Even though many dermatologists would deny it, hormonal acne is a real and serious problem for women.
Gut health and inflammation are both major players in acne. (read more about causes of acne other than hormones in this post, or my brand new acne program, for 50% off this week!).
Yet hormones can be the biggest problem for women.
In today’s post I discuss all the variations of hormonal acne, where it comes from, and what to do about it.
Hormonal Acne: When and how it shows up
Hormonal acne for many women presents at certain times of the month. Popular times include 1) at ovulation, which occurs almost precisely smack in the middle of the cycle, two weeks after the first day of bleeding (read about how to pinpoint ovulation in this post), 2) the few days before a period, and 3) at the start of a woman’s period.
Hormonal acne can also be present all of the time. For women with hormonal problems such as PCOS (read here to start figuring out if you have PCOS) and Hypothalamic Amenorrhea (read here to figure out if you have HA), this is unfortunately the case.
When I had both PCOS and HA at the same time, I had terrible acne every day for three years.
Hormonal acne usually occurs in the form of cysts. Cysts are those lovely, pus-filled, painful and inflamed red bumps. They often culminate in a peak of white pus.
Hormonal acne also appears as more mild forms called comedones. These are those whitehead “bumps” that never break the surface.
Hormonal acne can even show up just as smaller lesions. These are not quite as angry and painful as full out cysts, and may appear more rash-like or just smaller than typical acne. Below is a photo of my own cysts (on a “good” day) back in 2011.
These are cysts, classified as “stage 3” acne by dermatologists. There are 4 stages of cysts in hormonal acne
Hormonal acne occurs first and foremost around the mouth. It shows up on the chin, below the nose, around the sides of the mouth, and sometimes up the jawline.
As hormonal acne worsens, however, it spreads to the cheeks and the forehead.
Other body parts can be affected, too. This usually includes the shoulders, back, and buttocks–where the body’s testosterone receptors are most prominent.
The physiological mechanism of hormonal acne
Hormonal acne is caused by increased oil production beneath the skin. Think of it like a river. Ordinarily there is a healthy flow of oil to the surface. This is important because it lubricates the skin.
But when there is too much oil – and when it combines with the normal skin cells and other debris on the surface of the skin – it can clog the pores.
When oil clogs pores, bacteria go on a feeding frenzy. This causes inflammation.
The worse inflammation is, the more irritated the oil gland can become, and thus the more red, and the more painful.
Yet it is important to remember that hormonal acne does not occur unless there is an oil problem.
This is the reason no amount of washing will ever completely eliminate hormonal acne. Admittedly, it can be helped by antioxidant cleansers, serums, or creams.
But it will never go away completely without curing the hormonal acne from underneath. The only way to fix it is from the inside out.
Hormonal Acne: Causes of increased oil secretion
The primary causes of oil secretion are male sex hormones, also called androgens. Testosterone is the primary culprit. Another androgen, called DHEA-S, is also very important. They both increase oil secretion.
This effect is worsened when female sex hormone levels – particularly of estrogen – fall. Estrogen balances male sex hormones in the skin. Without a healthy balance, problems occur.
1. The most prominent androgen is testosterone.
Testosterone causes oil production in the skin.
Why might you have high testosterone?
You might have it if you have PCOS.
(Acne is one of the clearest indicators of PCOS.)
You may also have high testosterone if you have diabetes or insulin resistance, because when the body produces insulin, the ovaries produce testosterone. It’s a very simple yet very damaging process.
When might you show hormonal acne from high testosterone?
If you still have a menstrual cycle, you may find that you break out around ovulation. This is the middle of your cycle. It is also when your testosterone levels are the highest.
But if you have a hormone condition like PCOS – you will probably have hormonal acne most of the time.
(If you struggle with PCOS or think that you may have it, you may want to check out my handy guide on overcoming PCOS.)
2. Another androgen, called DHEA-S, causes oil production as well.
Yet unlike testosterone, which is a sex hormone, DHEA-S is a stress hormone.
It is produced primarily in the adrenal (stress) glands. Whenever a woman is under any degree of stress, her body faces a choice: it has to decide if it wants to produce normal sex hormones like progesterone and estrogen, or if it wants to produce stress hormones like DHEA-S.
For this reason, Hypothalamic-Pituitary-Adrenal (HPA) Axis dysregulation is usually the first place to look to as the origin of DHEA-S problems. Women with a lot of stress – whether from emotions, poor sleep, or under-feeding – have higher levels of DHEA-S levels.
3. Estrogen fights acne.
Estrogen helps promote clear skin. It does this in a number of ways.
First, it has the power to off-set high testosterone levels in the blood. Estrogen increases levels of sex-hormone-binding-globulin (SHBG), which in turn binds testosterone and makes it impotent.
Second, the skin has many estrogen receptors in it, so estrogen directly performs a balancing and soothing function at the site of acne.
For women with chronically low estrogen, hormonal acne is often a consistent problem. They have acne 100% of the time.
In women with relatively healthy hormone systems, low estrogen can still be a problem. This is because estrogen levels fall at the end of each menstrual cycle, and are low at the beginning. Having such low estrogen levels during this time can lead to monthly breakouts.
Because hypothalamic amenorrhea is characterized by low hormone, and particularly low estrogen levels, boosting estrogen is one of the main and most helpful ways women with hypothalamic amenorrhea cure their acne.
Because menopause significantly decreases estrogen levels–almost to zero–this is also the primary reason women in menopause can see a re-emergence of hormonal acne after decades of clear skin.
4. Finally, progesterone can also play a role in acne. Progesterone, in high doses, acts as an inflammatory agent, and can cause acne to flare up. Progesterone levels are highest during the days leading up to menstruation, which explains why many women experience outbreaks at this time.
Synthetic progesterone, such as that found in birth control pills, can also cause acne.
Whether a certain variety of the pill causes acne for you or not, however, is entirely dependent upon your own body chemistry and how your body reacts to external hormones. Know only that if you noticed a change in your skin while experimenting with birth control methods, this is most likely why. You may want to consider a birth control method that has a different kind of progesterone in it, or one that has a different progesterone-estrogen balance, to see if it helps relieve your acne.
(I discuss hormonal causes of acne with more complexity and depth in the program I just published, Clear Skin Unlocked: The Ultimate Guide to Acne Freedom and Flawless Skin.)
Aggravators of hormonal acne
There are many factors other than hormones that can worsen hormonal acne. Here is a list of the most common:
Stress: Stress plays an important role. It acts as an inflammatory agent, especially if cortisol levels remain high for a long time. Stress also decreases production of healthy, skin-supporting hormones like estrogen, and increases production of acne-causing stress hormones like DHEA-S. Stress is not necessarily the cause of hormonal acne, but does exacerbate it, and prevent proper healing.
Heat. Heat is inflammatory, and also causes sweat, which can clog pores.
UV Rays. The sun’s rays are some of the most potent acne inflamers out there. Protect the skin on your face with at least an SPF of 20, or consider wearing a hat in the summer months.
Inflammatory foods: grains, dairy, nuts, and omega 6 vegetable oils can all contribute to poor gut health and inflammation.
Dairy: While already mentioned for being inflammatory, dairy deserves special mention because it is a highly hormonal food. Pregnant cows produce several hormones designed for growth. Growth hormones can both cause androgen levels to rise as well as promote production activities that lead to acne.
I have seen enormous success with women with hormonal acne eliminating dairy for their skin. Many people at least anecdotally least respond to dairy with acne more strongly than any other food.
Phytoestrogens: soy and flax are the primary phytoestrogens to be concerned about, with legumes and nuts coming in a distant second place. Phytoestrogens (“phyto estrogen” is greek for “plant estrogen”) have the power to act as estrogens in the body. This may sound like a good thing for acne, but this role is ambivalent and should be treated with caution, especially with the skin. Different estrogen receptors read different kinds of phytoestrogens differently, such that phytoestrogens usually perform estrogen-lowering effects in skin tissue despite what they do in other locations.
Low carbohydrate diets: Having sufficient glucose stores is important for skin healing, and can speed the recovery of acne lesions. Glucose is also helpful for preventing hypothyroidism. Find out 8 of the most important signs you need to eat more carbohydrate here.
Poor sleep: Sleep both enables healing and promotes healthy hormonal production.
Hypothyroidism: Without sufficient levels of T3, the active form of thyroid hormone, in the blood, a woman’s skin cells lack the ability to heal properly. Many women who suffer hypothyroidism suffer chronic acne.
Dealing with hormonal acne
The best thing you can do for hormonal acne is get blood work done and figure out precisely what your underlying problem is. That way you can target the problem and treat it effectively.
Unfortunately not all of us can afford this, so it’s okay to guess. Nevertheless, the better an idea you have of what is going on in your body, the more specific you can be about what to do to fix it.
In general, hormone dysregulation that leads to acne can be broken down into a few broad categories:
1) high testosterone from PCOS (specifically the overweight and insulin resistant type of PCOS),
2) low estrogen from low body fat levels, chronic restriction, or living in an energy deficit,
3) low estrogen from menopause,
4) high progesterone from general hormone imbalance, possibly related to PMS,
5) any of these conditions worsened by stress or hypothyroidism, and
6) any combination therein.
The ultimate hormonal acne solution
The solution to all of these problems is to correct the hormone imbalance. I have discussed methods of doing so above and elsewhere.
So to get rid of hormonal acne for good, check out my manual that has now helped several thousand women overcome their PCOS, or some of my work on hypothalamic amenorrhea.
For women with menopause, it may just “take time” or perhaps medical interventions are appropriate, depending on the severity of the problem.
Medication for hormonal acne?
There are drugs designed to help with hormonal acne. Spironolactone and flutamide are the two primary ones that come to mind (though I don’t recommend taking either of them), as well as birth control.
The reason birth control pills are helpful for acne is because they enforce hormone regularity on a woman’s system. The precise pill that is helpful for each woman varies by her particular condition– but in general, BCPs are comprised of estrogen and of progesterone. BCPs can for that reason 1) raise estrogen levels–which either corrects an estrogen deficiency or helps balance the activity of runaway testosterone–and they can also 2) restore proper balance between estrogen and progesterone, which is important for keeping progesterone levels within their proper parameters.
Some BCPs also contain anti-androgenic substances, such as drospirenone, which is an added benefit for women who are living with androgen excess (but poses some health risks). In all cases, I do not generally recommend that women get on BCP, as it can cause worse hormonal dysregulation in the long run (sort of like handicapping a delicate hormonal system), and does not solve the underlying problem.
Flutamide acts in a similar way to spironolactone, but less effectively, and with more side effects. So spironolactone is typically the drug of choice.
Spiro has been hailed by many acne sufferers as God’s gift to womankind: it decreases testosterone activity. For many women this begets truly miraculous effects. Yet one should step cautiously with spironolactone. If a woman’s primary problem is not testosterone excess, spironolactone will very likely do more harm for her skin than good. (Check out the panicked discussion forums at acne.org to see what I’m talking about.) Moreover, even for those who have testosterone excess as their primary problem, spironolactone merits caution for a variety of reasons. First, spiro usually induces an infamous “initial breakout” which can last anywhere from weeks to months. This isn’t always the case– sometimes women improve immediately. Sometimes they never really do (I never did: in fact, my acne got worse on spiro.) But the typical case is for women to see an initial worsening of their acne, followed by relief in the upcoming months, especially if they increase their dosages.
Secondly, spiro cannot be taken by pregnant women because it induces birth defects, so women cannot stay on spironolactone indefinitely. This is problematic because spironolactone acts as a band-aid on the hormone problem, and does nothing to fix it whatsoever. What spiro does simply is block testosterone receptors. In most cases, if the underlying problem is not addressed while a woman is taking spironolactone, her acne will return once she comes off of the drug. This is why I recommend that women only consider taking spironolactone if they want a “quick fix” while they work on their diet and exercise in order to improve their PCOS.
Finally, spironolactone has a couple of other health concerns. First, it lowers blood pressure, since spiro is actually a blood pressure lowering drug proscribed “off label” for acne. Secondly, it acts as a diuretic, so women on it need to drink water constantly, may not be able to consume alcohol anymore, may have dysregulated salt cravings, and may never actually be properly hydrated. And finally, spiro acts as a potassium-sparing diuretic, such that women cannot eat potassium rich foods, lest they risk the chance of becoming hyperkalemic, which can lead to sudden death. It hospitalized me. An imbalance of electrolytes in the blood is no laughing matter, so women on spiro should limit their potassium rich foods as well as get their potassium levels checked periodically. Potassium rich foods include melons, bananas, potatoes, avocadoes, tomatoes, and leafy greens, among others.
For these reasons, spiro can help, but it cannot be relied on long term. It does not get at the root of the issue–drugs rarely do–and the true path to hormonal help is diet and lifestyle modifcation.
As a final note, bio-identical hormone supplementation can be helpful for women going through menopause. Estrogen patches can release small amounts of hormone into the bloodstream, and can lessen acne considerably. I do not think this is necessarily detrimental to a woman’s health, if it is in fact the case that her estrogen levels have simply dropped off during menopause. However, it does, in my opinion, make it difficult for estrogen levels to rise and hormone balance to re-establish itself on its own. This is a decision best left to the individual and to her doctor.
Hormonal acne is terrible, and for many women can seem incessant, and never ending. Girls are assured growing up that they will eventually out-grow their acne, yet many women see it persist throughout their twenties and thirties, and some actually do not even see the acne manifest until their twenties and thirties. Some women do not even see acne appear until after the birth of their first children, as their progesterone and estrogen levels are flying all over the map.
There are downsides to medication, and large ones. Medication is only ever a band-aid, and it can be a band-aid that in the long run leads to more harm than good.
Playing with hormones is like playing with fire. Sometimes things can go horribly wrong. For this reason, meds may be best left alone, depending on the circumstance and the level of risk a woman is willing to bear.
It is entirely possible as well as supremely healthy to cure acne from the inside out with good diet and lifestyle practices alone.
To do so with an experienced scientist (me!) walking you step-by-step through the process, check out my new program: Clear Skin Unlocked: The Ultimate Guide to Acne Freedom and Flawless Skin.
Clear Skin Unlocked was written specifically for women like you in mind. It’s for when you’re frustrated, looking for answers, and tired of falling through the cracks. In Clear Skin Unlocked I discuss everything I did in this blogpost here at much greater depth, as well as provide a Four Week Jumpstart to Acne Freedom to get you on your way to robustly healthy and radiant skin, for good.
You may also wish to check out my guide on weight loss, or my guide to overcoming PCOS. It may take experimentation and patience, but don’t all good things, in the end?
For some of my favorite topical solutions to acne, check out the antioxidant cleansers, serums, creams and topical probiotics I use.
I was talking to a friend the other day about carb cycling for women, specifically regarding the luteal phase and the best workouts to do while in the luteal phase versus the remainder of the month. She asked me to elaborate, as this was something she had never heard before. She was aware of the 28 day cycle that women experience with their menstrual cycles, but had no idea there were phases inside the 28 day cycle.
For a monthly process that happens internally, it seems a little curious that we as women don’t know as much about our menstrual cycles, but not surprising based on the negative attribution society gives our periods. I hope to elaborate and explain the phases so you can learn the benefits, hormonally, mentally, and physically below.
I am going to take a second and shed a little shade on the patriarchy for not allowing women to feel positive curiosity towards their menstrual cycle. It is often still considered a “gross” or “unattractive” to even discuss menstrual cycles. I am here to declare that now, and in the new year, we will be moving forward in our society and eliminating the taboo regarding our periods.
They happen, and often, and health issues can occur, SO WE ARE GOING TO DISCUSS THEM.
The Phases of the Menstrual Cycle:
1) Menstrual or Bleeding Phase:
Day 1 of bleeding is considered day 1 of your cycle. Typically, a woman’s cycle is around 28 days long. This can vary women to women though.
The menstrual phase can be the most exhausting part of your month, as your body is on overdrive working to shed the inner lining of your uterus. This is the discharge and blood flow we experience during our period. Often menstrual cramps occur as the uterine and your abdomen contracts and releases to help facilitate the passing of the blood and discharge. These cramps can be experienced before the menstrual phase, too, as the uterus prepares for the shedding. More on that below.
Because this phase tends to consume a lot of our energy, we subconsciously move towards introspection and time alone to restore and nourish our mental and physical health. This is not to say a women NEEDS to stay inside and restore during her bleeding phase; I know most women do not have the opportunity to do so. Our body is signaling us to rest, however.
If you are looking for exercise activities that may be best for you during this phase, think gentle but brisk. VInyasa yoga or power walks can be restorative, and there is science behind using exercising as a way to eliminate cramps. This can also be beneficial and balancing to our mood during this phase (and all phases, really.)
2) Follicular Phase:
This phase overlaps with the Bleeding phase. Follicular phase initiates on day one but continues through until day thirteen. During this phase, the pituitary gland promotes egg growth by releasing FSH (Follicle Stimulating Hormone) to your ovaries. In the ovary, the egg growth continues while inside a follicle. The follicle must be strong enough and ready to release the egg, a process that takes thirteen days, hence the thirteen days of this cycle. Blood vessels and other soft tissue are now growing in the uterus due to more hormone secretion caused by the follicle. LH or “Luteinizing Hormone” is also produced at this time. LH basically tells the uterus to start thickening its lining that was once shed during the Menstrual/Bleeding phase.
The female body is naturally more insulin-sensitive in the follicular phase when estrogen levels are highest and progesterone levels are at their lowest. This means the body tolerates carbohydrates in these two weeks better than the rest of the time.
Since insulin sensitivity is at its highest in the first two weeks of the menstrual cycle, and carb intake is free to be at its highest because we tolerate them best, exercise can be more aerobic (long, moderate heart-rate-elevating cardio exercises). It is at this time that you can do your best high performance cardio training. Here you can challenge yourself with longer-term exercises that may be more “stressful” for your body, like long bike rides, tabata sprints, night-long dance sessions, and the like. It is at this time in your cycle that your body can handle the most aerobic stress.
3) Ovulatory Phase:
On the 14th day, the pituitary gland releases enough hormones to encourage the egg to be released. The egg is then ushered through the fallopian tubes via cilia found in the fimbria.
Hormone levels, specifically estrogen and testosterone, are peaking during this time. This can result in higher confidence and libido, a natural process of our body to externally guide us towards finding a partner to reproduce.
4) Luteal Phase:
The luteal phase begins on the 15th and lasts until the end of the cycle. During this phase, the egg cell stays in the fallopian for the first 12-24 hours. It is during this time that the egg cell must be impregnated by a sperm cell or the egg disintegrates. By the end of the cycle the endometrium (the mucous membrane in the uterus that prepares the uterus for pregnancy) is used up, causing the initiation of the new menstrual cycle.
The estrogen and testosterone that was prominent in the ovulatory phase starts to decline. This is when progesterone starts to peak.
In addition, the female body is naturally slightly less insulin sensitive when progesterone levels are higher in the luteal phase (after ovulation, in the last two weeks of the cycle). This means the body does not tolerate carbohydrate as well in these weeks. Women who are diabetic know this well. I’ve read many studies and heard from many women who increase their insulin injections in the second half of their cycle because their blood sugar levels are inordinately high.
Since insulin sensitivity is at its lowest in the final two weeks of the cycle, and carb intake is also at its lowest, exercise should be more anaerobic (this means hard and fast, really getting your heart pumping). It should be focused more on high-intensity interval training, with short bursts of high intensity work, either from brief sprint exercises or from weight lifting. This is an excellent way to sharpen insulin sensitivity while simultaneously burning fat, increasing muscle mass, and spending calories. It also helps the body stay healthy and as stress-free as possible during this time in which the body is gearing up to menstruate and the least capable of handling stress.
A Few Important Things to Note Regarding Our Cycles:
- Estrogen and progesterone are elevated at different points in the menstrual cycle. Estrogen levels tend to be the most dominant in the first and second weeks of the cycle (especially the second week). Progesterone levels are at their highest in the third and fourth week of the cycle. This can affect on our energy levels.
- Period symptoms including blood shed, cramp types and amount, and hormonal effects can vary person to person.
- Birth control is regulating our periods, so if you have been on birth control since you started your period, you may have a different flow then if you were to get off birth control.
Factors that Can Change Your Menstrual Cycle:
We have covered this quite a bit on the PfW blog. But just to remind you- stress causes our bodies to choose which functions are most necessary and appropriate in the moment of stress or danger. More than not, if your body is going through a period of distress, you will not menstruate – as it does not see this period of time as a safe time to reproduce. If you are looking to reproduce, this can be one of the primary things to concentrate on that will assist in conceiving.
- Sleep :
Irregular sleeping patterns will cause disruptive hormone secretion which can cause a lapse or change with your menstrual cycle. It is seriously so important to give your body an appropriate amount of rest!
- Medical Conditions like PCOS or HA:
Both of these conditions can affect hormone levels in the body, in turn affecting our periods. For women with HA (Hypothalamic Amenorrhea), the woman’s body believes it is starving so the body shuts down hormone production. The body does this based on our instincts. Being pregnant while starving is considered life threatening by the body, so the body does not allow reproduction to be a choice. Women with PCOS have an excess of hormone production resulting in inflammation, weight gain, high insulin levels, and more. Read more on PCOS here, and HA here.
- Diet :
This can most definitely affect your cycle. When I was vegetarian for 4+ years, I did not have a single period. I attribute this to the lack of nutrients I was giving my body. If your body is feeling deprived or missing crucial nutrients, it will stop producing the hormones needed to menstruate.
- Routine Changes:
Our body is cyclatory. We see this in our circadian rhythm and our menstrual cycle. If you switch positions at a job, or you move to the night shift, this disruption in your normal schedule can cause your menstrual cycle to shift resulting in longer or shorter cycles, or even missed cycles. This is usually not permanent.
I know this is a lot of information, but I hope it’s useful for you. I really do notice a difference in my aerobic vs. anaerobic activity throughout my different phases, as well as my carbohydrate tolerance and overall energy levels. There are so many factors surrounding our menstrual cycles, especially because women can be so incredibly different. I have included a few extra links to further reading on PCOS and HA below for your reference.
I am always very curious as to how other women adjust to their different phases, or if any of their physiological or emotional responses vary from what I have researched. Drop me a comment with your feedback!
Hypothalamic Amenorhhea further reading:
PCOS further reading:
One of the most common questions I get in emails, on social media and here on the blog is how to overcome hypothalamic amenorrhea.
Most specifically, women want to know: how do you eat for hypothalamic amenorrhea? how much do you eat for hypothalamic amenorrhea? When do you eat for hypothalamic amenorrhea?
Hypothalamic amenorrhea, given that it’s the condition of having starved (intentionally or not) your body into a state of infertility with low calorie diets, fasting, or excessive exercise, requires a lot of nourishment and care.
I personally have done it. (And overcome PCOS at the same time, too.) I have coached countless women through it.
And you can do it, too.
Eat for Hypothalamic Amenorrhea: The General Principle
First and foremost, you need to eat.
Normally, our culture tells people to “eat less, exercise more.”
For hypothalamic amenorrhea, usually the problem however is that you have followed this advice. So now you have to reverse it.
You have to eat more, and exercise less. You have to relax. You have to give your body the nourishment (in the form of calories) it needs in order to consider itself well-fed. You have to reverse the damage done to your hormone signalling mechanisms from months, years, or even decades of under-feeding yourself.
You have to focus on your health, wellness, fertility, happiness, and activities rather than on the specific size of your body.
You have to learn to accept your body as a soft animal, and let it be the size that it wants to be.
Work on appreciating your body for what it does, not for what it looks like. (I know it is easier said than done – here is a great place to start, or here).
Then nourish yourself to high heaven, focusing on eating more, eating plenty, eating bountifully.
Here are the primary pieces of advice I give to all women I encounter with HA:
Eat for Hypothalamic Amenorrhea: Specifics
1. Eat more
You are probably used to eating at least half of what you should be. So eat more. A lot more.
Shoot for at minimum 2000 calories a day. If you are active, make it 2500. Julia Ross says that she believes all women should eat 2300 calories a day.
I don’t recommend counting calories precisely – but it can be important for a lot of people starting out with eating more to keep at least ballpark figures in mind in order to make sure you eat enough.
2. Eat when you’re hungry
Do not go hungry. Whenever your body detects hunger signalling hormones, it decreases thyroid and sex hormone production. In order to properly produce these hormones and get your fertility, sex drive, clear skin, and strong bones back, eat whenever you feel hungry.
3. Don’t stop eating until you’re reasonably full
Many people who suffer from hypothalamic amenorrhea eat regularly but always try to stop themselves from reaching a state of fullness. This ridiculously just deprives your body of good satiation hormones it needs to get “fed” signals. It also sets you up for more hunger faster.
4. When in doubt, eat more rather than less
If you don’t know if you’ve eaten enough, go ahead and eat more. There is nothing to fear – in terms of your health – from eating more food, especially if it’s nice, healthy whole foods. There is a chance you might gain a few pounds, especially if you are under your body’s currently desired set point due to your previous behaviors. But this will not be a bad thing. This will be a good thing because it means reassuring your body it is being fed.
5. Eat when you wake up
While you are sleeping, technically you are fasting.
After dinner and a full night’s rest, you have probably gone 8-14 hours without food.
You might wake up and not be hungry, but that is probably because you have conditioned yourself out of it. So eat when you wake up. Even if it’s just one or two hundred calories, that’ll be enough to break your fast and let your body know that today you are going to eat.
(Also: feel free to eat right before bed!)
6. Forget “3 square meals”
In paleo and other health spheres online, you will often hear people say that you should only eat in 3 square – or even 2 square – meals a day.
They say – don’t graze.
But here’s the thing:
Everybody has a different cure.
For someone dealing with diabetes, eating in meals could help them manage their blood sugar and insulin levels.
But you do not have diabetes.
You have hypothalamic amenorrhea. What works for someone else is not necessarily what works for you. What cures someone else is not necessarily what cures you.
The answer for them is to eat in meals. Your answer is to eat when you are hungry. And if you want to – you can eat all day long. Eat in six small-moderate sized meals if you like. Or eat in 5. Or just simply snack all day, if that’s what you feel like.
The point of eating to overcome hypothalamic amenorrhea is to eat, and to eat bountifully, and to assure your body that you are fed. Restricting yourself to three square meals a day is not the right course of action for you.
Of course, if you still want to eat in three square meals a day, you are more than welcome to. Just make sure that you still hit your 2000 or 2500 calorie minimum, and that you never force yourself to feel hunger between the meals.
7. Get all the macronutrients
Don’t be low carb.
Don’t be low fat.
Eat plenty of both. Your body needs fat to manufacture hormones; it needs carbohydrates to feel good and fed, as well as to produce thyroid hormone.
I recommend starting with 150 grams of carbohydrate a day for overcoming hypothalamic amenorrhea.
Start also with 50 grams of fat.
Get at least 50 grams of protein.
Now of course you’ll notice that adding up 50 grams of protein, 150 grams of carbohydrate, and 50 grams of fat is still much less than 2000 or 2500 calories. This is true. I am not saying that you should eat these amounts, but that they should be your absolute minimum for that particular macronutrient. If you don’t like fat all that much, just make sure you eat at least 50 grams, then fill up the rest of your diet with carbs. If you are the opposite and don’t like carbs all that much, make sure you still get at least 150 grams and fill up the rest of your diet with fat.
Set macronutrient minimums, not maximums.
8. Focus on quantity, not quality
Now, this is the exact opposite of advice I normally give people when they are trying to be healthy.
One of my favorite things to say is that people need to focus on the quality of their food, and care less about the quantity.
In general, this is great advice. High quality food is super important for being healthy in the long run.
But for overcoming hypothalamic amenorrhea, what you actually need more than anything is calories.
So, yes, if you decide to eat all 2500 calories a day in the form of vegetables and fruits and other paleo delights, you are more than welcome to.
But if you focus on being nourishing and then add in some hyper-caloric foods on top of that – like paleo desserts, or simply regular desserts, go right ahead.
I personally got my period back when I added chocolate and oat cereal to my diet. A good friend of mine got hers back when she was going through a period of anxiety and ate a lot of candy. No joke. What your body needs is energy. Quality is important, but you have got to make sure you get the quantity you need. Do what you need to to make that happen.
Beyond food: Overcoming hypothalamic amenorrhea
Bonus point 9. Exercise less
Exercise less. A lot less. If you have cut back on exercise and still haven’t seen results, keep cutting back. Just a couple work outs a week (and not 90 minutes in a spin class) and some gentle walking or yoga is a great way to go. Don’t make yourself work out if you don’t have the energy, and don’t stress your already tired body.
What your body needs now is gentleness. Let it be gentle.
Here is a list of indicators you may be over-exercising.
10. Don’t nitpick your weight
When women are overcoming hypothalamic amenorrhea, they almost inevitably express concern to me about their weight.
They say – “I know I might have to gain weight, but how much?” “Will I have to go back to how heavy I was before?” “Will I become heavier than I was before?”
The thing is – the relationship between weight and hypothalamic amenorrhea is different for everybody. Some gradually gain a little bit of weight until they start to menstruate. Some don’t gain weight but simply benefit from eating more calories. Some people swing up high in weight and then come back down. Others swing up higher in weight then don’t come back down.
So the only advice I can give you, if you really care about your period, your fertility, your sex drive, your strong bones, your clear skin, your good sleep, and your improved calm and mental health, is to learn to be okay with a bigger, squishier body.
I did. You can read a bit about my journey in this post here on being sexy while gaining weight, this one here on our lack of objectivity about our size, this one here on the health benefits of gaining weight for me, or in this book – in which I also give my best advice for body acceptance – here.
So that’s my advice on how to eat for hypothalamic amenorrhea.
Soon I will release a meal plan for those of you who would like more guidance. In the meantime, simply follow these ten guidelines. More food, at more of the time, with more relaxing. It’s simple – but it truly is the trick to eating to overcome hypothalamic amenorrhea.
For more on HA, see my posts Signs and Symptoms of Hypothalamic Amenorrhea, Overcoming Hypothalamic Amenorrhea, and Hypothalamic Amenorrhea Treatment.
Also, if you happen to be one of the 15% of American women who has PCOS – or maybe you have hypothalamic amenorrhea but also don’t quite fit the bill – check out this post on how you can have PCOS and hypothalamic amenorrhea at the same time.
There are many different problems that can cause women to stop menstruating. In rare cases amenorrhea comes from genetic defects and physical abnormalities. These cases usually require medical intervention.
More commonly, women stop menstruating due to conditions like PCOS or hypothalamic amenorrhea, both of which are highly influenced by (and overcome with) diet and lifestyle choices.
Because there are so many possible causes of amenorrhea, the most important thing you can do to overcome a problem with your fertility is to investigate.
Figuring out your problem is the first step towards solving it.
If you once had normal menstrual cycles but now do not, there is a very good chance that some underlying health problem is the culprit. PCOS, like I mentioned, is one potential culprit. Another potential and common culprit is hypothalamic amenorrhea.
In this post I discuss hypothalalmic amenorrhea symptoms and causes. This will help provide a road map for your healing – and will hopefully help you get moving in the right direction.
What is hypothalamic amenorrhea?
Hypothalamic amenorrhea is the technical name for when the hypothalamus stops sending “go ahead and reproduce” signals to the pituitary gland. This results in menstrual cycles being lost, along with other symptoms.
The primary hormone used for this signalling process is GnRH (gonadotropin releasing hormone). The hormones that the pituitary gland would then ordinarily produce but in hypothalamic amenorrhea fails to do so are LH (luteinizing hormone), FSH (follicle-stimulating hormone), and prolactin. Hormone levels that then fall as a result of those hormone levels falling are estrogen, progesterone, and testosterone (usually – though sometimes some of these may stay elevated for complicated reasons).
I like to think of the system a set of dominoes: hormones are produced in a cascade. If there is no agent (the hypothalamus) that knocks down the first domino at the beginning of the process, then none of the dominoes (hormones) get knocked down. Hormones do not get made if the hypothalamus does not tell the pituitary gland to make them.
A staggering 10% of American women suffer from hypothalamic amenorrhea at some point in their lives. And interestingly enough, hypothalamic amenorrhea is not confined to humans! Other primates also experience impaired fertility and lose their menstrual cycles due to hypothalamic dysfunction.
Hypothalamic Amenorrhea Symptoms
There are many symptoms of hypothalamic amenorrhea. These are the most common:
-Loss of menstrual cycles, or sometimes very light bleeding
-Failure to ovulate
-Depression, anxiety, or other chronic mood symptoms
-Cystic acne (occasionally, especially when you simultaneously have PCOS)
-Constant hunger, or changes to hunger cues
-Always feeling cold
-Other symptoms of hypothyroidism, which often accompanies hypothalamic amenorrhea, such as brittle hair and nails
These are problems that are a result of hypothalamic amenorrhea. There are many other signs that may indicate or even cause hypothalamic amenorrhea. They are:
-Low body fat percentage
-Rapid weight loss
-Excessive exercise (different for every woman – challenging workouts 1 or more times a day is generally a good, rough guideline for too much)
-Low fat diet
-Low carbohydrate diet
-Low calorie diet
Causes of hypothalamic amenorrhea
There is a common theme to the “signs” of hypothalamic amneorrhea I listed above:
each of them are a threat to a healthy pregnancy.
The science of this takes us back millions of years.
Way back in human history, when people hunted and gathered on the savannah, it was very important to be in a safe environment while pregnant. Famine could very easily kill a pregnant woman. Starving could very easily kill a pregnant woman. A stressful circumstance like war or a long hike could also be too much for a pregnant woman to bear.
Any sign of an “unsafe” condition on the savannah was life-threatening to a pregnant woman. In order to prevent pregnancy at an unsafe time, the female body developed a very keen sensitivity to starvation signals.
When the body detects “starvation,” it shuts down reproductive function. This prevents you from becoming pregnant while stressed – something which might very well have killed you on the savannah.
Having inadequate food, losing a lot of body weight, exercising a lot, having a low body fat percentage, eating too little fat or too few carbohydrates, or being under extreme emotional duress are all important starvation signals.
When we mimic these life-threatening savannah conditions in the modern world – and we do this so often by starving ourselves for the sake of diets, slenderness, or for atheltic goals – our bodies respond with the old programming of hormonal shut-down.
Hypothalamic amenorrhea special case: birth control pills
One final yet important thing to discuss about hypothalamic amenorrhea is what happens when women come off of birth control pills. Sometimes, women do so without any problems. Yet quite frequently when women come off of birth control they stop menstruating.
The reason this happens is two-fold: 1) while on the pill, the liver is responsible for filtering out “old” hormones. Sometimes hormone surplus builds up in the liver, such that when you come off of the pill the body still feels like it’s on it because the hormones are being released into the bloodstream by the liver.
2) The body does its best to maintain stable hormone levels throughout time. While on the pill, hormones enter the body from the outside. This means the pituitary gland doesn’t have to work as hard as it used to. Then, when coming off of the pill, the pituitary gland is still “lazy” and takes some time to kick back into gear.
Sometimes this problem of being infertile coming off of the pill takes several months if not a year or two to overcome. Sometimes it is primarily a hypothalamic amenorrhea-type problem – other times it is more like PCOS.
In all cases, a nutrient-rich diet full of organic vegetables and fruits, organ meats (here’s a supplement in case you do not like to eat liver), eggs, fermented foods (here are my favorites) and the rockstar superfood cod liver oil that focuses on eating more rather than less will almost always greatly accelerate healing.
I also happened to write a guide on birth control options and how to be as healthy as possible while using them (or not) – which you can read about and download here.
Hypothalamic Amenorrhea Symptoms: What to do about them
The solution to hypothalamic amenorrhea is simultaneously complex and simple. It is complex because every woman is unique and must meet her own specific needs. It is simple because it very often boils down to two very simple principles:
In hypothalamic amenorrhea, women suffer because their bodies want love. They want nourishment. They want reassurance. They want to feel safe and to feel fed. I talk about this in more detail in this post – but really most of all what it all boils down to is eating and love and eating and love.
And that is it for hypothalamic amenorrhea symptoms and causes. What do you think? What are your hypothalamic amenorrhea symptoms? What caused your hypothalamic amenorrhea? Then head on over to this post and tell me all about your progress on your journey overcoming it!
Mannequins do not menstruate, and this is not just because they are made out of plastic.
Here are some images of mannequins in clothes and fully nude. I think this difference is important to pay attention to because seeing mannequins in clothes the majority of the time impairs our ability to process just how specifically manufactured they are to drape clothing just so and to go beyond all reasonable body size aspirations. We don’t regularly see what’s underneath. But what’s underneath is nothing but angles and Barbies.
Note, for example, how hip bones often jut out, which is a way to cause skirts and pants to taper and hang low and stereotypically sexy. Note also how waists are tiny. Note also how legs are longer than the list of activity on my credit card accounts. Which is to say – Long. Disproportionately so.
To which I can only say, holy crap thigh gap.
Mannequins are problematic for a lot of reasons. One of the worst is that this is a subconscious problem. We are well aware of the damage magazines and celebrities and runways and the like do to our self-love, but how often do we consciously acknowledge the power mannequins have over us?
Not very often.
Which is unfortunate – because it has been at least somewhat scientifically proven that mannequins do not have a high enough body fat percentage in order to menstruate.
Two Finnish researchers, Minna Rintala and Pertti Mustajoki, tested standard accepted body fat percentages for women against measurements they made on mannequins (of arm, thigh, waist, and hip circumference are all standard means by which to measure body fat percentage) they found in Finnish museums that were from the 20s, 30s, 50s, 60s, and 90s.
Women need, on average, at least 17% body fat to begin menstruating. The researchers also use the data point of 22 % body fat for regular cycles – though I would argue that this is a statistic biased from the sample being drawn from the super industrialized nations of Western Europe and the United States. For the purposes of our investigation, however, their standards hold since we are largely of industrialized nations such as the US. Our mannequins, we should also note, are typically about 5’10 — the same size as the “fit” models on runways.
In this study, the pre-WWII mannequins had levels of body fat that were consistent with those seen in a healthy, young female of reproductive age population: up to 23 percent, at least. All the way up to 23 percent! That feels incredible – though it makes me sad to write that sentence. Women are known to be quite healthy up to and around 30 percent.
Starting in the 1950s, the estimated body fat on the mannequins decreased significantly. By the 1990s, a significant number of mannequins would not have sufficient body fat to menstruate if they were, you know, actual people. Check out the graph below. The bars detail body fat percentages for hypothetical women of “healthy” body mass indexes of 20-25. In the early decades the mannequin measurements come close, but in later decades fall far below a healthy BMI (note also that the WHO standard for “healthy” BMI goes down to 18.6..though this is contested, as in all things).
So what do we do with this knowledge?
Stop expecting clothes to look on us like they do on mannequins, I think.
And think about that maybe not even as a neutral thing, but as a good thing.
Sure, there are women out there with body types as slender and tall as mannequins with as little body fat, and perhaps naturally so. That’s great – beautiful – natural, what-have-you. I am sure some of them menstruate, especially if they live in less industrialized countries. But the majority of us plain old are not, and its a simple fact that extremely low body fat percentages result in impaired fertility, and, hey, isn’t it cool that we have enough body fat to menstruate?
And, hey, isn’t it cool that we know (more about which forthcoming in a HuffPo article by yours truly) that runway models starve themselves precisely in order to be the same size as mannequins, and that when we do the eat-sufficient-calories-healthy thing we are simply doing the human thing?
And, hey, isn’t it cool that we have lumps and jiggly parts and quirks and scars that only real human beings who love and dance and have sex and laugh can have, and not ones made out of plastic?
My book, Sexy by Nature
, describes a whole foods approach to health, sex appeal, and confidence for real human beings.
The one thing that we talk about most in this community is how to be in hormone balance. How to be fertile. How to enjoy being a woman instead of constantly fighting the basic facts of natural womanhood.
Every day I send emails to women making recommendations regarding food choices, lab tests, and self-love and body image issues. I thought it perhaps best, then, to share with you the differences I have experienced at different points in my life regarding my hormone balance.
Pre-weight loss; pre-exercise-binger; pre-paleo
As an adolescent and very young adult, I had some but not extreme acne. I weighed 137 pounds at my “heaviest,” which at 5’2 is approximately a size 7, and on my larger days a 9. I was also quite stressed out so did not menstruate super regularly, but still menstruated on a fairly regular basis. My periods were not always, though sometimes, incredibly painful, and lasted approximately 6-8 days. I do not have any good photos from the time (and I deleted off of my facebook any of the ones that actually showed my body fatness… choosing to leave tagged only those photos that were most flattered). But here is what I looked like, more or less:
(College “I’m drunk meditating on the side of the road in Beijing” phase)
(College “I’m dressed as a fairy holding the ‘make out’ hat” and “this photo is actually super flattering” phase)
Yet I dug up one from another angle in which I appear a bit less flat:
(Yes, I’m kissing someone, not a phase.)
(College “I’m a crunchy hippy” phase)
In the fall of 2009 I finally achieved the momentum I needed on my low fat, low calorie, vegetarian diet, 90-minute-sprint-workouts-every-day regimen to shrink down to, at my lowest, I think I was probably around 105 pounds. I bounced back up to 115 for the next few years but I still wore size zero, 25 inch waist pants.
In this time period, I experienced:
-the complete cessation and continued absence of anything resembling a sex drive
-an vagina that was, all of the time, as dry as Oscar Wilde (if not more so-if such a thing is possible)
-a completely absent menstrual cycle
-constant hunger (though I did not know it at the time since I had yet to experience the real cycle of intuitive eating yet)
These five bullet points might not look like much – but when you’re a woman who prided herself on her voracious sex drive and then it completely vanished, and you became infertile, and had acne… the thing was, I always suspected that my weight was to blame for my acne, at least in part, but I always thought it still worth the trade off. I’d rather have acne and be thin than be fat with clear skin.
This is what I looked like in this time period:
(“I cover my face because the sun burns my acne” phase)
(“I have eight pack abs, so what, b*tches?” phase)
(“Thigh gap!” phase)
(“Holy crap I’m so comfortable in this tiny body please don’t take it away” phase)
Lots of women probably menstruate at the size I was in the photos above. They probably had sex drives. I did not. All I had managed was to salvage my skin, mostly by reducing the fiber and protein contents of my diet, as well as by adding a topical probiotic to my daily regimen and ceasing to use conventional soaps and such. I had also managed to ovulate a few times, mostly by radically reducing stress or by having a particularly potent sexual encounter, but I did not have a true menstrual cycle, not by a long shot.
I also ate paleo the whole time, so anyone who says all you need to be healthy is a paleo diet is woefully uninformed.
Then came a time in which I prioritized my work and energy over everything else, and was extraordinarily stressed out. I gained weight. fast. And surprise of surprises, I menstruated. (Literally, it smacked me right out of the blue.) My sex drive had steadily increased up until that day, and has remained not just “oh thank god sex doesn’t disgust me anymore” or “well sure I’ll kiss you I guess” but “holy crap I want to do it now” since then. I have continued to cycle since. And my skin has cleared, almost entirely (to be fair: my stress has also been radically reduced), and I have, to my mingled dismay/resignation/fear/acceptance, continued to gain weight.
This is what a Stefani that can menstruate looks like:
(“I’m such a big deal I do photoshoots and holy crap I’ve got hips” phase)
(“Holy crap back fat stomach fat” phase)
(“Bear in mind that the camera on my phone elongates and I’m not nearly this tall or slim” phase)
If you want to see a video of me partner dancing in a body that menstruates (which is, still, a size or two smaller than I am now, I am more than happy to invite you to do so, here).
Looking at these photos, you might hardly see a difference. So what, you say. “She’s not overweight.”
No, of course not. I agree. I mean — there is definitely a difference, and just about everybody in my life has remarked upon it. My thighs are about 3 inches thicker, each. My face “fuller.” My abs, gone. My periods, pain free, and quite short (thanks to paleo!). I used to be a size 26 jean, and last night I wore a 30. I can no longer wear any outfit with carefree abandon — I now have to worry about placement and what the most flattering cut is and how to handle the parts of my that jiggle.
Some people say I look better. I don’t know. Can I compare? I don’t know. I know I look different, and that’s all that has mattered, and all that made this, while on one hand the best thing in my life, also, on the other hand, one of the harder things I have done (at least in 2014 🙂 ).
It’s been a small difference, but I had to read my own writing, and reach out to others for reassurance, and make a deliberate effort to arm myself against the tides of psychological baggage that tells me putting on weight makes me a failure, marks me as lazy, and renders me unfit for love. I believe so strongly in allegiance to our natural bodies, but that does not mean that I still did/do not have to fight for it on my “bad” days. Only because the gains I have had have been so great — I’m never giving up sex again — and because I have such loving, supportive people in my life, and because I’m currently finishing editing a book all about self-love, was I able to fall asleep peacefully at night rather than in a fit of frustrated, frightened tears.
Our society makes it hard. Even at my own relatively small weight gain and size. It makes it hard to “lose ground.” It makes it hard to “backslide.” But that doesn’t mean we give up. We remind ourselves of our own inherent worth, and we push through, and we change the face of womanhood one woman at a time.
I am no longer a fitness champion. I can no longer compare myself to Victoria’s Secret models. But I am different. I’m a new kind of sexy (more about which in coming days). I am me. And I am happy, and fertile, and healthy, and alive.