How Is FHA A Reason For Irregular Periods In Women?

Did you know that around one million healthy eggs are present in the ovaries and as the puberty starts hormone like Follicle Stimulating Hormone (FSH), Gonadotropin hormones, Estrogen, Luteinizing Hormone (LH) and Progesterone causing release of one egg cell called ovum each month.¹ As the women ages and reaches late forties, the concentration of estrogen and FSH declines, the menstrual cycle or periods becomes irregular and stops naturally at menopause (permanent end of menstrual cycle in women). But, sometimes women experience no or irregular periods even at a very early age. So, if you or someone you know is experiencing such symptoms then you or the other person might be suffering from Functional Hypothalamic Amenorrhea (FHA). In this article we will explain to you what FHA is and how it causes irregular periods. Read through to know more. 

What Is Functional Hypothalamic Amenorrhea?

Functional Hypothalamic Amenorrhea (FHA) refers to ovaries malfunctioning due to abnormal levels of pituitary gonadotropin² (hormone regulating the ovaries for development of sexual organs).³ The diminished hypothalamic pituitary gonadotropin causes loss of continuous secretion of LH and FSH, which results into less production of estrogen. Reduced estrogen leads to chronic anovulation or a condition when the egg is not released during periods.⁴ Anovulatory cycles act as barriers to conception; thus, it's important to address and find its root cause.

Influence Of FHA On Women’s Health

Functional Hypothalamic Amenorrhea has extreme effects on women’s reproductive functioning and causes conditions as stated below.

• Infertility - Women suffering from FHA are unable to become pregnant naturally. Also, FHA increases the risk of miscarriage and preterm delivery if these women become pregnant spontaneously or immediately after the fertility treatments due to low Body Mass Index (BMI).⁵
• Growth of reproductive organs during puberty - Long-lasting and untreated FHA affects the growth and development of women’s secondary and tertiary sex characteristics like rounded hips/figure, reduced ability to generate muscle mass at a fast rate, decreased upper body strength, onset of menstrual cycle, and increased body fat composition.⁶
• Delayed menarche - FHA causes delayed occurrence of period for the first time during puberty.⁴
• Changes in the uterus muscles and urogenital mucosa - ⁴ FHA can cause vaginal dryness due to less lubricating mucus and the genital skin becomes pale.
• Abnormal weight gain - Functional hypothalamic amenorrhoea can cause excessive weight gain and undergrowth of baby in the uterus during pregnancy.⁴
• Increased risk of Osteoporosis (weakening of bones) - FHA can exert a negative effect on the bones due to less bone mass and decrease estrogen which is crucial for proper bone metabolism. Thus, there is higher risk of osteoporosis in women with FHA.⁴
• No or irregular periods in young women - FHA causes termination or irregularity in menstrual cycles due to decreased estrogen. It occurs mainly due to factors like stress, intense exercise and improper eating.

Let us get more insights into another common condition causing irregular periods in women- Polycystic Ovary Syndrome (PCOS). And understand how FHA is different from PCOS. ⁷

Difference Between Polycystic Ovary Syndrome And FHA

FHA is often confused with Polycystic Ovary Syndrome (PCOS). These two conditions are the most common causes of secondary amenorrhea or irregular periods, with FHA contributing 1-2% of the cases and the latter 2-13%. ⁸ PCOS is often associated with increased body mass index (BMI) or obesity whereas FHA is uncommon in overweight women. ⁸

Women with FHA can experience late menarche (onset of periods) if body fat percentage is low. On the other hand, PCOS causes periods to start early during puberty in women if BMI is high.⁹ Also, FHA leads to amenorrhea or absence of menses/period for more than 3 months (having less than 3 menstrual cycles per year), whereas PCOS is more related to oligomenorrhea or 4-9 menstrual cycles per year. Also, Let’s dive in and learn more about Amenorrhea to understand it in detail.

Understanding Amenorrhea

Normally, the menstrual cycle lasts between 21-35 days. But factors like stress or hormonal imbalance affect the normal functioning of ovaries leading to irregular periods or Amenorrhea. It is defined as the absence of menstruation/periods in women during the reproductive years (approximately 12 to 49 years).¹⁰  Let us dig inside and understand the types of Amenorrhea.

What Are The Two Types Of Amenorrhea?

1. Primary Amenorrhea: A condition when a woman never gets menses/period or there is no initiation of menstruation¹¹.
2. Secondary Amenorrhea: It is a condition when there is absence of periods in previously menstruating females.¹² Secondary FHA is one of the most common types of secondary amenorrhea.¹³ 

Now that we learnt about the link between Amenorrhea and Functional Hypothalamic Amenorrhea, we need to know about the causes of FHA in females.

What Causes  FHA?

Primary amenorrhea is caused majorly due to birth defects, damage to endocrine (hormone secreting) gland, pregnancy or tumor.¹⁴ Whereas, functional Hypothalamic Amenorrhea (type of secondary amenorrhea) is often linked with excessive exercise, weight loss, stress or the combination of above mentioned factors. Let us learn about them in detail here.

1. Weight loss: Women who have normal weight may experience amenorrhea but those who have very low body weight are at higher risk of FHA. ¹⁵ In fact, a hormone known as Ghrelin which is responsible for stimulating hunger prevents the secretion of pituitary gonadotropin hormones and results in long-time amenorrhea.⁴
2. Stress (physical/psychological/emotional): The adolescent crisis (often faced by girls during or post puberty) causes menstrual irregularities and hypothalamic dysfunction. Stress instantly increases the concentrations of corticotropin -releasing hormone  in the central nervous system which in turn stimulates Adrenocorticotropic hormone. The increased level of these hormones prevents the release of Gonadotropins thus causing FHA.⁴  
3. Excessive exercise: A research revealed that 50% women who exercise regularly have minor menstrual disorders and around 30% of those women have amenorrhea. Furthermore, studies have shown that women who exercise for at least 8 hours/week can display FHA due to amenorrhea and may experience absence of periods for 6 or more months. ¹⁵

Diagnosis And Treatment Of FHA

The best way to diagnose FHA is to test other disorders causing irregular periods like PCOS and eliminate them. The basic approach for FHA diagnosis is testing the levels of gonadotropin and knowing if there is low or no secretion of hormones from ovaries. An important diagnostic tool is Gonadotropin releasing hormone stimulation test to measure gonadotropin level. The gonadotropin helps to make testosterone in males and estrogen along with progesterone in by ovaries. The positive result confirms FHA. 

Treatment Of FHA

The treatment of functional hypothalamic amenorrhea (FHA) should be started as early as possible. Fortunately, FHA is reversible and as per the endocrinology guidelines, a multidisciplinary approach can be improved by resolving the behavioral issues like overexercising, stress and eating disorders.¹⁶ 

The treatment thus primarily involves lifestyle modification. Only after 6-12 months when non-pharmacological is ineffective, then pharmacological treatment should be applied to treat FHA. The pharmacological treatment includes use of hormone doses. Also, the most effective therapy for treating FHA  is transdermal cyclic estrogen-progesterone therapy. It has a positive effect on brain functioning and reducing anxiety in FHA patients.¹⁷

Concluding Remarks

Functional Hypothalamic Amenorrhea (FHA) is a common disorder in adolescents and women during reproductive ages. ¹⁷ It causes no or irregular periods due to abnormal levels of gonadotropin in young females. Long-term amenorrhoea can not only affect reproductive health but also leads to bone weakening, heart disorders, anxiety, depression.¹⁷ Diagnosis followed by appropriate treatment  must be done as early as possible considering the medical history of the patient . Thus, if you are experiencing any irregularity in periods, then it is advisable to immediately get tested for gonadotropin and seek medical help.