The dangers of under-eating. My story with Hypothalamic Ammenorea
Intro
After getting off birth control the end of June 2022, my period did not come back. In fact, it took almost 6 months to come back. It took me a few months to realize what was going on. I was not eating enough food to support my ovulation. Once I increased my calories and stopped exercising, I got my period back within 2 months.
In this blog post, I share my story on how I lost my period and how I got it back. At the end of this post, I discuss our cultural obsession with body image. I also discuss why I think I got myself in this situation and what I am working on now.
How it started
I read a lot and love to learn about new ideas. Especially when it comes to nutrition and health. In particular, I have spent a good amount of time learning about weight loss. This is largely because my client’s number one goal is weight loss. However looking back, I also think part of my drive to learn about weight loss was due to my own fixation on my body (more on this later).
My perception on how to lose weight shifted over the years. At the end of 2020, I came to the realization that a low carb diet was not necessary to maintain a healthy weight and/or lose weight. The only way to lose weight/fat is to be in a caloric deficit. If you want to better understand why carbs are not inherently fattening, I recommend checking out this blog post. I also saw low carb diets/fasting not work in my professional/personal life as well. A lot of my clients on low carb/keto/fasting diets gained/plateaued on their weight loss journey. I too was on a low carb diet, fasted 16 hours most days and 24 hours once per week. I felt like I gained some weight. I did not weigh myself at the time, but I think I gained maybe 5 lbs. But after a month or two of just eating more regularly balanced meals, I felt like I lost the extra weight.
After coming to this conclusion, I started to learn more about macro/calorie counting. I learned all about maintenance/weight loss calories. I learned that if you are consuming the same quantity of calories each week on average and are not losing weight, those average weekly calories are your maintenance calories. In order to lose weight, you need to subtract 200-500 calories from your maintenance. That would be your weight loss calories. This is what I learned in school as well but I was sidetracked for a few years by the low carb diet approach.
Calorie tracking
After coming to this realization, I started tracking calories myself. I wrote about this in a previous blog post that you can find here. Part of the reason why I started tracking was to better help my clients. I wanted to understand how to apply this information so I could best support my client’s weight loss goals. I noted in the blog post that I did not track calories in an effort to lose weight for myself. I noted that I just wanted to understand my maintenance calories.
But looking back, I think the drive to track calories was partially personal. It was a way to exert control on myself. I feared I would become “fat” if I did not have a structured diet. This fear was not something new. I have felt this way most of my life. This fear was part of my drive to experiment with other diets such as low carb, fasting, carnivore and vegan. Sure my motivation was not solely driven by fear. I had good intentions as well. I was curious to understand what dietary approach is best to feel healthy and reduce risk of chronic disease. I wanted to best help my clients with this as well. I truly find nutrition/health/the body fascinating, so I do not want to make it seem like all my motivations came from a bad place. But looking back, I do think my motivations were partially driven by a fear of becoming fat.
Through tracking calories, I determined my maintenance calories at the time was roughly 1600 calories/day. At first I thought this quantity of calories was my maintenance because my weight did not change after 3-4 weeks of tracking. But then after roughly 3 months of sticking with 1600 calories, I slowly lost 5-7 lbs. I would stick with roughly 1400 calories Mon-Fri and maybe closer to 2100 Friday and Saturday (I would go out to dinner on those days and drank alcohol at the time. I did not carefully count calories on those days but that is my rough estimation). In regards to exercise, I was not moving much during that time. I had a sedentary job and did not engage in a lot of walking at the time. Maybe 5,000 steps per day. I probably worked out 3-4x per week, 30 minutes of cardio for 3 days and 1 day of strength training.
Even though I claimed I was not looking to lose weight, if I am honest with myself I was happy to see the number go down. I was not considered “underweight” by BMI standards, so I rationalized it was not a problem to lose weight. I rationalized that loosing fat is a good thing. It felt like I was achieving something. I felt a false sense of control which was comforting. In addition, my wedding was coming up which further motivated me.
After losing this weight, I maintained it for roughly 1 year. I was not super consistent with tracking. I would maybe track Sun-Thursday then not so much on Friday-Saturday. I did not feel the motivation to track every day because I weighed myself most days and my weight remained relatively constant.
But even after this drop in weight, I still felt this weird pull to lose more. I decided to crank up the exercise a bit. Strength training increased from 1 to 3x per week. I kept cardio consistent at 3x per week. On top of that I was walking 10,000 steps most days and hiking on the weekends. I maybe increased my calories a bit to 1700 per day on average (again maybe 1500-1600 during the week and more on the weekends). I maybe lost like 1-2 more lbs. I maintained this weight for another year.
Looking back, I was never fully satisfied. I was constantly looking to control, manipulate and “improve” my body. The more I thought about it, the more I wanted to control it. I think weighing myself each day and tracking calories just made me fixate on it too much. As noted above, this was not an entirely new feeling. The urge to change my body always existed in the background. But during certain periods of life, the feelings emerged stronger.
Getting off birth control
Everything changed the end of June 2022 when I got off birth control. I got off birth control to get in touch with my regular cycles. I was on birth control since high school (roughly 12 years) so I had a sense it would take some time to get my period back. I researched that it is ok for your period to take up to 3 months to return. Well 3 months passed and no period. I waited it out another month or two and still no period. I started to do some research. I came to the conclusion that the issue was likely driven by one of two conditions. PCOS or Hypothalamic Amenorrhea (HA).
Essentially PCOS is an endocrine disorder that has a negative impact on your ability to ovulate. It can manifest in a number of ways. Some symptoms that are common with PCOS are an excess of “male” hormones like testosterone. This can lead to certain physical characteristics like male pattern baldness and acne. Another symptom of PCOS is insulin resistance. Insulin resistance is complicated but essentially it means dysregulated glucose. Both PCOS and HA can result in polycystic ovaries so it is inaccurate to diagnose PCOS solely on that.
HA is a condition when the hypothalamus, a gland that regulates bodily processes, slows down the release of the hormone GnRH. This hormone is necessary for ovulation/your period. You can develop HA from being underweight, under eating, over exercising and/or being over stressed.
I gathered that my lack of period was likely not driven by PCOS because I had no physical characteristics (acne, facial hair, male pattern baldness). In addition, I regularly check my blood sugar and I know I am insulin sensitive.
My first inclination that this issue was likely driven by HA came after listening to other women’s stories on social media. I discovered that many other women lost their period at around 1500 calories, even with normal BMI. Interestingly, a lot of these women consider themselves very health conscious. Many of them are Registered Dietitians, including Cynthia Donovan. She discovered she had HA after not getting her period 6 months after getting off birth control. She was maintaining her weight at roughly 1500 calories for years. Her BMI was considered normal.
After doing this research, I increased my calories from an average of 1700 per day to 1900/2000 per day. I gained another 3-5 lbs within a few weeks. Even though I was pretty convinced the issue was related to under-eating, I knew I would feel more confident in my journey if I got confirmation from a medical professional. I went to my gynecologist to see what she had to say. Through some lab work, discussion of my medical/diet history and checking physical symptoms, she ruled out PCOS and diagnosed me with HA. I was happy to get confirmation. Through listening to other women’s stories online, many medical professionals do not understand HA. Many do not think under-eating is a problem if you have a “normal” BMI. One story I heard came from a woman who finally got her period back after gaining 6 lbs. Her doctor was concerned about her weight gain even though that is what it took to get her period back. Gaining weight is not always a bad thing! I am lucky my doctor was knowledgable about HA! She told me I was already doing all the right things and encouraged me to continue what I was doing.
No period, now what?
To understand what was going on more clearly, I read the book No Period Now What (NPNW). The author, Nikola, had a similar experience to me. She too lost a few lbs from a calorically restricted diet. I believe she was aiming for 1500 calories/day, close to where I was at. She got off birth control and her period did not come back. Through her own investigation, she discovered the root cause to her missing period was driven by under-eating and overexercising. She decided to stop calorie counting and exercising for a period of time. Her period came back. Nikola wrote NPNW due to the fact that there was not a cohesive resource for women with HA to refer to. In addition, a lot of women with HA are misdiagnosed with PCOS. As noted above, a lot of doctors do not have a clear understanding of HA. The book goes into detail what HA is, the health consequences of HA (low estrogen/progesterone from HA can drive a whole host of health problems such as bone/heart issues), how to recover and how to get pregnant (if that is your goal). She also surveyed 300 women who were diagnosed with HA. I touch on some of the survey results in the section below. She also has an online forum for women to come together to share their experiences with HA. I found the community incredibly valuable to support me on this journey. You can find that forum here.
What is HA? How does it happen? How can we recover from it?
The name HA comes from the symptom amenorrhea (or missing period) and the cause (hypothalamus).
The hypothalamus is a region of the brain that basically makes sure the body is in homeostasis.
The hypothalamus takes in messages from all parts of the body and responds through making other hormones that impact other parts of the body. Including reproduction.
There is constant feedback going on in the hypothalamus to make sure things are going well. However when things are a bit out of wack, the hypothalamus can not keep up. This can sometimes result in lack of period.
Many factors can drive HA. Food restriction, weight loss, exercise, stress and genetics. Each person with HA will develop it for a different reason. However the primary driver is under-eating and overexercising. Yes you can develop HA from just stress, but it is more rare. It is usually in combination with under-eating. And this is regardless of body size. HA can occur at a variety of sizes.
Restriction of certain foods can also play a role in disrupting the hypothalamus. All three main macros (Protein, carbs and fats) send signals to the hypothalamus to support homeostasis. So if you are restricting one food group, you can be messing up your hypothalamus. For example, when we consume carbs, it increases the hormone insulin. There are hormone receptors in the hypothalamus that can sense insulin. If insulin is always suppressed, this can throw the hypothalamus out of wack and negatively impact the ability to have a period. In fact, uncontrolled T1 diabetics who have very low insulin commonly have amenorrhea.
We need energy to survive. The top priorities for energy are pumping the heart, the brain and keeping cells working. After that, energy is delegated to growth of hair and nails, immune cells, bones and body temperature. Least important is fat storage and reproduction. So essentially if we are not fueling ourselves enough, we will shut down functions that are not as vital. So first our body may stop regulating temperature. Then the ability to make babies. If you are cold and sick frequently, this could be a sign that you are under-fueling.
In NPNW, Nikola conducted a survey on 300 women with HA. Through the survey results, she demonstrated you can lose your period at a variety of BMIs. However the majority of people who lost their period had an underweight or low BMI. With this said, there are certainly some people who lose their period with an overweight BMI.
Outside of diet and weight, exercise also plays a huge role in increasing the chance of developing HA. Exercise does this by restricting total calories (less energy for reproduction) and also driving up hormones such as cortisol and endorphins. Cortisol and endorphins suppress the hypothalamus. Yes you heard that right, the same endorphins that make us feel good could also drive HA. You can see a graph of the feedback loop between endorphins/cortisol and the ovulation hormone (GnRH) below. Many studies have demonstrated this impact. One study that I found interesting in NPNW was conducted on a group of women who started a running program. These women increased their calories to support their runs. 80% of them had menstrual abnormalities 2 months after starting the program. This demonstrates that even outside of a calorically sufficient diet, sometimes too much cortisol/endorphins from exercise can drive HA.
In survey respondents of HAers, the median caloric intake per day was roughly 1481 calories. Yup, just under what I was targeting when I was most restrictive at 1600 calories/day on average.
In survey respondents of HAers, the majority of people were exercising at least 5 days per week 1-1.5 hours per day. Before I realized I had HA, I was exercising roughly this amount.
Nikola shared studies that demonstrated a fertile BMI is closer to 22 to 23. I was under this BMI range at my lowest. I got my period back once my BMI hit 22. However for others, they need a higher BMI than this to get their period back. Everyone is different!
Birth Control Pills
Birth control pills mask whether or not you are ovulating. When I was on birth control, I did not think there was a problem because I would always get my period when I was off the active pills for a week. However this period is not the same as a period you have when you are off birth control. The period you get on birth control is not driven by ovulation. It is driven by a drop in synthetic hormones. Only when you get off birth control can you really tell if you are fueling yourself enough to support ovulation and reproduction. That is what happened to me! What kills me about this is that I know people who were given birth control because they stopped having a period from under-eating. The doctor told them the birth control was good because it would give them a period. However as noted above, this is not a real period and does not fix your ovulation. It does not get to the root of the issue. The way to fix a missing period is to eat more and exercise less!
How to recover?
Nikola recommends aiming for a minimum of 2500 calories per day. This may seem like a lot, but Nikola does a great job of breaking this all down. Equations from the Institute of Medicine (IOM) computed that an active weight stable women with a height of 5’6″ burns about 2450 calories per day. Other research groups studied the relationship between lean body mass and caloric intake to determine optimal amount. For an active fertile woman with 20% body fat, she needs 2500 calories to maintain her menstrual cycle. You may think well why is the mainstream recommendation to maintain weight for an average female 2000 calories per day ? According to Nikola, that number is outdated. It is based on self-reports and people tend to underestimate their intake. People with HA likely do not under-estimate their intake! Maintenance for the average person is actually higher than 2000 calories. So add on top of that more activity and you are around 2500 calories. If you are shorter and sedentary, you would drop this number closer to 2000. If you are taller and/or more active, it would be closer to 3000. Active means walking 5-7 miles per day. So if you do more activity than walking 5-7 miles per day, you would need more than 2500 calories.
After reading Nikolas book, I stopped calorie counting. I knew this behavior was not serving me and that I can trust myself to eat the proper amount of food. I knew I was getting in at least 2000 calories because I bumped up my calories from where I was at before . I also stopped exercising for a month or two and only walked. I gained a little more weight, another 3-5 lbs and got back to where I was before I started calorie counting. All in all, I got my period back after 2 months of eating a sufficient amount of calories.
Cultural fixation on body image
As a culture, we value being skinny. We associate skinny with healthier and better. Female bodies depicted on social media and TV tend to be very small. So small that it is likely that many of them are not at the healthiest weight to support their body optimally. We do not know what these people do to maintain that weight. It is very possible it is through unhealthy practices (drugs/eating disorders). As we can see through my experience, even just 7-10 lbs lighter was not healthy for me. I also think back to times when I was even smaller than that. I used to be on adderall which suppressed my appetite. I never weighed myself during those times but I was even smaller, maybe 15-20 lbs lighter than now. I do not know if I was eating enough to support ovulation at that time because I was on birth control. So you never know what people are doing! Also genetics certainly play a role. Some people can thrive at a smaller weight for their height.
We live in a pretty self-centered culture. Mirrors everywhere, photos everywhere. It can drive you to fixate on your body. I thought it was interesting that when I went to Vietnam on vacation with friends there was limited mirrors. I remember feeling less fixated on my body and more in tune with the environment around me. Sure I was also on vacation so I was generally more relaxed. But relative to other vacations where there was access to mirrors, I felt less attached to my body image.
I also think that certain people are more susceptible to fixate on their bodies. It seems to be driven by some underlying neuroticism. I see that a lot of my friends who are lower in neuroticism tend to not fixate on their bodies as much. I think it is crucial to not spend all your energy consuming content about health/nutrition. It is really important to balance out how you spend your time and engage in activities outside of health to reduce the chance of fixation. More on this in the last section!
Why did this happen to me?
I always had a complicated relationship with my body. Ever since I was a young girl, I have been highly conscious of the way I look. I never had a weight problem. In fact, by normal social standards I had an acceptable body. I was frequently praised for my body. Because I was always complimented on my body, I got a lot of self worth around how I looked. So I did what I could to preserve that. Preserving my body is partially what drove me to want to study dietetics. Yes I was also curious about how to eat and live in a way to reduce the chance of chronic illness and feel your best. But I can not deny the fact that a good reason why I was driven to study dietetics was to learn how to remain lean.
It is a complicated thing. I am sure a lot of people in my field of work can relate. As a dietitian, there is extra pressure to represent society’s image-based version of health (skinny/lean). We are constantly praised for how we look. People are always asking us how to lose weight. They ask us what we do to remain lean. It puts us in a position where we are thinking about this stuff all the time. Since we are thinking about it all the time, it can put us in a position of OVER thinking about it. Resulting in us fixating on our image a bit too much. It can sometimes be hard to draw the line. At what point am I thinking about body image/weight too much? What can I do to negate this from occupying too much of my brain space during this short life?
Where I am at now
As noted above, I completely stopped calorie counting. Maintaining a slightly smaller weight at 1600 calories is not worth it. It is not worth being infertile. In addition, now that I am eating >2000 calories per day, I feel a lot better. Looking back, I was experiencing negative symptoms when I was under-eating. I just totally downplayed them at the time. I had a lot of sleep issues. I now know when you are under-fueled, your body can have a tough time relaxing. In addition, I had a higher baseline hunger. It was not overwhelming but it was slightly uncomfortable. I rationalized that I should be able to toughen through feelings of hunger. I would tell myself that people would go days without eating in the past and they survived. What is another 2-3 hours of waiting to eat again? Looking back, I was being too hard on myself. Now that I am eating more, I feel really satisfied between meals. I feel more comfortable. I also do not push myself to wait to eat. If I am hungry, I will eat within 30 minutes. Lastly, my hair is better and I have slightly more energy. A few people have complimented me on my hair in recent months without even knowing my journey! As noted above, when we do not fuel ourselves enough, “nice to have” functions of the body such as hair/nail health will be lacking.
After this experience, I decided to spend more time on activities outside of health/nutrition education. Outside of work, I now spend most of my free alone hours reading fiction books and watching movies. I have also been working on some crafts! If you are in a similar situation to me, I highly recommend focusing your time on activities outside of health/nutrition. Or doing anything that is helpful or creative. It helps broaden your perspective and fixate less on body image.
Since focusing less on nutrition/health, I find myself generally more content and less fixated on my body. I now do not think it is healthy for me to spend a full work day counseling people on nutrition and then consuming health podcasts/books during my free hours. Maybe that works for some people. But for me, it is too much. It drives neurotisim and puts me in a weird bubble. Predisposing me to fixate too much on my image and health. Life is way to short to only focus on one area of education!
However, this is not to say I will never consume health/nutrition books/podcasts again. I just need some space. And when I do go back, I think my focus will be less on weight information and more on other aspects of health.
With all of this said, things have not been perfect. I still feel compulsions to get back into my previous exercise routine and engage in more restrictive eating patterns. It is difficult for me to fully accept that doing less is better. It is also sometimes hard to accept that being in a slightly larger body is more ideal for my health. Logically I know what to do, but it is hard due to long-learned behaviors. Luckily I have a loving husband who is so supportive. He reminds me to take it easy and he values me not just for my body but my mind as well.
Share with me your story
I hope this blog post sheds some light on the fact that being smaller does not always equate to healthier! Fueling yourself adequately is so important. Life is too short to spend too much of your energy on your looks and health. And look I am not perfect. I still struggle with body image and taking care of myself. It is a continuous process. But if you are in the same position as me, I hope this blog post helps you understand you are not alone. I would love to hear your comments below!