Understanding Hypothalamic Amenorrhoea

By Marina Bull

What is Hypothalamic Amenorrhoea?

Hypothalamic Amenorrhoea (HA) is a common condition amongst women. It has become more prevalent in this era when “wellness”, and appearing fit and conscious of “healthy” dietary habits are all praised.

There are two elements of the condition:

Hypothalamic = related to the hypothalamus, a region of the brain responsible for functions that include releasing hormones, controlling temperature, appetite, emotional and sexual responses.

Amenorrhoea = absent menstrual cycles for 3 months or longer.

HA affects around 17.4 million women worldwide1 and may be primary (a woman has never had a period) or secondary (periods have stopped).

HA accounts for approximately 30% of cases of secondary amenorrhoea in women of reproductive age.2

HA limits the capabilities of the athlete in their pursuits, be they professional or personal goals.

You may have heard of the Female Athlete Triad, an old term that encompasses inadequate nutrition, loss of bone density and menstrual disturbances. New terms recognise that, although men don’t have a menstrual cycle, they are still affected.

Some of these terms include:

Overtraining Syndrome (OTS)

OTS is ‘a condition of maladapted physiology in the setting of excessive exercise without adequate rest. … Symptoms are multisystem in nature and often representative of underlying hormonal, immunologic, neurologic, and psychologic disturbances’.3

Low Energy Availability (LEA)

LEA occurs where ‘the body does not have enough energy left to support all physiological functions needed to maintain optimal health. Athletes are particularly at risk’.4

Relative Energy Deficiency in Sport (RED-S)

RED-S occurs when there is excess energy expenditure and/or insufficient caloric intake.

Female and Male Athlete Triad. 

According to The Female and Male Athlete Triad Coalition, the Female and Male Athlete Triad is a syndrome of three interrelated conditions that exist on a continuum of severity, including:

1. Energy deficiency: low energy availability with or without disordered eating

2. Reproductive suppression: menstrual disturbances and amenorrhea in women, altered hypothalamic-pituitary-gonadal axis and hypogonadotropic hypogonadism in men

3. Impaired bone health

There is a growing awareness around the negative consequences of overtraining and under-fuelling, but it is still not discussed enough and there is a general lack of understanding of the effects on the endocrine system.

How Do You Know If Someone Has HA?

HA is often misdiagnosed, due to a lack of understanding and awareness about the condition amongst the public and even medical professionals, as well as the crossover of diagnostic criteria with other conditions, and the possibility of coexisting with other conditions.

It is important to recognise that mental health is a significant factor in HA.5

Mental health conditions, such as anxiety, depression, body dysmorphia and eating disorders, are frequently present in patients with HA.5 The stigma associated with mental health conditions, especially paired with the idolisation of elite sportspeople, makes for a difficult discussion in diagnostic attempts.

It is important to note that HA may come about as a result of intentional or unintentional LEA or RED-S.

The underlying mechanism of HA in women is a disruption in the communication between the hypothalamus of the brain and the ovaries. Specifically, the suppression of gonadotropin-releasing hormone in the hypothalamic-pituitary-ovarian axis results in low follicle stimulating hormone and luteinising hormone being released from the pituitary.5

Why Is It Important for a Remedial Massage Therapist to Understand HA?

Clients with HA may typically be underweight or have recently lost weight, follow a strict dietary regime, train intensely and/or have undergone recent stress.

We might suspect HA if a client presents to the massage therapist with ongoing pain, slow recovery times, multiple injuries – particularly fractures and conditions related to poor bone density – low energy, feeling cold, frustration at lack of progress in their sport or training, low mood, disturbed sleep, altered appetite, and particularly if they mention that their menstrual cycle is delayed, absent, very light or short, or they are experiencing spotting.

Because many of the reported symptoms of HA are also common reasons clients seek massage, massage therapists may miss the link to HA while focusing on treating the symptoms.

In circumstances where a massage therapist believes that HA may be the diagnosis, it is helpful to know who to refer our clients to for help.

Referring When You Suspect HA

A referral to a sports medicine doctor, gynaecologist, nutritionist or psychologist who understands these complex conditions in both men and women is recommended.

When the focus is solely on amenorrhoea, the oral contraceptive pill (OCP) is commonly prescribed as a blanket remedy to “regulate” a menstrual cycle.5 HA is more complex and the OCP may produce a withdrawal bleed in some patients with HA (withdrawal bleeding is the monthly bleeding women experience while using OCP) and does not allow for ovulation and the proper cycling of female sex hormones that occurs in a health menstrual cycle. Patients with more severe HA will not have any endometrium to shed and will not experience even a withdrawal bleed with the OCP. It is noted that the Endocrine Society Clinical Practice Guideline (2017) does not recommend the OCP for women with HA for the reasons stated above.

Don’t Say It

As massage therapists, we don’t comment on a client’s physical appearance, including weight loss or weight gain. Reinforcing negative behaviours or thought patterns can contribute to poor outcomes. Passing comments can be a trigger for disordered eating, even well-intentioned comments.

The worth of a body is not in its aesthetics but its abilities, particularly in sports.

Why Early HA diagnosis and Treatment is Important

In some cases of elite athleticism, such as ballet dancers or gymnasts who have trained from a young age and maintained high levels of activity in conjunction with low body weight, a person may be seen to be a “late bloomer” but may be in LEA, at detriment to their health and physical performance.

There are many short and long-term consequences of HA, many reversible and some not so much. Menstrual cycles can be recovered, even after one or two decades without menses, or primary amenorrhea may be resolved. Although HA may cause infertility, women can successfully conceive children after HA.6,7

Bone loss can occur as early as 6 months of HA.5 While bone density problems such as osteoporosis or osteopenia are more difficult to resolve, improvements can be made.6,7

Never Forget the Power of Touch

As massage therapists, we can support our clients to seek a correct diagnosis for management and treatment of HA. Our touch can be affirming to those who doubt their body’s worth and reassure them that they still deserve caring attention.

With greater awareness of HA in the massage community, we can help our clients get faster access to diagnosis and treatment and hopefully there will be less denial, or failure to see the links between health behaviours (exercise, nutrition, sleep, rest, stress).


  1. McDevitt TM. World population profile: US Government Printing Office; 1996
  2. Adult-onset amenorrhea: A study of 262 patients (1986), Reindollar et al
  3. Diagnosis and prevention of overtraining syndrome: an opinion on education strategies (2016), Jeffrey B. Kreher
  4. Reasons for and Consequences of Low Energy Availability in Female and Male Athletes: Social Environment, Adaptations, and Prevention (2020), Wasserfurth et al
  5. Hypothalamic Amenorrhea and the Long-Term Health Consequences (2017) Shufelt et al
  6. Strategies to reverse bone loss in women with functional hypothalamic amenorrhea: A systematic review of the literature (2008) J Vescovi, SA Jamal, MJ De Souza
  7. Recovery of Bone Mineral Density and Fertility in a Former Amenorrheic Athlete Case Report (2008) K Hind

Further Reading

Current understanding of hypothalamic amenorrhoea (2020), Roberts et al

Useful Links

Bright Girl Health

No period. What now?

About the Author

Marina Bull is pretty stoked to be a massage therapist. Previously a professional ballet dancer, her massage practice is heavily influenced by ramifications of the toe-crushing forces of appearing ethereal. When not dancing or massaging, you’ll find her riding her bike into the sunset.

Cover image by Zhengwen Guo from Pixabay

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