What is Amenorrhea?
Before we can talk about food for amenorrhea, let’s talk about what it is first. Amenorrhea is defined as the absence of the menstrual cycle in a woman of a child-bearing age. We commonly see amenorrhea in women with eating disorders who chronically under-eat and/or over-exercise.
There are several factors that may cause amenorrhea:
Food intake and amenorrhea go hand in hand. Diet plays a large role in period loss. Whether a result of restriction or over-exercising, under-eating starves your body of essential nutrients. When under-fed, your body prioritizes the energy needs of organs like the heart and the brain, and shuts down other processes that it considers less important, like the menstrual cycle.
Amenorrhea is not just about low food intake. Women with amenorrhea often exercise more frequently, or with more intensity, than the average woman. Female athletes that train multiple times per week, like runners or gymnasts, may lose their periods as a result of over-training. Eating a ‘regular’ diet (i.e. eating when you are hungry and stopping when you are full) may not be enough food to compensate for heavy exercise. It is a misconception that it is “normal” to lose your period when training for a marathon. For example, marathoners that eat enough during training will maintain their menstrual cycle.
Low body fat/weight
It is possible to lose your period at a “normal” weight or in a larger body. Although it is more common to see women with low body fat and low body weight lose their periods.
While low body weight may cause you to lose your period, weight loss in general is a more common finding among amenorrhea sufferers. Losing 10 pounds, even years ago, can affect the loss of menstrual cycle. Weight loss can occur as a result of both under-eating and over-exercising.
Physical stress like malnutrition, excessive exercise, rapid weight loss, and emotional stress like trauma can play a large roll in period loss. Stress causes cortisol levels to rise and estrogen levels to fall, signaling your body to shut down your regular menstrual cycle.
Some other causes include might include genetics, PCOS, and, in rare cases, pituitary tumors.
How is amenorrhea related to bone density?
Bone density and amenorrhea are linked in several ways. First, estrogen, a hormone that helps regulate your menstrual cycle, also helps regulate bone health. Estrogen does this in two ways: It stimulates bone formation and suppresses bone breakdown. When you lose your cycle, estrogen levels drop, which allows for more bone breakdown and less new bone formation.
Birth control pills (estrogen-replacement pills) are not a cure for bone loss during amenorrhea. It is possible to get your period while on birth control and still be losing bone mass. The only exception to this is the estrogen patch, which has been shown to positively impact bone density.
The second way amenorrhea and bone density are linked is through exercise. Exercise like resistance training has been shown to strengthen bones. However, in women with amenorrhea, exercise will further deplete bone density stores.
Testing for bone density levels
A DEXA scan is a non-invasive, x-ray-like procedure that examines bone mineral density. DEXA scans identify if any bone loss has occurred by measuring the thickness of your bones. Your DEXA scan results are an important tool your physician may use to diagnose osteopenia or osteoporosis.
Is amenorrhea and bone loss reversible?
Bone loss that occurs with women experiencing amenorrhea may be reversible following lifestyle changes. The longer you are experiencing amenorrhea the weaker your bones get. Addressing the cause of your amenorrhea as early as possible will help preserve bone mass.
The Gold Standard for reversing amenorrhea is adequate food intake. The goal is to fully restore your nutrition. Having your menstrual cycle does not inherently mean that your body weight has fully been restored.
Food for Amenorrhea, Osteoporosis and Bone Loss
Consider the following in an effort to restore body weight:
Increase food intake to improve nutrition status
Restoring body weight requires more calories than you may expect or be used to. Your body’s metabolism (RMR or resting metabolic rate) will speed up quickly once you begin to re-feed it. It will need a lot of fuel to rev up processes that it had previously slowed or stopped due to inadequate calories, like your menstrual cycle.
Know what to expect
Going from under-fueling to adequately fueling might feel strange at first, so it’s important to know what to expect. When you begin to eat more, you may experience swelling, bloating, constipation, and acid reflux. Although most of these are temporary, don’t hesitate to reach out to your care provider regarding ways to soothe any discomfort. You may also feel very full quickly after eating even small portions. Focus on eating high-calorie, low-volume foods that deliver a lot of energy in small amounts. Examples include eating full-fat dairy products, replacing water with juices or smoothies, and mixing in peanut butter, cream cheese, or butter into your foods. Energy bites are also a fun, tasty way to increase your calories throughout the day.
Eat calcium-rich foods
Dairy products like milk, yogurt, and cheese are calcium-rich options. Some other sources of calcium include: leafy greens like kale, seeds like sesame and chia*, beans and lentils, almonds, canned salmon, and tofu. You may be wondering if calcium supplement is right for you. Calcium is best absorbed in food-form. If you are not eating enough calories, calcium foods alone will not help improve your bone density.
It is also important to note that we only absorb about 300-500mg of calcium at a time, so supplements with higher amounts are not helpful. Be aware that calcium supplements may cause some constipation and upset stomach. Work with your dietitian to choose quality supplements that are better tolerated and absorbed as you work on improving your nutrition.
Understand your barriers
If you are currently experiencing barriers to consuming enough food to fuel your body, take a moment to answer the following:
- Do you have forbidden foods or food groups that you don’t allow yourself to eat?
- If you eat one of these foods, do you feel guilty and anxious afterwards?
- Is your eating dependent on exercise – do you allow yourself to go out to dinner only if you go to the gym to burn off the extra calories or skip other meals?
- Do you cook separate meals for yourself? Or avoid social gatherings because you don’t want to deal with the food or people asking why you are not eating?
- Have you trained yourself to ignore your hunger – getting pleasure out of not “caving in?”
If you answered ‘yes’ to any of the above, consider reaching out to a dietitian who can help you work through some of these barriers. Again, regaining your menstrual cycle and reversing bone loss depends on you eating enough to properly fuel your body and restore a healthy body weight.
Amenorrhea treatment is about more than just food
It is important to scale back on the frequency and intensity of exercise, especially cardiovascular exercise. Even moderate exercise paired with inadequate energy intake, stress, and genetics can lead to amenorrhea in some women, so taking time off from the gym, team practice, and training is important.
Your body’s reaction to high stress levels may be affecting your ability to restore a healthy weight. By nourishing your body with adequate food and resting your body from exercise you are already lowering your body’s response to physical stressors. Emotional stress may also be wreaking havoc on your hormones. Consider ways to lower your stress levels at home, school, and at work like meditation, yoga, deep breathing exercises, or aromatherapy. We love using Lavender Essential Oil* from Young Living to lower stress levels!
If you or a loved one is experiencing amenorrhea and would like to meet with a Registered Dietitian, please call us at 301-474-2499 or email email@example.com. Dana sees clients in our Annapolis and Columbia Maryland offices.
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Source: “No Period. Now What: A Guide to Regaining Your Cycles and Improving Your Fertility” by Nicola J. Rinaldi
Gaudiani JL. Sick Enough: A Guide to the Medical Complications of Eating Disorders. Routledge; 2018.
Dana uses her advanced training in functional nutrition and food sensitivities to help her clients love and trust food again as they heal from years of painful symptoms that have dominated their lives. Co-author of Nourished: 10 Ingredients to Happy, Healthy Eating and Cooking with Food Sensitivities Survival Guide.