated with a high BMI, there are also negative consequences of living with an underweight BMI for their body (note, everyone’s ‘healthy’ weight is different). Those who are underweight are more likely to develop osteoporosis, be anaemic, have irregular periods or absent periods and experience becoming sick more frequently.
Weight gain is one of the hardest parts of recovering from HA but some helpful tips to guide you through this process are to buy more clothes (that you feel confident and comfortable in) and throw away the ones that don’t fit, stop ‘mirror checking and micro-analysing body changes, unfollowing or mute ‘fitspo’ or other social media accounts that make you want to change your body type or size in any way, follow body-positive/non-food or fitness-focused accounts and research on the “Health At Every Size” movement which advocates on focusing on healthy behaviours, rather than focusing on body size.
Reading books such as “No Period Now What”, “Intuitive Eating”, “Pretty Unhealthy” and “Period Power”, listening to podcasts speaking on HA and joining the “no period now what” Facebook group can be helpful to support your mental health as you navigate through healing HA.
6. Get restful sleep
Sleep deprivation or disrupted sleep patterns will affect sex hormones, increase anovulation and have been associated with cardiovascular disease, glucose dysregulation, mood disorders and anxiety. Disruptions in the normal circadian rhythm may disturb menstrual function and shift workers are more likely to experience longer and irregular menstrual cycles compared to non-shift workers.
Try to be in bed by 10 pm & refer to the post on “sleep” on the lifestyle" tab for tips on getting at least 7-9 hours of good quality sleep.
7. Supplement
The combined oral contraceptive pill (OCP) will not protect against, manage or treat bone loss associated with HA. The pill may also mask the underlying pathology and provide a false sense of belief that the client is menstruating normally (a key sign of recovery). Bisphosphonates, testosterone and leptin are not recommended for premenopausal women due to their long half-life, the risk to unborn babies (if women become pregnant) and teratogenic potential.
Transdermal patches in conjunction with cyclic use of oral progestin are the safest option for patients who need long-term treatment/do not improve after psychological intervention and nutritional assistance. the patch can be halved or divided into quarters to reduce the oestrogen dose as treatment progresses.
Whilst there is no magic pill that will cure HA if the underlying causes are not addressed, there are a few supplements that may assist in the treatment of HA. Adding supplements in will not cure HA if the underlying root causes have not been addressed.
To assist with the negative impacts of a hypoestrogenic state, it is recommended for the individual to take calcium, magnesium and vitamin D supplements. These are important nutrients for bone health. Furthermore, an activated B vitamin complex and magnesium may assist with enhancing the body’s stress response, but these supplements should be discussed with the individual’s health care practitioner.
8. Have patience
On average, it will take around 6 months to recover from HA after lifestyle shifts are made. In the meantime, relax & have fun (yes, much easier said than done sometimes). Prioritise self-love & self-care, take therapy if you have the finances for it (I view therapy for my mind and mental health the same way other people view the gym for their physical health), spend time with loved ones, take a fun class (painting, pottery, etc), meditate, sleep early, put your phone away and revisit your old hobbies (drawing, singing, journaling, cross-stitching, anything really)!
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