March 7th, 2023 12:00am
Having healthy and regular menses for reproductive-age women is so important to not only our reproductive health, but our cardiovascular, bone, and mental-emotional health as well. Oftentimes when our menses goes missing (amenorrhea), it can indicate a deeper problem is present. In this article, I'll cover some of the causes of missing menses and what to do about it.
Primary amenorrhea is defined as the lack of onset of menses by age 15 but with normal growth and secondary sex characteristics (i.e. breast growth and development of pubic hair) or lack of onset of menses AND lack of signs of puberty by the age of 14. Some causes of primary amenorrhea include:
Secondary amenorrhea is defined as when you have previously had a menstrual cycle but have not had it for at least three consecutive months if your cycle was previously regular, or 6 consecutive months if your cycle was previously irregular. This is something I commonly see in practice and can be due to a variety of causes. So let's get into what can cause secondary amenorrhea and what you might be able to do about it. Causes of (econdary amenorrhea include:
1. Functional Hypothalamic Amenorrhea (FHA):
Functional hypothalamic amenorrhea (FHA) is suspected to be responsible for 30% of secondary amenorrhea experienced in women who are of reproductive age. FHA is a diagnosis of exclusion, meaning all other known causes of secondary amenorrhea should be ruled out prior to receiving a diagnosis of FHA. In this condition, the loss of menses is a result of various stressors on the body which can be both physical and/or emotional. Some common stressors causing FHA include over-exercising, excessive weight loss, stress, and bulimia or anorexia nervosa.
Long-term consequences of amenorrhea in someone with FHA can include (but is not limited to) memory/concentration impairment, increased cardiac risk, infertility, and decreased bone mass and increased risk for fractures. If you have been diagnosed with FHA, it's important to talk to your doctor about your different options for treatment. Per the Endocrine Society, it is recommended that this condition not be treated with oral contraceptives, but rather with a multi-faceted approach addressing the root cause. This is because despite bleeding while on birth control, those bleeds are not actually a period but rather a withdrawal bleed from the pill. Therefore, it is impossible to properly assess if treatments are working to prevent other long-term consequences since the pill is preventing you from getting a true period.
2. PCOS (Polycystic Ovarian Syndrome)
PCOS is a very common condition that often goes unrecognized. An estimated 6-12% of women in the US have been diagnosed with PCOS and is considered one of the leading causes of infertility. If you experience symptoms such as acne, unwanted hair growth the on chin or face, hair loss on the head, unexplained weight gain and/or difficulty in losing weight, difficulty in conceiving, or amenorrhea/irregular periods, it might be a sign to ask your doctor to test you for PCOS.
PCOS is often treated in the conventional world with oral contraception and metformin, and while these things can help alleviate many of the symptoms of PCOS, it is not addressing the root cause. If you at any point in time want to come off of the oral contraception, you'll likely get a resurfacing of many of the symptoms you previously had.
3. Thyroid Disease
Thyroid disease is separated into a few different categories. Hypothyroidism is an under-functioning thyroid, the most common cause of hypothyroidism is autoimmune thyroiditis. Autoimmune thyroiditis (AKA Hashimoto's disease) results when your body's immune system sees your thyroid cells as "not-self" and creates antibodies to attack those cells, ultimately leading to thyroid dysfunction. Symptoms of Hashimoto's/hypothyroidism include dry skin, constipation, chronic fatigue, hair loss, depression, cold intolerance, and irregular/absent menses.
On the opposite side, hyperthyroidism is an over-functioning thyroid. The autoimmune cause of this (Grave's disease) is again the most common cause but rather than causing an under-performing thyroid, it results in the thyroid releasing an over-abundance of thyroid hormone. When your thyroid hormones are too high, you end up with symptoms such as diarrhea, anxiety/panic, elevated heart rate, heat intolerance, tremors, insomnia, and irregular/absent menses.
4. Prolactinoma/Elevated Prolactin Levels
Prolactin is a hormone that is produced in higher amounts when a woman is breastfeeding. It promotes the production of breast milk and inhibits the production of another hormone (FSH), thereby preventing you from getting your period. In a breastfeeding woman, this is completely normal. However, it is possible for a small benign tumor to develop on the pituitary gland that secretes unnecessary prolactin in non-breastfeeding women. When this happens, it results in a missing period and possibly even breast tenderness and galactorrhea (milk production outside of lactation). This is why when your period goes missing, it's important to get a prolactin level, and if elevated, imaging may be necessary to assess for this benign tumor.
5. Post-Pill Amenhorrea
It is often not explained to women what the oral contraceptive pill actually does and how it works. It might appear that when you go on birth control that it regulates your period, however, what is actually happening is it stops you from ovulating and having a true period. The bleeding period that happens while you are on the pill is not a true period, it is actually a withdrawal bleed from the abrupt removal of the artificial hormones in the pill for a period of time (the sugar pill week). Once you stop the pill, it is common for your body to have to re-adjust to having to ovulate every month and having a true period again. This is called post-pill amenorrhea. While your body is regulating, your period can go missing for the months following discontinuation of the pill. This phenomenon can affect 3-6% of women who had taken oral contraception.
1. Get a full work-up
It's important to establish with a functional medicine or naturopathic practitioner to get a full workup and get to the root cause of why your period is MIA. A full workup may include the following labs:
2. Prioritize Sleep
No matter what the cause of the amenorrhea, it is important to establish a good foundation for health. This includes sleep. Our circadian rhythm is tied to our hormones and poor sleep quality can negatively impact them. Good sleep hygiene includes having a nighttime routine with limiting screens and blue light within the hour before bedtime, time to "wind down" (however that looks for you), and sleeping in a completely dark room with minimal distractions. Your goal for sleep should be at least 7-9 hours of good sleep per night consistently.
3. Adjust Your Exercise Routine
Exercise can contribute to amenorrhea directly as a stress to the body. If you are exercising too much or too intensely, it acts as negative stress on the body and results in FHA and amenorrhea. If you are finding that you are having a hard time recovering from your exercise in the days after or are pushing yourself hard enough to feel sick, it might be time to re-evaluate how you're exercising to something that is more tolerable to your body.
4. Dial in Your Diet
Nutrition is one of the most important foundations to address in almost all health concerns. Nutrition isn't always just about calories-in calories-out, it's about ensuring that you are getting enough nutrients in the diet to support your body and reproductive functions. Making sure you are getting proper nutrition in the form of enough good fatty acids, protein, and complex carbohydrates is important, but it's not only about the macros. The actual nutrients in the food are just as important. For example, increases in oxidative stress have been shown to negatively impact fertility and reproductive health, so incorporating foods high in antioxidants (think vitamin C, vitamin E, resveratrol, and lycopene) is important to support your cycle. In one study, Vitamin D was also implicated in amenorrhea with 12% of vitamin D deficient patients reporting loss of menses compared to 6% of people in the non-deficient group.
Oral contraception has also been known to cause nutrient depletion. If you currently are on or have recently discontinued oral birth control, it's important to make sure you are supplementing the following nutrients that the pill might have been depleting:
5. Manage Stress
It has been shown that activation of our stress response (whether emotional/mental or physical) sends signals to our bodies that tell us we're not safe. If our bodies don't think we are safe, it will divert focus away from reproductive goals and towards survival. But because stress is so inherent in our daily lives in our current society, this can result in long-term hormone and menstrual dysfunction.
Managing stress looks different for everybody, but some good tools to get started include daily meditation (even if just for 5 minutes), deep breathing exercises, going for a nature walk, journaling, Epsom salt baths, acupuncture, and massage. Often times it is also good to have a licensed therapist on board to guide you.
All of the information discussed in this article might feel overwhelming. The best way to start on your journey to reclaiming your period is to start with the foundations: sleep, stress management, diet, and exercise. It's also worth noting that some conditions such as PCOS and thyroid disease can be tough to navigate on your own. I recommend booking an appointment with a naturopathic or integrative provider to discuss your concerns, get to the root cause, and work as a team to reach your optimal hormone health.
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