Functional Hypothalamic Amenorrhea: What Parents Need to Know

It is problematic for teenage girls to have irregular or missed periods.

But the perception I have gleaned from speaking with many of them is that missed periods are ‘not a big deal’ and ‘happen all the time’ to their athletic peers.  In fact, medical literature suggests that lack of (called ‘amennorhea’) or irregular periods occur in approximately 60% of female athletes. This is of particular concern for girls in sports such as gymnastics and figure skating, where leanness may confer a competitive advantage.

The reality is that missed and irregular periods can cause a slew of health issues for teenage girls and can be related to a bigger health problem. This issue has become so prevalent that I chaired a task force to develop clinical practice guidelines, which were recently published in the Journal of Clinical Endocrinology & Metabolism.

After the onset of menarche, adolescents should develop a 28-45 day cycle. Anything longer than 45 days is too long, and could be a sign that your daughter has functional hypothalamic amenorrhea (FHA). Here’s what parents need to know about it and why it’s detrimental to her body.

7 Things Parents Need to Know About Functional Hypothalamic Amenorrhea:

1. It’s caused by three major factors.

Stress, inadequate nutrition, and over-exercising are common causes of FHA. Sometimes it is caused by a combination of these factors. When a girl has FHA, she has created an energy imbalance, which affects brain function. When this happens, the hypothalamus will slow or stop releasing a signaling hormone called GnRH which controls her menstrual cycle. Girls with FHA may also have low body weight, a low percentage of body fat, and restrict calories and fat intake. We see this more commonly in girls who play sports where low weight is an advantage, such as running and dancing.

2. The detrimental effects are numerous.

FHA can contribute to delayed puberty in adolescents, bone loss, stress fractures, greater risk for osteoporosis later in life, as well as infertility. The teen years are critical for bone accrual – by about the age 20, we have our bone mass for life. If your daughter also has an abnormally slow heart rate, low blood pressure, or an electrolyte imbalance, she should be monitored more closely as she may have an eating disorder. A high mortality rate is associated with both FHA and eating disorders, particularly anorexia nervosa. She may also need to have a brain MRI to assess for abnormalities in the pituitary gland.

3. Similar symptoms can happen in boys, too.

We created our guidelines with a focus on females, because missed periods are a significant health issue. However, I think it is important to note that aside from missed menses, boys can still have some of the same weight loss, diet, exercise, and social isolation issues. And while less common, this is sadly increasing in prevalence.

4. It’s diagnosed by exclusion.

There are other conditions can interrupt her menstrual cycle and they will need to be ruled out before a diagnosis of FHA is given. In addition to pregnancy, her doctor will check estrogen, thyroid hormone and prolactin levels.

5. It’s reversible.

The good news is that FHA is reversible if treated properly. Our newly developed guidelines recommend that your daughter see a dietitian as well as a mental health professional. Increased calorie consumption, improved nutrition and decreased exercise activity can restore menstrual cycles. This of course, is often easier said than done, as many young teens are resistant to changing their habits. They like being thin, or they feel like they are performing better. This is where a mental health professional can help. Retrospectively, patients with whom we have helped recover say that their performance improved once they had the energy reserves to withstand the sport.

6. It can be a side effect of an eating disorder.

The two often coincide. If your daughter is altering her diet or over-exercising, pay close attention and get your daughter help if you’re concerned. About eight million people in the U.S. have anorexia nervosa, bulimia and related eating disorders.

7. It’s important to watch for red flags.

The warning signs of functional hypothalamic amenorrhea can be subtle. Here are some things to look for: weight loss; greater focus on what she is eating or not eating; skipping meals; refusing to eat what the family is eating; not having a period; social isolation such as refusing to go out with friends for pizza or ice cream; and particular obsession with exercise, such as continuing to do it despite injury or bad weather.

Having a period is a barometer of wellness. If your daughter is having irregular or missed periods, it is worth a conversation with her and her health care provider. One of our main goals in creating these clinical practice guidelines is to spread awareness of the issue. Please share this post with your friends, daughters, athletes, and anyone else with whom you think may benefit.

For more information about the Teen Health Center, or to schedule an appointment, email or call 513-636-4681 .


Catherine Gordon, MD

About the Author: Catherine Gordon, MD

Catherine Gordon, MD, MS, is the director of the Division of Adolescent and Transition Medicine and a professor of Pediatrics at the University of Cincinnati College of Medicine. She has a long-time interest in reproductive endocrinology and bone health in adolescents and young women. She has a special interest in stress fractures and other skeletal health issues in female athletes and adolescents with restrictive eating disorders.

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