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psychological stress and hypothalamic amenorrhea by stefani

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.


So, just as a heads up - some links above may be my affiliate links, which means I get a small commission if you click on it and make a purchase. Doing so is no additional cost to you, but helps me tremendously. Your support is SO greatly appreciated, so thank you in advance if you choose to do so. Check out my entire disclosure to know exactly how things work.

Managing director of Paleo for Women and author of Sexy by Nature.


  1. Wow the last study you cite is quite telling, and makes me hopeful I’ll see improvement this year. I’ve found that while I began voracious reading about all this scientific health stuff motivated by perfectionism, what I’ve learned has actually helped relieve me of perfectionism. I used to blame and hate myself for not knowing how to sustainably or effectively improve my health. Now, as I continue guessing what will help me most, I’m not shaming myself about my health anymore. I know I’m doing my best … and I know that hating myself could cancel out any other efforts to heal and lose weight! Looking good is always gonna be a motivator.

    Btw, I have irregular periods instead of amenorrhea, but I imagine a lot of women’s health/period problems result from some HPA axis imbalance caused by many of the same things.

    • Oh, yes, totally. Amenorrhea is the extreme, but as I mentioned, the monkeys witnessed lengthened cycles, for example. Rats in laboratory conditions also experience increased cycle length and irregular cycles. The same most, most definitely applies to women.

  2. This is exactly what I’m going through! It’s insane to read it because I’ve been having trouble explaining it to people. I’m at a loss for words because this sums it up so much. I haven’t had my period in over a year and I’ve gained 10 lbs and was never that underweight to begin with. The problem is with my stress and perfectionism. Following a paleo/primal way of eating makes me feel better but I find myself in that same struggle of wanting to do it perfectly and that has caused me to remain so stressed. I’m in therapy twice a week and do neuro feedback. What do you think of that or should I stick with cognitive behavioral therapy? I’m also going to a “living centered” program for 6 1/2 days where I’ll deal with a lot of these issues. I’m hopeful that I will regain my sanity and my periods. Even if I don’t have any more children, I know this is making me a better person and I will pass on all I learn to my daughter so she won’t have to go through this. Thanks for you post!

    • Congratulations on taking initiative to learn what’s happening and to figure out what’s going on for you. Really. That’s inspiring and wonderful and beautiful despite how hard it all is. Thank you for sharing.

      I’m certain that with all of this action you’ve had a lot of medical testing done to rule out physiological causes? Also– you said you were not “that” underweight. I would say a body fat of 22 percent should probably be the lower limit for women dealing with stress and reproductivity. And also, remember that it takes time to convince your body you are not starving. This involves your physiology as well as your psychology. Give your hips some time and some love while you work on your brain with the CBT.

      I don’t know much about neuro feedback. I DO know that CBT is largely effective. I think you should stick with what feels best for you. Pick something, and then commit to it. Believe in it. They’re all wonderful therapies, so I don’t think you can go wrong as long as you feel comfortable. I would love to hear more from you as you continue on this journey.

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  4. Thanks for this thoughtful post! I have been dealing with HA for the past two years, and I am still trying to regain my cycles through reduced exercise and increased weight. Looking forward to your next post on recovery!

  5. I was reading an extract from The Encyclopaedia of Sports Medicine An IOC Medical Commission Publication / Endoncrinology of Overtraining (ref below…you may have interest) and started to cross check some HPA-axis intel and I stumbled across your blog. This led me here to your site. So, I am now following both of your sites. Good stuff, indeed!

    Yeah, I know, I am a guy. So what? Knowledge is power and good science is for everyone, and that’s why I am now a fan. That said, if I could offer one suggestion; darker font please. “Do the work, be super well!”


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  8. Have I missed the post about recovering from this? Can’t seem to find it?!

    • You mean other than relaxing? 🙂 No, you didn’t. It’s in my long queue. My apologies. It’s on the way, though maybe not for another few weeks. The most important thing I wanted to say is that cognitive behavioral therapy in most studies cures >50 and sometimes as much as 80 percent of hypothalamic amenorrhea. There are other ways to tackle it, such as by taking different neural modulators, but I think therapy is honestly the best, even while those can be decent place holders.

      • Hi Stefanie – Any update on the followup recovering post? I was diagnosed with HA last year after going off the pill and having no periods/terrible migraines for 6 months. I’ve tried 2 different pills and now starting to suffer from the headaches often again. The doctor’s solution was to stay on the pill until I’m ready to get pregnant (in about a year) and we’ll see what happens. I feel so unsettled by this solution of waiting, and I don’t feel great these days regardless. I wonder if they should’ve tested me to rule out more things, but I think all they did was a blood test. I’m a pretty healthy eater and exercise 1-2 times/week so I don’t think that is the cause. Your post is very interesting and I think I have a ton of stress due to my job and striving to always be perfect/impress people with how I look. Just wondering where you would start for someone like me? I’m unsure of what type of doctors to see but want to take a more active approach to resolving this before infertility becomes an even bigger stressor next year. Any advice or guidance would be SO helpful. Thanks!

        • Oh, yes. Always err on the side of over rather than under-eating, and don’t restrict macronutrients. Really I can’t get any more specific than that. What works optimally for some women is probably different than others, but it ALL falls within the range of eating lots, exercising just a little, and radically restructuring our lives to reduce our stress.

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  11. Thank you for your work on this and all these hormone related topics. As someone struggling to regain her fertility, access to a knowledgable source of information such as yourself is invaluable.

  12. Very interesting! Before I got Chronic Fatigue Syndrome, I have always had elongated menstual cycles if I was not taking hormones to regulate my cyles. Now I take Prednisone and that increases the cortisol in my body which I am reasoning is helping because it is stimulating my underactivated HPA axis. I learned elsewhere that stressful childhood can cause an underactivated HPA axizs… I have to put the puzzle peices together, but this is something to think about… Yes I have suffered from eating disorder, perfectionism and a high need for social approval as well. I just don’t think that doctors spend enough time actually putting the peices of the puzzle together.. they never asked me about my menstrual cycles nor my perfectionist issues but they are quick to offer psychiatric drugs instead of helping me reduce my stress levels and help me change my beleifs. I find the whole medical situation extremely stressful and the fact that I worry about going back to work is not likely to help the situation. But I think I am going to be able to help myself. Thanks!

    • This explains my situation better than anyone has; been dealing with this for 13 years after the death of my mom…..where do I go for help?

  13. Thank you, thank you, thank you! I have been researching EVERYTHING that could be the cause of my lack of menstruation for 2 1/2 years and this is the first thing that matches what could be going on with my body. I can’t wait to keep reading into this. 🙂 Thank you!

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  16. HI I lost my period almost 11 months ago due to an eating disorder and over the past 5 months have been trying to get it back. I am currently have a healthy BMI and have returned to the weight i lost it at ,which i have maintained for nearly 2 months but have still not got it back. I am also not doing exercise to get it back (which is really hard not to do). Please please please tell me what else i can do?

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  19. Hi! I have been suffering from amenorrhea after transitioning to a gluten free diet and removing fodmaps for autoimmune disease. I have adopted an autoimmune version of the paleo diet which has done wonders for me. I’ve gained weight and got my period back! However when my period came back, so did my hormonal responses and they feel like they are all over the place. Is this a normal response as my body adjusts to getting used to them again? I felt better emotionally when I was having no periods! Thanks

    • Hi Emma,
      It may just take you some time to adjust. For my first few cycles back I had pretty significant symptoms, and they leveled out over time. ? It is possible this is what you are going through as well?

  20. Hi Stephanie, thanks so much for all you do. I have amenerrhea. As I’ve put on weight(25lbs this far)…. estrogen will not come up(at all, if anything it went down at one point). What does this mean? I’m not in menopause, that has been confirmed. However I have a gut infection, moved to a new state (with no friends), hashimottos, and a whole host of health issues. My fault, should of never lost weight, but wondering what’s going on with the estrogen? Appreciate your time Steph! Any input would help.

    • And I’m only 29.

    • Gut infections can have a big impact on hormone production! So can hashimoto’s. So if you focus on those issues for a while, that’s at least what I would do, and just have a bit of patience watching to see those numbers come back up

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