When my period didn't come back after getting off the pill (and it didn't return for 8 years!!) I didn't think I was doing anything wrong. I ate "healthy", exercised, worked on my own business - something I enjoyed, and I'd just moved countries on my own to live in Australia. Which is what I wanted and had made happen for myself.
Looking back, it's obvious what was going on. My body was protecting me because I was doing too much, experiencing stress, and not eating enough. I trained way too much and too hard, and I didn't fuel my body enough for all of that exercise.
Working on my own business was also stressful in ways that I underestimated. Having moved countries, being on my own, and going through a stressful relationship: all of those things didn't feel like that much stress at the time. But sometimes what we can mentally put up with is still more than our body can handle without making cutbacks elsewhere.
That's what hypothalamic amenorrhoea (HA; also spelled amenorrhea) is, and it's far more common in high-achieving, busy, driven women than most people realise.
Your hypothalamus is the part of your brain that runs your hormones. When it senses that you don't have enough fuel, or that you're under too much stress, it slows the signals that tell your ovaries to work. Ovulation stops, and if ovulation stops, so does your period.
Doctors often call it functional hypothalamic amenorrhoea. "Functional" means nothing is structurally wrong. Your body has simply decided that now isn't a safe time to spend energy on a cycle. Basically, it's not a good or a "safe" time to have a baby.
HA usually comes from a combination of things, rather than one big cause:
The Endocrine Society's guideline on HA links it with low body weight or body fat, eating too little, and emotional stress, and notes that athletes who burn more energy than they take in are at risk.
My free guide, Your Period Is a Vital Sign, includes five questions to help you reflect on whether HA might be what's going on for you. They're not a diagnosis, but they're a good place to start.
Download the free guideThere's no single test for HA. It's diagnosed by ruling out other causes, so your doctor will usually start with a pregnancy test and hormone blood tests (often FSH, LH, oestradiol, prolactin, thyroid and testosterone), and sometimes a pelvic ultrasound. HA and polycystic ovary syndrome (PCOS, now called PMOS) can look similar on an ultrasound, which is why the full picture matters.
If your period has been missing for six months or more, ask about a bone density scan too.
In the end, I believe you are your own best judge, especially if your doctor has ruled out most other causes. You will probably know in your gut if some of those reasons HA shows up (see above) apply to you. Even if you want to secretly deny it or can rationalise why that would not be the case for you.
Without a cycle, your oestrogen stays low. Over time that speeds up bone loss and raises your risk of stress fractures and osteoporosis. Low hormones can also affect your heart, energy, mood, sleep and libido, and for active women, training and recovery.
The Endocrine Society's guideline says recovery comes from correcting the energy imbalance, which often means changing habits and often means some weight gain. It also suggests psychological support, such as cognitive behavioural therapy (CBT).
In practice, that usually looks like:
The pill gives you a monthly withdrawal bleed, but that isn't your own cycle coming back. The Endocrine Society suggests against taking the pill just to bring back a bleed or to protect your bones, and notes that it can hide whether your natural cycle has returned. If you need contraception, talk it through with your doctor or on a call with me. I've written more about what happens when you come off the pill.
Knowing what to do is one thing. Actually doing it is another. Eating more and doing less, when every part of you wants to push and force and grind and optimise (it's what you're good at), is hard. That's why I'm here and what I help with, because I deeply understand it.
If eating more or resting feels more than just a little scary, that's ok. No judgement. If you know it's more than we can work on together, consider getting support from someone trained in eating disorders. In New Zealand, EDANZ is a good place to start; in Australia, try the Butterfly Foundation.
See your doctor to rule out other causes, then download my free guide for what usually helps and the signs your cycle may be coming back. If you'd like support along the way, you can book a free 30-minute call.
This post is general information, not medical advice. Please see your doctor about your own situation.