The HPA axis: Psychological Stress and Hypothalamic Amenorrhea

The HPA axis: Psychological Stress and Hypothalamic Amenorrhea

I’m going to pick up here where I left off on my last post. There, I covered the role that exercise and energy deficits play in HPA-axis-induced amenorrhea. Here, I cover the effects of psychosocial stress, and also how the two kinds of stress play off of each other.

Hypothalamic amenorrhea (HA) typically results from pschyological stress coupled with a mild energy imbalance–so generally both social stress and metabolic distress are present. These two stressors are too intertwined to separate out in studies.

Hypothalamic Amenorrhea affects 5 percent of women of reproductive age, and subclinical women I suspect double that number, at least.

It is generally believed that psychosocial dilemmas activate neural pathways (ie, worrying about a job will stem from the prefrontal cortex) and hit the HPA axis that way, causing stress hormones to be released and sex hormone production to decline.

Exercise and weight loss disturb the HPA axis via metabolic disturbance. Although it seems logical that specific cascades exist for different types of stress — for the psychological or the physical — there is currently no method for clearly delineating psychogenic from metabolic stress. So far as we can tell, they are both equally damaging to sex hormone production, and can cause hypothalamic amenorrhea.


Hypothalamic amenorrhea: the power of stress

One way to test the potence of pyschosocial stress on female fertility is with primate studies. It enables researchers to control for all of the variables that affect human lives.

This is how big of a deal it is:

In one study, across more than 1200 menstrual cycles in cynomolgus monkeys, the stressed out, socially subordinate monkeys consistently exhibited ovarian impairment, whereas others did not.  

The thing is, in primate societies, much as in our own, it is inherently stressful to be at the bottom of the social ladder. All that researchers have to do in order to study primate fertility is to monitor the behaviors and physiology of lower rung versus higher rung monkeys.

For the lower rung monkeys in this study, their cycles increased in length and variability, and both their levels of progesterone and estradiol dropped. Additionally, they experienced elevated cortisol levels (almost in a perfect inverse relationship with the estradiol), as well as osteopenia, which is the precursor to osteoporosis. (An important side note: the researchers also tested soy on the monkeys to see if it would help. It did not.)

These monkeys were not energetically stressed. They ate the appropriate amount of food. The only thing that had the power to change their reproductive capacity was psychosocial stress, and it made a significant impact.

Kinds of stress that cause hypothalamic amenorrhea

There are many stressors associated with stress-induced amenorrhea. They include affective disorders, eating disorders, various personality characteristics, drug use, and external and intrapsychic stresses.

“External and intrapsychic stresses” sounds clinical and like a small category of disease, but it is in fact huge. If you think you are fat, if you think you are stupid, if you think you are ugly, if you think you aren’t good enough, if you think other people think you’re fat, stupid, ugly, or not good enough… the list goes on and on. This is “intrapsychic stress.”

(To read about how I got rid of my own intrapsychic stress and help my clients do the same, check out my best-seller for women’s confidence, Sexy by Nature, here!)


“Intrapsychic” stress is the nebulous stuff that women impose on themselves–encouraged by society or otherwise–and it kills the HPA axis. Almost literally. Cortisol blocks signalling to and activity of both the pituitary and thyroid glands, in addition to on hormones themselves while in isolation in the bloodstream. The stress of living in today’s world is one of the greatest health threats a woman can face.

In one study, women with stress-induced hypogonadism were compared with a) “normal” women and b) women with hypothalamic hypogonadism from other pathologies.  Those with stress issues were the only ones who measured unrealistic expectations and dysfunctional attitudes.  They were both highly perfectionistic and sociotrophic, which is defined as (its amazing we even have a word for this)– a high need for social approval. Perfectionism and sociotrophy play off of each other.  Perfectionism interferes with social approval, and social approval feeds back on notions of what being perfect is.

Women with stress-induced hypogonadism also test as having trouble realxing and having fun. They do not typically meet the criteria for eating disorders, but they do as a whole exhibit disordered eating.   That’s almost as insidious, in my book.  And they do exercise a lot. These two facts of disordered eating and excess exercise do not help the stressed out hypothalama.

I am going to mention my book again here, because it really has been so helpful for so many women dealing with this. Really. Take a look. 🙂 Here: Sexy by Nature.

The intersection of psychological and physical stress

Other sources of hypothalamic stress, as we’ve covered, include caloric restriction, excess exercise, and low body fat, all of which signal to the hypothalamus that the body is starving. These very often act in concert with psychosocial stress, a la the perfectionism discussed above, and feed off of each other in nasty ways.

For example, women become amenorrheic when suffering from anorexia. Clearly this is a metabolic effect, but the self-tortured stress and the isolation that often accompany anorexia take huge tolls from the cognitive angle as well.

And tellingly: once anorexic women both regain weight and supplement with exogenous hormones, such that their systems should be working normally, they still often do not experience bone accretion. Bone accretion is enabled by estrogen. The fact that these women still lack estrogen demonstrates that the normalizations these women experience from regaining weight are not 100%.  They are ineffective, and clearly not all parts of the HPA axis are working properly. This is likely because psychological stress is still high and the adrenal glands have not yet recovered. It may also be due to ongoing metabolic derangements such as altered growth hormone action, or hypothalamic hypothyroidism.  These women’s systems need time to recover.  But they also need psychological healing, or else the HPA axis will not run happily.

In one study, 88 percent of women with hypothalamic amenorrhea recovered menstruation with just 20 weeks of cognitive behavioral therapy.  Not all, but a significant portion of, women who suffer from hypothalamic amenorrhea need psychological healing, far more than anything else. After that, not only do stress levels fall, but healthier eating habits become the norm.

For more on how to recover from HA and make healthier eating habits become the norm, check out this post, or my confidence- and love- inspiring book on Amazon, Sexy by Nature.