It’s been about 18 months since I last had a period. There, I said it.  As you all know, I’m typically not one to shy away from revealing the dark crevices of my personal life on the Internet, but for some reason, my reproductive health left me a little speechless.

It’s no secret that with anorexia, comes period problems, and throughout my illness and recovery I expected to faced with conversations with consultants and eating disorder specialists regarding the reinstatement of my ‘time of the month’. However, in almost three years, not a single one of my small army of medical professionals has offered any constructive advice regarding my period (or lack there of). Having been on the contraceptive pill since the age of 18, I was stupidly unaware of the fact that the light bleed I reluctantly welcomed every three weeks was in fact, a “fake” period and gave no indication that my ovaries were working as they should be. A year into treatment, I came off the pill and – needless to say –   I haven’t had a period since.

Despite my “healthy weight” (whatever the hell that means) and re-discovery of my aversion to exercise, nothing seems to be going on down there. Like, literally nothing at all. On further investigation, it would appear that I have a condition known as, Hypothalamic Amenorrhea, otherwise known as no periods- and I’m not the only one. Lizzy Collier, 24 (below), suffered with anorexia as a teenager and, although she’d been in recovery for several years, it was only last year that she re-gained her “cycle”.

“I went without a regular period for six or seven years,” she says, ” [having] no period at 18 doesn’t seem so bad, but it is a little more worrying at 23. Despite feeling healthy in every way, it took a long time for it return.” What was Lizzy’s secret? Did she suddenly become awash with hormonal vibes which stamped out any disordered eating forever? Of course not. “I don’t know what I did for it to come back,” she tells me,”one day it just returned and so far…touch wood…it hasn’t left me.

According to Chris Sandel, a nutritional therapist with a client-basis largely affected by eating disorders, Hypothalamic Amenorrhea is: “When menstruation stops and it’s linked to the hypothalamus. The hypothalamus is a region in the brain that regulates reproduction (amongst other things) and under certain conditions it makes changes so that menstruation temporarily ceases.”

These “certain conditions” include, amongst other things:
1. Under-eating – aka keeping total number of calories too low
2. Low body-fat percentage
3. Over-exercising
4. Psychological stress

Given this criteria, it’s hardly surprising that a huge percentage of eating disorder sufferers find themselves, at some point or other, experiencing Hypothalamic Amenorrhea.  Without boring you with the scientific, womb-related stuff, here’s Chris’s explanation of why disordered eating/exercising behaviours affect your periods. “From a genetic perspective, the body wants to procreate so it can pass on copies of your genes to the next generation. But at the same, the body is also aware of the huge energy demands that are required as part of this.  Despite our innate desire to procreate, the body only wants to make this opportunity available if it feels safe and secure enough to do so. If it doesn’t, then a female is more likely to have anovulatory cycles (cycles when ovulation hasn’t occurred) or Amenorrhea. Hence, the causes can be anything that is signalling to the body that now isn’t the right time to think about reproduction.”  In other words, your body is protecting you from dying/breaking something during childbirth by making the option totally unavailable to you. Your body is clever – it’s not taking any chances.

Endocrinologist (aka hormone expert), Dr Helen Simpson, regularly sees patients who find themselves experiencing Hypothalamic Amenorrhea, and often finds herself encouraging them to end their affair with intensive exercise or restrictive eating. “I see a fair amount of HA cases due to dietary restriction or over-exercising,” Dr Simpson says, “it’s not uncommon.

“I see ballet dancers, gymnasts and some who have been taking testosterone when they go to the gym,” she accounts, “with teenagers – it’s more likely that they will be experiencing HA due to an eating disorder, whereas an over-exercising issue tends to be more common in women in their 20s and 30s.” So what is actually happening for these women and their respective ovaries? “The hypothalamus sends signals to brain – essentially linking the environment to the body,” she explains, “when the body is put under physiological stress- i.e through over exercising or under eating, the hypothalamic signals are dampened down and therefore the ovaries aren’t given the right signals from the brain.  Specifically, the hypothalamus controls the pituitary gland which regulates the hormones FSH and LH – both which signal the ovaries to a) produce oestrogen and, b) to release an egg. In short; lack of hypothalamic signalling = no LS/FSH = no oestrogen; = no lining of the womb thickening/egg releasing (i.e period).

While one seemingly obvious method route to hypothalamic happiness may be simply to gain weight, Dr Simpson suggests it might not be as simple as bigger body = more periods. “There’s some evidence for the role of leptin [the fat hormone] in restoring fertility health,” says Dr Helen, “leptin is a hormone which is a regulator of fat and some research has shown that an increased amount of leptin from body fat cells helps to restore periods. Hence why some women with a higher BMI still don’t have their periods restored.” So even though your “BMI” (note the quotation marks) may show you’re recovered, you may not have quite enough body fat to do the trick.  Although Helen admits that there are several factors to consider when treating someone with HA, on the whole, those who are working to restore their weight could expect to wait around 1-2 years (from the point they reach a healthy weight) until they get their periods back. I for one was also relieved to know that, according to Helen, “ovarian health isn’t affected in the long-term by a significant period of Amenorrhea,” should you reach your healthy weight eventually.

The so-called (by me) ‘God-mother’ of HA is Dr Nicola Rinaldi; a researcher, recovered HA sufferer and author of book, NO PERIOD. NOW WHAT? After experiencing HA following a brief period of intense exercise and caloric restriction, Nicola used her science background to explore the biological underpinnings of HA in order to help herself and others in a similar position. After successfully regaining her periods AND going on to birth a beautiful, healthy baby, Nicola vowed to dedicate her professional life to answering the million dollar question – No Period, Now What? If you’re affected by this piece, I would strongly recommend you join her Facebook group, and buy her book. After scouring the internet for answers myself, I can whole-heartedly assure you that Nicola is your one and only woman. The researcher has come across thousands of women experiencing much the same as she did and has since guided them through to a natural solution – i.e 99% have got their periods back.  Naturally, when I got the chance to speak with Nicola (via Skype, she’s based in the U.S), I bombarded her with every single period-related question imaginable.

WHAT ARE THE MOST COMMON OF HYPOTHALAMIC AMENORRHEA?

A: “A combination of under-eating/restrictive eating/weight loss, and exercise, are the culprit for almost every woman I have come across with HA.  but “clean eating” or a diet, coupled with high intensity exercise seem to be much more detrimental for us than we are led to believe. it is so important that we adequately fuel our exercise, which many of us do not, either intentionally or unintentionally. And once the under-fuelling has gone on long enough to shut our system down… it can take a lot of physical and mental work to get everything back to normal again.”

Q: HOW ISHYPOTHALAMIC AMENORRHEA TREATED?

A: “The “simple answer” for someone whose HA stems from undereating / food restriction and exercise, is eat more of all foods, and exercise less (specifically high intensity exercise). We have to do the opposite of what society tells us – eat “fertility foods” (aka calorie dense maybe not so “clean” probably containing sugar and carbs and fat foods) – and cut out the high intensity “if some exercise is good more is better right” exercise. It. Is. Hard.”

WHAT’S THE ‘COMPLICATED ANSWER’?

A:  “It is really important to understand that what many doctors recommend “go on the birth control pill to protect your bones” is not supported by the medical research. While there are a few studies that find increases in bone density with oral contraceptives, analyses of all high quality studies do not support this view.  Oral contraceptives (AKA The Pill), will also not “jumpstart” your system, and nor will hormone replacement therapy- a combination of estrogen and progesterone. Oral contraceptives suppress your natural hormones – yes, you get a bleed after you take them, but unlike in a natural cycle it’s not because of ovulation. Other treatments for HA can include Clomid or Femara, which *can* actually jumpstart a cycle because they do get your natural hormones increasing/decreasing as they should. These medications are unlikely to work if you haven’t gained weight/cut exercise, however.  Injectable gonadotropins (hormones FSH and LH that cause eggs to grow and mature, then hCG to cause ovulation) are an option – although this is mainly appropriate for those trying to get pregnant.”

WHAT’S MORE IMPORTANT FOR HYPOTHALAMIC AMENORRHEA RECOVERY? BODY FAT OR BODY WEIGHT?

A:  “I can only share my experiences with this one.  Women who are more muscular are more likely to be at a higher BMI when they get HA, suggests that lack of body fat is more important than absolute weight. One could turn that around and say that increased body fat is going to be more helpful for restoring cycles than increased lean mass – which makes sense because your increased, lean mass actually needs even more fuel! There are additional benefits to more body fat, as our fat actually creates hormones that are sensed by our hypothalamus and can thus help with turning the hypothalamus back on (like leptin and adiponectin). Honestly, though, it’s not like there is a number I can give you – recovery is about eating more and letting your body decide the size that it wants to be rather than us making a conscious determination about what that size should be.

HAS INCIDENCES OF WOMEN WITH HYPOTHALAMIC AMENORRHEA INCREASED IN RECENT YEARS?

A: “It’s hard to say whether cases have increased in recent years because there is also a lot more awareness, so it may just be that more cases are being recognized. Looking more long term, HA has absolutely increased since Title IX [U.S sex discrimination law] was passed due to athletics for women becoming much more accepted.  Being athletic coupled with caloric or food group restriction plays havoc with the reproductive cycle of many women, and accurate information about our caloric needs seems to be lacking. Not to mention the glorification of the thin, athletic bodies and fat-phobia that are pervasive in our society at the moment. There is also the mistaken belief that the more you exercise and the less you weigh, the healthier you are. I am NOT saying that all exercise is bad,, or that women should not exercise, just that it is so important that we adequately fuel our exercise.

WHEN WILL I GET MY FUCKING PERIODS BACK?!

A: “I did a study of just over 300 women for No Period. Now What? about women who have reached a healthy weight and are still in HA.  Generally, the median time to recovery is about six months. However that varies widely.  Firstly, a “healthy weight” varies a lot by individual, with some women getting HA at a BMI of, say, 18, and others at a BMI of 23, 24, or even higher. Generally, however, I encourage women to strive for a minimum BMI of around 22.It’s not six months from the time that you reach a ‘healthy weight’, but from the time you started working on recovery. In my sample there were a number of women who had taken some steps toward recovery prior to finding me and my message. ”

HOW WILL A LONG PERIOD OF HYPOTHALAMIC AMENORRHEA AFFECT MY FERTILITY?

A: “Of all the women I have helped with HA, 100% of them have gone on to have children. Some on their first cycle, some after oral medications, some after injectables, some used ivf, a few decided to adopt and then later went on to have additional biological children. There is path forward for everyone (and all this fertility stuff is discussed in detail in NPNW).

Of the women in my survey, 95+% have recovered natural periods after completing their families. The number is probably higher but I haven’t checked in a few years. It’s on my to do list!”