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Hypothalamic Amenorrhea: The Hidden Hazards of Diet Culture and “Discipline”

by Ellie Stein 

The ever-churning machine of diet culture has once again evolved — a slim, toned body has reentered the trend cycle, and the media is once again dominated by stick-thin celebrities promoting minimalistic diets and weight loss drugs. The idolization of these bodies is accompanied by the popularization of workouts like pilates designed to shrink and sculpt, the widespread promotion of restrictive dieting and calorie deficits, and a “clean, fit girl aesthetic” that appears more and more each day like an unhealthy, unattainable lifestyle.  

Beauty standards change year by year so drastically that it’s difficult to keep up with the current “dream bod.” Many of these trends have involved extreme, expensive procedures, such as the Kardashians’ popularization of BBLs and filler. However, social media’s current ideal is just within reach of the average person, but it still comes with a caveat: a life governed by discipline and exertion.  

To achieve the skin-taut-over-muscle body with little visible fat that fitness influencers sell, most people must turn to dangerous measures. Manipulating one's body this way involves undereating and overexercising, often in the form of astronomical step counts, rigorous training, fasting, and a distinct lack of rest. Though this may achieve a “desirable” figure and is marketed as “wellness,” it has grave health implications, especially for women, which many don’t realize until it’s too late. 

Hypothalamic Amenorrhea (HA) is a condition that directly results from these behaviors. It is the cessation of menstruation caused by abnormal signalling between the hypothalamus and the pituitary gland due to deficient pulsatile secretion of GnRH. Essentially, when a woman eats too little and/or exercises too much, her body will entirely stop ovulating to minimize unnecessary energy expense. 

The neuroendocrinological mechanisms of HA are complex and depend on a number of factors. The hypothalamic-pituitary-ovarian (HPO) axis, a system comprising the hypothalamus, the pituitary gland, and the ovaries, determines reproductive functions like ovulation, conception, and menstruation. It is essential for reproductive health, and is a powerful indicator of whether the body’s energy needs are being met. It is also deeply involved in the process and outcomes of HA. 

The HPO axis regulates reproductive function through the release of essential hormones called gonadotropins, such as the luteinizing hormone (LH) and the follicle-stimulating hormone (FSH). These hormones are secreted in response to pulsatile GnRH release from the hypothalamus. In the absence of adequate energy, GnRH secretion is drastically reduced, leading to critically low LH and FSH, and therefore insufficient ovarian function and estrogen deficiency. 

HA is most commonly caused by a relative energy deficit in the body related to weight loss, undernutrition, or excessive exercise,  which are all promoted today as ideals in achieving a popular body type. It may seem obvious that deliberate starvation and overexercising aren’t necessarily good for you; however, these behaviors are often encouraged under the guise of “discipline.” Women, especially young women who are easily impressionable by the media they consume, are taught that these habits make them “healthier” than most. In reality, being overweight is not the only way to be unwell – in fact, it may not be unhealthy at all. 

Fertility and energy availability are closely linked, as caloric balance takes permissive action on their reproduction. Our neuroendocrinological systems have been shaped by evolution to adapt to periods of famine and stress. In prevailing conditions of undernutrition, the body inhibits the extra expense of reproduction by suppressing the HPO axis. Though we may not live in wild, dangerous environments, or struggle to forage for food as our ancient ancestors did, we replicate these conditions by undereating and overexercising. Our hypothalamus responds accordingly based on thousands of years of adaptation. 

Stress also has a tangible suppressive effect on the HPO axis. Whether it be the psychosocial stressor of constant pressure to change our appearances, concern about how our bodies may be judged by fickle standards, or unconscious, urgent physiological panic in response to undernutrition, stress is another layer that blankets the HPO axis and contributes to HA. In response to anxiety, the body aggressively secretes critical stress hormones which inhibit GnRH secretion and further suppress ovulatory function.  

Far too many women fail to realize the long-lasting impacts of HA until their reproductive hormone levels are dangerously low. Though an absent period may seem like a reasonable price for the ideal body — even an advantage for women with painful or emotional menstrual cycles — it has grave consequences, as hormonal health is deeply intertwined with bodily function. Dr. Pouneh K. Fazeli, Chief of the Division of Endocrinology and Metabolism at UPMC, asserts that “having a regular period is one of the best indicators of your body being in good nutritional balance and having appropriate [hormone] levels.”  

Predictably, HA leads to infertility and sexual function problems like low libido. Less known, however, is that young women with HA also experience low bone mineral density (BMD), which compromises crucial bone mass accretion and leads to weakness, fractures, and even osteoporosis that persists over the life course. According to Dr. Fazali, “The biggest negative consequence of HA, at least in the short term, is losing bone. You only have a certain amount of time to accrue bone, and that’s until about the age of 30. That’s when you don’t make any more bone.” The horrifying long-term effects of HA on BMD may not be apparent to young women until much later in life, as Dr. Fazeli says, “It can be a hard message to get across, because it’s not affecting you and there are no symptoms.” Women with HA show significantly higher rates of depression and anxiety, and, perhaps most urgently, increased risk of cardiovascular disease, impaired endothelial function, and severe bradycardia (low heart rate). 

So, what drives young women to continue these harmful habits, even as their musculoskeletal, mental, and heart health is damaged? Modern fitness trends misrepresent health and teach us to value our appearance over our well-being, suggesting that sacrificing a balanced diet, food freedom, and experiences that distract from our aesthetic goals is necessary to attain a perfect figure. Often, this narrow mindset gives rise to eating disorders like anorexia and orthorexia by aggravating perfectionism and self-loathing. However, most women struggling with HA do not have a diagnosed eating disorder; they may not meet medical criteria, such as extremely low body weight or intense fear of weight gain, or their behavior may not be “extreme” enough to warrant a diagnosis. They simply appear controlled and driven, unknowingly promoting destructive patterns, unaware of the treatment they need. 

Treatment for HA almost always involves increasing energy intake and decreasing energy expenditure to restore a regular ovulatory period. Dr. Fazeli states, “Recovery to a state of neutral or positive energy balance is the best thing we can recommend.” However, certain hormonal treatments exist that may help to mediate the long-term effects of HA during recovery.  

Estrogen in the form of oral contraceptives has been widely used by physicians as a treatment for HA, because it tends to restore a monthly period. However, Dr. Fazeli attests to the “masking effect” of oral contraceptives on the adverse effects of HA, stating, “When someone is taking an oral contraceptive, they are getting a monthly period. They don’t realize that, if they were to stop it, they would not have a period.” This is because contraceptives deliver a high dose of estrogen that shuts down the HPO axis, hence why they are used for pregnancy prevention. The illusion of hormonal health that oral estrogen produces is incredibly dangerous, as it conceals declining bone density and heart health. Dr. Fazeli claims that “stopping the oral contraceptives and seeing if menstrual periods come back is the most effective treatment for low bone density.” She believes that “educating other physicians about oral contraceptives and their lack of benefit is important.” Dr. Fazeli goes on to state, “I think a lot of people still think that oral estrogen is the treatment for HA, but if we’re thinking about the outcome of bone, it shouldn’t be.” 

Transdermal estrogen has recently emerged in Dr. Fazeli’s research as an effective treatment for low BMD in women with HA, showing improved BMD over the course of a 6-month pilot study on young women. In contrast to oral contraceptives, it delivers a “physiologic dose” of estrogen aligned with the levels the body would produce to maintain a normal menstrual cycle. This makes it a hormone replacement, as opposed to the hormone overload that contraceptives use to shut down the reproductive axis. Though transdermal estrogen is not currently an FDA-approved treatment, it may be an important component of HA recovery in the future. Dr. Fazeli maintains, “always, the ultimate goal is for weight recovery and menstrual cycle recovery, but this [transdermal estrogen] can help preserve bone while that’s happening.” 

It is worth noting that HA is an extremely personal experience. The degree of weight loss, exercise, or stress required to induce HA (and to recover menstrual function after HA) varies widely from person to person. Diet culture tends to paint health as a one-size-fits-all: if you work hard enough, you can achieve the same body as those currently apotheosized by the trend cycle. However, the set-point theory asserts that everyone has a biological blueprint that determines what their body looks like in energy balance. It defends this range through mechanisms that regulate appetite and metabolism, which may not be conducive to a slim figure. One’s set point is dictated by their body composition, which depends on a multitude of factors, from genetics to environmental cues and even nutrient availability during fetal development. The sentiment that everybody must strive for one paragon of fitness and femininity ignores this reality, instead pushing bodies past their genetic capabilities to uphold an ever-changing standard. 

Young women, who are most targeted by and most susceptible to pressures surrounding body trends, are also most at risk for the long-lasting effects of resulting HA. Though HA is generally reversible, the solution to decreasing the prevalence of this condition lies in discrediting the diet culture which promotes profoundly unhealthy behaviors disguised as discipline. As Dr. Fazeli puts it, “Understanding that your body is in a state of physiologic stress, because that’s what HA represents, is important.” With education surrounding the dangerous results of restriction, and perhaps a certain degree of acceptance that health may look different for each young woman, we can move toward a future of improved hormonal health; of balance and safety for those who need it most.