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Q&A with Australian Health Practitioners
What are the Reasons and side-effects of amenorrhea?
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I am a 24 year old female at 1.72m, who has trained quite heavily for triathlons for the past 2 years. I lost 8kgs (72-64) in the first 12mths which I put down to the increase in physical activity. I ended up quite stressed from work and relationship issues and developed IBS which got worse after a parasite infection which I lost a further 10kgs from. By this time I was well underweight (51.5kgs). Since antibiotics I have got back to 56kgs and am much happier. My cortisol during that time was very high but was back to just elevated when it was last checked (5 months ago). Presently, I am still training reasonably hard and have slightly low thyroid activity. I was taken off the pill in July so I don't know when I lost my period but I have not had a period since being off the pill. My doctor doesn't see it as a big issue but the dietician I was seeing does. Does anyone have a professional opinion they would like to share? I want to have kids and don't want to jeopardise this in anyway. -
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Dr David Moore
Gynaecologist, Gynaecologist - Infertility (IVF) Specialist, Obstetrician
David received a solid foundation to training in tertiary obstetric units and has developed skills in the management of complex and high-risk pregnancies and deliveries. … View Profile
Hi there,
From the information you provide, you may have a condition called functional hypothalamic amenorrhoea (FHA). This is a condition often seen in women who are very lean, and often have high energy expenditure (generally from over-exercising). It results from changes in hormone levels in the hypothalamus (in the brain) that usually control a woman's ovulatory cycle. Basically, the physical state of being of low body mass is a sort of physiological stress that causes the brain to shut down ovulation.
Please note that FHA is a sort of "diagnosis of exclusion", and it would be important for you to under assessment, examination and investigation by a specialist to exclude other causes of amenorrhoea. Generally, a gynaecologist or endocrinologist would be your best bet. The following information is intended in a general context only, and should not be seen as specific advice to your situation.
The main problem with FHA is a low oestrogen level. This may cause symptoms such as increased hair loss, sleep disturbance, mood disturbance, vaginal dryness (which may cause discomfort with sex), reduced libido, etc. The lack of oestrogen also means a lack of a menstrual period, as ovulation is not occurring. This, therefore, is the mechanism of infertility with FHA.
An important consequence of FHA and low oestrogen is bone loss. This can lead to irreversible osteoporosis in very young women. Contrary to popular misconception, is that the loss of bone from low oestrogen is not compensated by the positive effects of exercise on bone mass - not even close. The "Pill" will mask the effects of FHA - by causing a regular period and covering up symptoms of low oestrogen, however the underlying problem is not addressed and, obviously, the Pill does not help with fertility issues. Generally, however, the Pill does not adequately guard against bone loss, and women with FHA should also be taking supplemental calcium and vitamin D.
In short, I would agree with your dietitian - FHA is a big issue.
With regards to fertility, the good news is that ovulation can be restored with optimisation of weight / body mass. Although your current BMI (18.9) may be considered "normal" by some reference ranges, it is still relatively underweight (<20), and I would expect most women to resume normal menstruation once their BMI increases over 20. This is generally achieved with increased caloric intake and reduced energy expenditure (less exercising). This is not always practical (e.g. professional athletes training for the Olympics) and, in those cases, use of the Pill and calcium/vitamin D should be encouraged for bone protection.
While there are fertility treatments that can induce ovulation in FHA, it is always appropriate to attempt correction of the underlying issue first, since a healthy pregnancy also requires a healthy body weight and nutritional status. Along with your specialist, Dietitians are very valuable in the management of FHA and, in some cases, the expertise of a Psychologist may be beneficial.
Although I am not aware of any lasting fertility issue directly due to FHA, I would expect that, the longer a woman's lifestyle is conducive to FHA, the harder it may be for her to make the appropriate changes to restore normal ovulatory function, within a timeframe that she finds suitable.
Obviously your particular circumstances will influence your next move. However, I think at least having a consultation with a Gynaecologist and/or Endocrinologist, in addition to regular review with your Dietitian, will go a long way to helping you avoid any lasting consequences of FHA, and help you optimise your body weight and health.
Best wishes,
David.
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Thanks so much for your response David. All of your points made a lot of sense, particularly the hormones. My cortisol and thyroid function is changing dramatically everytime I get it checked and I do have much more trouble sleeping and maintaining my stress levels still. With this, the hard training, lower body weight and immune system only just recovered, there are multiple reasons why I have not regain my period.
I will look at seeing a gynaecologist and discuss further with them.
Thanks again, so much for your response,
Best regards
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