Reasons For A Missing Period

There are many reasons for a missing period, and you shouldn’t ignore any of them. Left untreated, the hormone imbalances associated with missing periods can wreak havoc on your cardiovascular, neurological, and bone health. 

In this article, I will explain common reasons that can cause your period to stop or never start in the first place, plus what you can do about it.

Reasons For A Missing Period

Amenorrhea is the medical term for the absence of menstruation. There are two types of amenorrhea — primary and secondary amenorrhea. It can be temporary, intermittent, or permanent due to dysfunction of the hypothalamus, pituitary gland, ovaries, or uterus.

Primary Amenorrhea

Primary amenorrhea is when menarche (your first-ever menstrual period) does not occur by 14 years of age if you lack other signs of puberty, and 16 years of age whether you’ve hit puberty or not. 

If you have breasts and pubic hair but haven’t had a period by age 16, you should call your doctor for a complete evaluation. You should also have a conversation with your doctor if you don’t have a period or any other signs of puberty by age 14. Both scenarios can indicate serious issues that should be investigated.

The most common reasons for primary amenorrhea include:

• Anatomical defects
• Too much follicle-stimulating hormone (FSH) 
• Too much prolactin 
• Problems with the hypothalamus
• Polycystic ovary syndrome (PCOS)

Secondary Amenorrhea

Secondary amenorrhea is when you’ve previously had a period (regular or irregular), and it has gone missing for a specific time period, depending on your cycle’s patterns. 

If your period was regular then the diagnosis of amenorrhea is made after three months of more loss. If your period was lighter or infrequent, then the diagnosis is made after six months or more of a missing period.

Some examples of what can cause secondary amenorrhea include too much prolactin, hypergonadotropic hypogonadism (reproductive glands are too small), primary ovarian insufficiency, eating disorders, or chronic conditions.

What Causes A Missing Period

Losing a previously established period can result from high stress. When you’re stressed, the body interprets the environment as unsafe and puts reproduction on hold. Stress can be in the form of mental or emotional factors, infections, over-expenditure of energy (over-exercising) or low caloric intake. Stress of any kind can make your period go missing.

We’ll explore some of these stressors, as well as other conditions that contribute to a missing period.

Nutrition And Lifestyle Factors

Undereating or eating disorders can lead to a missing period. In addition, overexercising or not eating to meet your exercise expenditure can also lead to a loss of menstruation. Feeling super-stressed and not sleeping enough? Definitely contributing factors for missing periods and may lead to a diagnosis of functional hypothalamic amenorrhea (FHA).

Functional Hypothalamic Amenorrhea

Functional hypothalamic amenorrhea (FHA) is a diagnosis of exclusion. That means that your medical provider investigates all of the possibilities, and when your condition doesn’t meet criteria for another condition, your diagnosis is FHA. 

FHA is often the result of overexercising, low body weight, and stress. It is associated with eating disorders like anorexia nervosa and bulimia. 

It is important to investigate and address the cause of FHA. While your provider may be quick to offer you the pill to restore your period there are two things that you should know before going that route. The first is that the bleed on the pill isn’t your actual period. This is important because unless this is explained to you, you may be left with a false impression that you’ve regained your period only to find it is still gone when you stop taking it. 

Secondly, The Endocrine Society guidelines does not recommend the use of the pill as a treatment for hypothalamic amenorrhea in order to induce a bleed or to address bone mass. This is because the pill suppresses ovarian function and would make it impossible to evaluate if the period is restored using other therapies. In addition, they recommend that medical providers educate their patients that using the pill may mask underlying issues that can lead to a missing period.

Thyroid Disease

Thyroid disorders can lead to menstrual cycle irregularities. Although thyroid disease is well-recognized as a cause of amenorrhea, it isn’t always an area that doctors test or address right away. 

If you’ve lost your period, having a thorough evaluation of your thyroid is essential. 

Polycystic Ovary Syndrome

Polycystic ovarian syndrome (PCOS) is a common cause of anovulatory cycles (lack of ovulation) and amenorrhea. PCOS is a condition that is common and often overlooked, leading to a delayed diagnosis. 

Experts estimate that 1 in 10 women have PCOS. If your period is missing and you have other symptoms like unexplained weight gain, acne, hair loss, hair growth on your chin or chest, and blood sugar issues then it is important that you bring up treating your PCOS with your doctor.

Post-Pill Amenorrhea

After discontinuing birth control, you may find your period comes back right away, or it is delayed in returning. With the pill, we can see a loss of menstruation for four to six months after discontinuing. This is called post-pill amenorrhea and affects an estimated 3 to 6% of women.  

With the Depo-Provera injection, a return to a normal cycle may be delayed by a year or more.

It’s essential to recognize that many doctors prescribe the pill for irregular or missing periods, and while it can cause your endometrial lining to shed, it does nothing to address the underlying issue. If you stop the pill, then we’d expect your regularly scheduled medication-induced bleeds to stop too. This may be the reason for higher post-pill amenorrhea statistics. This is also why we should know why your period is missing before prescribing the pill.

If you’ve come off birth control and lost your period, don’t assume it is post-pill amenorrhea. Work with a provider to help you get the right lab testing and understand the cause of your amenorrhea.

Perimenopause

Perimenopause marks the time where our fertility begins to decline as we transition into menopause. During this part of your life you may find that your periods become irregular, sometimes even skipping a month. 

Just because your period may go missing does not mean that you can’t still get pregnant. In fact, this is a good warning for anyone with a missing period because ovulation precedes menstruation, which means you could ovulate spontaneously without even knowing it. 

If you suspect this is you, please read more about perimenopause symptoms and management.

Breastfeeding

Sometimes mother nature gives us a break for an extended period postpartum. If you’re currently breastfeeding, then you may not have a period, and that is normal. For those who exclusively breastfeed, they may not see their period return for the entire duration of breastfeeding. Sometimes it comes back with night weaning and other times, despite breastfeeding, it starts up within a few months of birth. 

A missing period while breastfeeding doesn’t mean you’re completely protected from pregnancy though — remember that ovulation comes before menstruation. 

How Long After You Miss Your Period Should You Worry?

If you’re sexually active and miss your period then it’s a good idea to take a pregnancy test. In general, once you rule out pregnancy, we are not concerned about a missing period until it has been several months.

If your period has been regular and does not return within three months then it is a good time to see your doctor. If your period is typically irregular then we become much more concerned after 6-9 months of its absence. In any case, if you’re concerned and feel something more may be going on, talk with your medical provider. All of your health concerns are valid – no exceptions –  and your doctor should treat them as such. 

What To Do To Get Your Missing Period Back 

Partnering with a clinician is essential for helping you investigate why your period is missing. It’s also important to know that there are things you can do right now to restore your period and optimize your hormones.

1. Get The Right Tests

Talk with your health care practitioner about ordering the following tests:

• Pregnancy test
• Follicle-stimulating hormone
• Luteinizing Hormone
• Estradiol 
• Prolactin
• Thyroid panel
• Total and free testosterone
• Adrenals

Pregnancy Test 

This might seem obvious, but the first step for a missing period in a sexually active woman is a pregnancy test. A lot of women will take a home test when their periods are late, but your doctor will want to confirm your pregnancy status ASAP.

Follicle-stimulating Hormone, Luteinizing Hormone, and Estradiol 

Follicle-stimulating hormone (FSH) and luteinizing hormone (LH) are brain hormones that guide your ovaries. Take a look at this article to understand your menstrual cycle and the roles of each hormone. 

Estradiol is a form of estrogen that can help you understand how and if your ovaries respond to their signals. In addition, very low estradiol levels are associated with bone loss and other unfavorable changes, so it can be helpful to evaluate.

Prolactin 

Prolactin is a hormone that helps with milk production in a breastfeeding woman. It blocks you from having your period by inhibiting the secretion of FSH. The mechanisms that cause thyroid-stimulating hormones (TSH) to rise can also lead to an elevation of prolactin, which is why both are important to test. 

A condition called prolactinoma, a benign brain tumor, can lead to elevations in prolactin, which is why a missing period needs to be taken seriously.

Thyroid Panel 

Your thyroid could be to blame for your missing period since the thyroid and menstrual cycle are intimately connected. Evaluated TSH, free T4, free T3, TPO and thyroglobulin antibodies are important to measure in anyone who is having irregular or absent periods.

Total And Free Testosterone 

Total and free testosterone will often be elevated in PCOS. Elevations of androgens can cause your period to become irregular and even disappear. 

Adrenals 

Your adrenal glands, stress, and periods are all connected. If they are not functioning properly we can certainly see issues with menstruation. In addition, a rare autoimmune condition known as Addison’s disease can be a cause of early menopause or primary ovarian insufficiency.

Your provider may order a morning adrenocorticotropic hormone and cortisol test via blood or 4-point urinary cortisol and cortisone with DHEA-S.

2. Build A Nutrient-dense Diet

It’s not simply a matter of calories, but also nutrients that your body needs to menstruate and ovulate regularly. Creating a whole foods diet focused on high-quality fats and proteins like wild-caught fish, nuts, legumes, and grass-fed meat can help deliver what your body needs. 

Including plenty of fiber and antioxidant-rich vegetables as the foundation of your diet is also important to help balance your hormones. You can grab a free meal plan and recipe guide to get you started.

You may also want to consider including an iron-free multivitamin in your routine. Unless you know you need iron, it’s best to skip it because iron can cause problems in a woman who isn’t menstruating and isn’t deficient.

Myth: Losing your period because of your diet is a sign of a healthy diet.

Just no. I’ve seen this one too many times on social media where someone tells people that their period is unnatural, a sign of a hemorrhage, or makes some other outlandish claim that isn’t rooted in science by any means. Your period is a natural process and losing it during your fertile years is not. If you’re on such a strict diet that it changes your hormones’ ability to operate normally, then it’s time for a change.

3. Keep Track Of Your Data

Track your symptoms — mood, energy, sleep, stress, digestion, skin, and anything that might be a sign of your period. Keeping track of what you're experiencing not only motivates you to keep up the positive change, it can also provide you clues as to what is and isn’t helping your health. 

4. Re-Evaluate Your Exercise Routine

If you’re feeling completely wiped out from your exercise, struggling to recover days later, or feeling like you might throw up during it, odds are the intensity is dialed way too high for your body. 

Low exercise tolerance coupled with a missing period means it’s time to re-evaluate your routine. 

In addition, you need to be sure you’re meeting your caloric needs for this level of energy expenditure. Remember, your body needs to feel safe to ovulate and menstruate. Feeling like it’s always running for its life or in the midst of a famine will not achieve that.

Myth: Losing your period is a normal part of a good fitness routine.

It’s not. And I’ve had many patients personal trainers or coaches tell them it is and then recommend they just get on the pill if they are concerned. First and foremost, trainers and coaches aren’t qualified to comment on your hormones or a medication you should be on. Second, this is not normal for a female body and is a sign of dysfunction of your endocrine system.

5. Tend To Your Sleep

Our circadian rhythm is intimately tied to our menstrual rhythm. Lack of sleep or low quality sleep is a stressor to your body and it is important to tend to when you’re trying to recover your missing period. 

Sleep in a completely dark room and avoid all light-emitting electronics (TV, computer, cellphone) for two hours before bed. Take steps to wind down before bed, and consider giving your system extra support if you’re struggling to get the quality sleep you need.

7. Stress Management

When stress goes high, whether emotional or physical, your body is all hands on deck in the name of survival. That means shifting hormone activity into cortisol production and away from reproductive goals (ie, ovulation). 

This is why high stress can cause your period to go missing, and sometimes you feel its effects a month later. Try a variety of practices like meditation, deep breathing, prayer, walks, float tanks, journaling, acupuncture, massage, and even getting a mani-pedi to find what works best for you in managing your stress.

8. Get Proper Nutrients

Your nutrition is vital to recovering your period. Not just calories, but nutrients as well, signal to your body that the environment is safe — safe enough for baby-making. 

Whether or not you want a baby, the body needs to know the environment is conducive to having one so that you ovulate. What to eat can feel confusing, so I’ve simplified it in this free hormone balancing meal plan and recipe guide. These recipes are also gluten and dairy-free, so if you can’t tolerate those, I’ve got you covered. 

Optimal vitamins, minerals, and other nutrients help you better manage conditions like absent periods, PMS, PCOS, and PBCS symptoms. Your hormones depend on many nutrients to perform at their best. 

For example, vitamin D has been shown to play an essential role in having regular periods. In one study it was found that 13% of women with low vitamin D (<30 ng/mL) reported having amenorrhea. 

If you have a history of using the birth control pill, it’s important to note that nutrient deficiencies can develop if you’re not tending to your diet and using a quality multivitamin or prenatal. Key nutrients depleted by the pill include:

• Vitamins B2, B6, B12, and folate
• Antioxidants
• Magnesium
• Zinc
• Selenium
• CoQ10

You need these nutrients for more than just your ovaries. They are also crucial to support your adrenals, your thyroid, and they help enable your pituitary (the master gland) to do its job. 

How To Get Your Period Back

Taking the steps listed above can help you make progress towards recovering your period. But it’s important to note that with conditions like PCOS, PBCS, hypothyroidism, and the loss of your period can be a lot to navigate on your own. I recommend working with a naturopathic physician or functional medicine practitioner to help you understand the specific needs of your body and help you create an individualized plan for healing.

References

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2. Amenorrhea: Evaluation and Treatment. American Family Physician.
3. Williams, N. I., Leidy, H. J., Hill, B.R., et al. Magnitude of daily energy deficit predicts frequency but not severity of menstrual disturbances associated with exercise and caloric restriction. American Journal of Physiology-Endocrinology and Metabolism. 2015. 308. 29-39.
4. Gordon, C.M., Ackerman, K.E., Berga, S.L., et al. Functional Hypothalamic Amenorrhea: An Endocrine Society Clinical Practice Guideline. The Journal of Clinical Endocrinology & Metabolism. 2017. 102. 1413-1439.
5. U.S. Department of Health & Human Services. Polycystic Ovary Syndrome. OASH Office on Womens’ Health.
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