Red Alert: Why you should never ignore a missing period

Cerys Jones with Dr. Nicola Rinaldi, PhD

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Cerys Jones speaks to Nicola Rinaldi, PhD, lead author of No Period – Now What? and a hypothalamic amenorrhea recovery coach, about the condition and its challenges.

It’s a strange thought that the malfunction of a whole organ system could, at least for a time, go untreated – but, in the case of female reproduction, it can happen all too often.

What is hypothalamic amenorrhea?

Secondary amenorrhea is defined as the absence of menstruation for three or more months. It’s been estimated to affect 3-5% of adult women, but some might not realise its potential seriousness – or even that it’s worth consulting a doctor. One cause of period loss is hypothalamic amenorrhea – a condition that has been normalised to a worrying extent in some fitness circles.

“I can’t tell you how many people I’ve spoken to who say ‘my doctor said it was fine, it’s normal for a runner not to have their period!’” says Dr. Rinaldi.

And there are indeed studies suggesting that athletes are more likely to suffer from amenorrhea – but it’s far from normal. Put simply, hypothalamic amenorrhea occurs when someone is ‘under-fuelling’ to an extent that the body begins to shut down the menstrual system to protect itself.

Dr. Rinaldi says that this is generally a result of not eating enough and exercising too much, with stress compounding the problem:

“The body’s main goal is to survive, and so it has to pump our blood, we have to breathe, it has to send energy to our brain… anything more than survival is a ‘nice-to-have’. Reproductive cycles are low on that list because reproduction is a very energetically intensive process, and so under-nourishing can very easily lead to the shutdown of menstrual cycles.”

Running on empty

This under-nourishment, egged on by fad diets and the glorification of at-all-costs fitness fanaticism, has come to be accepted as the norm by some – as a way of ‘adapting’ to elite training, and something of little concern if the person in question isn’t trying to get pregnant. But the shutdown of the reproductive system can have terrible consequences.

“The under-fuelling that causes hypothalamic amenorrhea is also associated with a host of negative side effects”

It might come as a surprise to know that the hormones associated with reproduction are actually protective of our health overall. Dr. Rinaldi explains that the menopause (which involves a drastic change in the levels of these hormones) is associated with decreasing bone density, and an increased risk of cardiovascular disease.

The under-fuelling that causes hypothalamic amenorrhea is also associated with a host of negative side effects: “it’s not just that your period goes away, but also your body is less able to repair things, it doesn’t keep you as warm, it can have detrimental effects on your immune system, on your digestion.”

Losing your period due to under-eating and/or over-exercising isn’t a marker of fitness prowess – it’s a sign of a body in crisis. According to Dr. Rinaldi, many (but not all) people experience negative short term effects such as feeling cold all the time, frequent urination, brittle hair and nails, lack of libido and natural lubrication, increased anxiety, digestive problems or injuries.

Under the radar

So why is hypothalamic amenorrhea relatively unknown? Dr. Rinaldi says that, in many cases, it might not even be diagnosed. Some don’t even get as far as the doctor’s office – it could be that their cycle is suppressed for another reason, such as birth control or breastfeeding, so they don’t know anything is awry.

“the wider lack of understanding about reproductive health can lead to patients being sent away, often told to ‘wait and see’ – with no real answer about what’s set their body off-kilter.”

Even if they’re aware of hypothalamic amenorrhea, there’s a misconception that it only happens to elite athletes or people who look emaciated – this might even taint medical advice, where Dr Rinaldi says people (particularly those in larger bodies) can be misdiagnosed with polycystic ovarian syndrome.

Racism can also work against those trying to get an accurate diagnosis; for example, the use of BMI as a measure of ‘healthy weight’ is coming to be seen as increasingly exclusive and based on white, European and American bodies.

And the wider lack of understanding about reproductive health can lead to patients being sent away, often told to ‘wait and see’ – with no real answer about what’s set their body off-kilter.

“Don’t take ‘unexplained’ as an answer.”

Between the lack of awareness about hypothalamic amenorrhea, next-to-no knowledge of its potential severity, and the potential difficulties of getting an accurate diagnosis, it’s easy to feel overwhelmed by the idea of treating the problem.

But Dr. Rinaldi is emphatic: ‘It’s not normal not to have a period… if you have a uterus you should be bleeding on a regular basis. And if you’re not – something is messed up.”

Don’t be afraid to ask doctors to dig in, she says. “There are so many conditions that can lead to missing periods… walking around not knowing is unacceptable.

Don’t take ‘unexplained’ as an answer.”

And if the period loss does turn out to be because of diet or exercise, the thought of making changes to the lifestyle you’ve come to see as ‘healthy’ could be frightening. But letting go of a fascination with diet culture can be incredibly liberating. “Let’s get out of this notion that the smaller you are, the healthier you are – because it is blatantly false.”

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Special thanks to Dr. Nicola Rinaldi, PhD for her contributions to this article.

Advice for those suffering from amenorrhea can be found on the NHS website. Dr. Rinaldi’s work can be found at www.noperiodnowwhat.com. 

Featured image courtesy of pikulkeaw_333 on Pixabay. Image license found here. No changes were made to the image.