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From an evolutionary point of view, this is a survival tactic for both mother and baby.

      The main triggers for hypothalamic amenorrhoea that I see on a recurrent basis are stress, diet and overexercising – or, usually, a combination of all three.

       Stress

      You’ve probably heard of cortisol, the stress hormone. It influences production of female hormones by telling your brain that you’re under stress (even if you don’t realise it) and to halt ovulation until you’ve overcome it. Unfortunately, we are so used to living our lives in ‘turbo-power mode’ that we’ve forgotten what it’s really like to press the pause button, or even that it exists. I frequently meet real-life superwomen. They typically have several children, a zoo-worth of animals and a husband who isn’t very domesticated. And often an irregular cycle. Recently, I called one of these superwomen into my room and apologised that the clinic was running late. She said, ‘Oh, don’t worry; it’s been lovely to sit and read a magazine and have some time to myself …’ So before she’d even sat down I was pretty certain of what the problem was, although it can be a tricky one to solve because so many women have lost sight of how important it is to take that critical time for themselves.

       Dietary factors

      If you’re not eating enough to be able to provide the energy requirements of your own body, you’re not going to be able to sustain a healthy pregnancy. So here again, your brain shuts the system down, saving the energy and nutrients that would otherwise be used on ovulation. Fat tissue is one of the sites of oestrogen production, so women with very low body fat may not produce enough oestrogen, which is made from a specific type of fat called cholesterol. Fat tissue is also able to send signals to the brain to tell it whether there is enough of the stuff to maintain a pregnancy. Female hormones are made of fats, so if your diet is devoid of good, healthy fats, your body doesn’t have the right ingredients to make the goods.

      I recently had a difficult conversation with a patient who had become a vegan right around the time that her periods stopped, but she was convinced that couldn’t be the reason why, because to her, veganism was the healthiest diet out there. However, any extreme change in diet can lead to nutrient deficiency (see Chapter 14).

       Overexercising

      Adrenaline is the ‘fight-or-flight’ hormone that is going to save you from that wild bear. Nowadays, there are very few bears or other life-threatening mammals running around, but your body doesn’t know the difference between thrashing it out on the treadmill or running from said bear. Your body senses this exertion as a stress and says to your ovaries, ‘Hold your horses! This woman is in danger – do not ovulate.’ It’s common for long-distance runners to lose their periods, but it’s not just running that can be a problem. Any intensive exercise can have the same effect. Many women that I see are training like athletes, then running off to their full-time jobs, families and social commitments and it can be too much for their bodies to cope with. They can also be putting themselves in a calorie deficit if they’re not eating enough, which takes us back to dietary factors. All of this – and how to address it – is discussed further in Chapter 15.

       Post-Pill amenorrhoea

      After stopping the contraceptive Pill you will have your usual bleed, assuming you stopped at the end of the pack. But when is your next period going to come? That’s the million-dollar question. Some people will go back to having a regular cycle pretty much straight away. Others sit and wait … and wait … and wait some more. And in my experience, this is much more common than the textbooks say. But if the Pill is out of your system after a day or so, why does this happen? There is no single answer. It’s likely to be a combination of three factors:

      The Pill essentially takes over your natural hormones, so it can take some time for them to get back into sync to the point where they can resume ‘business as usual’.

      The triggers for hypothalamic amenorrhoea (see here), which I find to be very common.

      The possibility of an underlying problem such as PCOS, which has been masked by the Pill.

       Premature menopause

      Also referred to as premature ovarian failure/insufficiency (POF/POI), premature menopause is actually a misnomer. You run out of eggs when you go through the menopause, whereas with POF/POI your ovaries stop responding, despite still having eggs on the shelf. I can’t even count the number of times I’ve had women come and cry in my clinic room, convinced this is happening to them when their period has gone AWOL. It takes a very simple blood test to confirm or refute the diagnosis (oestrogen levels will be low and FSH will be through the roof) and, thankfully, it’s pretty uncommon, affecting about 1 in 100 women before the age of forty, and 5 in 100 before forty-five (the average age in the UK for menopause being about fifty-one years). It tends to run in families, so asking your mum when she went through the menopause is helpful.

       Hormonal diseases

PCOS is the most common hormonal disorder that can affect your periods and is discussed at length below. Diseases associated with hormones that seem unrelated to your ovaries can also have a dramatic impact due to the interconnection of the hormonal system as a whole. Thyroid disease (high or low levels) is particularly common in women, and changes in thyroid hormones have both a direct and indirect effect on female hormone levels, which can change the timing of your periods and also how heavy they are (see here). A thyroid blood test can be done by your GP, and this can reveal thyroid problems in many women. Type 1 diabetes (where your body is unable to make insulin) and type 2 diabetes (where your body becomes less responsive to insulin) are both associated with irregular cycles due to the interaction of insulin and female hormone production.^{9, 10} Type 2 diabetes can also be associated with PCOS, as described below. There are, of course, other hormonal diseases which, although less common, will be checked with blood tests.

       Polycystic ovarian syndrome (PCOS)

      This is the most common hormonal disorder seen in women, with some studies suggesting that up to 1 in 5 of us is affected. It is diagnosed based on the presence of two out of the following three characteristics known as the Rotterdam Criteria:

       Irregular or absent periods

       Signs of excess male hormones including excess body/facial hair or acne or high levels on a blood test

       Polycystic ovaries seen on an ultrasound scan

      PCOS does not typically cause pain. Polycystic ovaries are often seen on scans to investigate lower abdominal pain, but are not the cause of this pain.

       What causes PCOS?

      PCOS is a syndrome (i.e. a collection of symptoms), so it’s not the same cause in everyone. It is a complex mash-up of your in-built genetics, epigenetics (which is how genes are turned on and off) combined with environmental aspects of how we live our lives now.

      One of the key features of PCOS is insulin-resistance, which is found in about 70 per cent of sufferers. This is when your body is able to make plenty of insulin (one of the key hormones responsible for keeping your blood sugar under control), but your tissues are less sensitive to it, and therefore you have to ramp up production to maintain the same response. The problem is that insulin forces your ovaries to convert oestrogen to the male hormone testosterone, which stops ovulation (goodbye regular periods) and gives you all the fun hormonal side effects (hello acne, excess hair, mood swings …). Blood tests and ultrasound scans are carried out to confirm it and rule out other causes of the symptoms.

      So what causes PCOS in those who are not insulin resistant? The adrenal glands. As well as making cortisol, and the fight-or-flight hormones adrenaline and noradrenaline, they also make testosterone and its precursors, resulting in the same effect on your ovaries.

      

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