My labs are normal. Why is my period missing?

Jun 25, 2024 | Blog

If you’ve recently come off the pill only to realize your period is MIA, you’re not alone.

Post pill amenorrhea can happen from prolonged birth control use, especially if you tend to skip avoid the placebo pills leading to thinning of the uterine lining. It may take between 3-6 months to have a regular period after stopping the pill.

However, women who went on birth control for the purpose of bringing on a period or regulating an irregular period are at a greater risk of having irregular cycles and amenorrhea after they come off the pill. In this scenario, it is less likely that you have post-pill amenorrhea and much more likely that an unaddressed hormonal imbalance is causing your lack of period.

Hypothalamic Amenorrhea impacts 17.4 million women worldwide and account for 20-35% cases for secondary amenorrhea according to the American Society of Reproductive Medicine. However, these numbers may be under reported due to the confusing overlap between HA and PCOS.

Hypothalamic amenorrhea (HA) is a diagnosis of exclusion. This means ruling out all other possible causes of a missing period is a must. With that being said, lab values – estrogen, FSH, and LH, among others – are often used as further proof of the condition in women who undereat and/or overexercise. But what’s the verdict when a woman’s lifestyle screams “HA,” but their lab values are normal?  Before we dive into what this means, let’s first review the main hormones of interest:

Estrogen 

Estrogen is a sex hormone essential for reproductive health. It also plays a role in circulation and blood flow, bone metabolism, collagen production, and cognitive function/memory. The ovaries primarily produce estrogen during reproductive years, but the adrenal glands and fat tissue also secrete estrogen.

Although it often falls under the umbrella term “estrogen,” there are actually three major forms: Estrone (E1), Estradiol (E2), and Estriol (E3).

  • Estrone (E1) is the primary form of estrogen that your body makes after menopause.
  • Estradiol (E2) is the primary form of estrogen in your body during your reproductive years. It’s the most potent form of estrogen.
  • Estriol (E3) is the primary form of estrogen during pregnancy.

In the context of HA, E2 is the form of estrogen being tested on a typical sex hormone panel. Most women will with textbook HA will have estrogen below 50, and many will have E2 below 30 pg/ml.

Signs of low estrogen can include the following: night sweats, vaginal dryness, thin endometrium, light or absent periods, dry skin, headaches, low sex drive, frequent urination, and difficulty sleeping.

FSH

Follicular stimulating hormone (FSH) is a hormone released by the pituitary gland that acts on the ovaries. Appropriately named, it is responsible for the growth and maturation of follicles, which are tiny fluid sacs located inside the ovary. 

FSH stimulates follicles on the ovary to grow and prepare the eggs for ovulation. As the follicles increase in size, they begin to release estrogen (E2). With HA, there is improper signaling from the brain which is why follicles don’t grow to an appropriate size and estrogen levels remain low. 

The normal reference range for FSH is 3.0-20 IU/L and women with HA typically have low/normal FSH. In rare cases, we can also see elevated FSH levels signs diminished ovarian reserve from prolonged under fueling and over exercise.

LH

Luteinizing hormone (LH) is also released by the pituitary gland. This plays a role in triggering the release of an egg from a mature follicle for ovulation. In fact, it’s the surge in LH that you’re testing for on an ovulation predictor kit or OPK test. LH only surges right before ovulation. So getting an LH surges typically means your body is about to ovulate. A blood progesterone test should confirm ovulation 7 days past suspected ovulation, or through basal body temperature tracking).

LH also causes the corpus luteum to secrete progesterone after ovulation- hence its name luteinizing hormone. 

With HA, LH levels are typically low/normal. Much like estrogen levels, the lower your LH typically the more “severe your HA is”. In fact, there are more than 75% of women have LH levels < 2 IU/L.

Progesterone

Progesterone is our pro-gestation hormone and only increases significantly after ovulation in preparation for pregnancy. 

Progesterone’s main function is to prepare the endometrium (lining of your uterus) for a fertilized egg to implant and grow. If a pregnancy occurs, the corpus luteum secretes progesterone for the first ten weeks. Then the production is taken over by the placenta. If a pregnancy doesn’t occur, the endometrium sheds (aka your period). 

Since progesterone levels only rise after ovulation, progesterone is always low with HA. If you’re getting your period but aren’t seeing a rise in progesterone above 3 ng/mL in your luteal phase, you aren’t ovulating.

Testosterone

Testosterone is not one of the major hormones in the diagnosis of HA. But it does play a role initially when figuring out why your period is missing. As previously mentioned, HA is a diagnosis of exclusion, and testosterone is key in ruling out polycystic ovarian syndrome (PCOS).

Testosterone, the primary male sex hormone, is also produced by the adrenals and the ovaries in females. It’s one of our main androgen hormones. Elevated levels of this hormone are a primary driver of PCOS in most women with this condition. Not all women with PCOS exhibit the pattern. However, the vast majority do have physical signs of elevated androgen or elevated testosterone levels on a blood test. 

Testosterone plays a key role in libido, bone health, muscle metabolism, mood, energy, and libido. Testosterone levels are often low or normal In women with HA. Whereas testosterone is high in over 70% of women with PCOS. 

Normal Labs but still HA?

At this point we’ve discussed Estrogen, Progesterone, FSH, and LH. These are the primary hormones you’re going to want to look at for diagnosing HA and assessing progress in recovery.

So why can someone have normal labs and still have HA?

The reason is that the reference range for normal can vary slightly lab to lab. But overall, the reference range for normal is quite broad.

For example, estrogen is typically < 50 pg/mL in women with HA, yet the reference range of “normal” is 20 – 150 pg/mL. This means that a woman could have an estrogen level of anywhere from 20 – 49 pg/mL. Also, depending on who’s interpreting the values, be told that the value is either indicative of HA or completely normal. A similar trend is seen with FSH, LH, testosterone, and DHEA-S– another hormone often used in the diagnosis of PCOS.

This overlap between normal versus clinically abnormal values can be extremely confusing. These misleading ranges can convince women, who are certain that they have HA.

To make matters more difficult, it’s important to remember that lab values are merely a snapshot of what’s going on in the body at one point in time. Hormone levels in the blood are constantly fluctuating. So the hormone levels in blood drawn at one specific moment are not always an accurate reflection of one’s current status. Taking these two factors into consideration, it’s no wonder why countless women struggle to get a definitive diagnosis for their missing period. 

Until more medical professionals learn the ins-and-outs of HA, finding a trained clinician who considers both medical and lifestyle factors in their diagnosis and treatment is a must. 

Inside the Food Freedom Fertility Society, we have worked with hundreds of women who have either been diagnosed with or suspect they have HA. We’ve helped them modify their habits and restore their fertility. Using lab values and physical signs of recovery to monitor your recovery, we’re able to help you go from having no period to being pregnant in just 3 months.

You Can Recover from HA and Restore Your Fertility

Apply to Join the Food Freedom Fertility Society.

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MEET THE HOST
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I’m a fertility nutritionist and registered dietitian who specializes in hypothalamic amenorrhea. My passion is helping women trying to conceive find freedom with food and exercise, so they can recover their period, and get pregnant naturally.

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