Period Irregularity: Nutrition & Exercise Recommendations for PCOS vs. Amenorrhea

Period irregularity affects upwards of 25% of women of reproductive age. Many are told they have polycystic ovary syndrome (PCOS) when experiencing cycle irregularities. However, there may be more to the story!

Both PCOS and hypothalamic amenorrhea (HA) are two causes of period irregularity. We define irregular periods by a cycle that is shorter than 21 days or longer than 35 days. Amenorrhea is defined as a lack of a period. It’s estimated that about 1 in 25 women who are not pregnant, breastfeeding, or going through menopause experience amenorrhea at some point in their lives.

It’s important to distinguish PCOS from HA to treat it effectively, regulate cycles, and rebalance hormones. While both may manifest as period irregularities, they have different root causes and driving factors, and therefore different nutrition and exercise recommendations.

Understanding PCOS

PCOS is diagnosed by meeting two of the following three criteria: irregular periods, elevated androgens (i.e. testosterone, DHEA, DHEA-S), or multiple cysts on the ovaries. Beyond these three characteristics, those with PCOS often experience a lack of ovulation, acne, facial hair growth, mood fluctuations, and hair loss. 

PCOS is not only an issue involving reproductive hormones, but also metabolic hormones. Insulin resistance is a major metabolic piece that can contribute to the development of PCOS, and can further drive PCOS symptoms such as weight gain and difficulty losing weight.

The 4 PCOS types help point to different underlying driving factors of the condition. These include insulin resistance, inflammation, post-birth control, and adrenal gland dysregulation. 

PCOS goes beyond reproductive hormones, and often involves the nervous and immune systems. There is significant overlap between PCOS and autoimmune thyroid conditions, such as Hashimoto’s. We often see elevated cortisol levels at play with PCOS, with cortisol being our main stress hormone.

Understanding Hypothalamic Amenorrhea

The two types of amenorrhea are primary and secondary. Primary amenorrhea is more often a genetic, developmental, or brain-derived issue that causes a girl to not get her first period by the age of 15. Secondary amenorrhea is when someone who already menstruates experiences a pause in her period for 3 months or more, without being pregnant. 

Hypothalamic amenorrhea (HA) is a form of secondary amenorrhea, diagnosed by the following hormone levels: 

• Estradiol (E2) <50 pg/mL
• Follicle-stimulating hormone (FSH) <10 mIU/mL
• Luteinizing hormone (LH) <10 mIU/mL

Some causes of HA include low body weight, rapid weight loss, eating disorders, stress, hypothalamus or pituitary dysfunction, thyroid dysfunction, premature ovarian insufficiency (POI), PCOS, and other chronic medical conditions, such as inflammatory bowel disease (IBD). 

It’s important to understand and uncover or exclude any of these underlying conditions when distinguishing between PCOS and HA. 

HA occurs when a hormone called gonadotropin releasing hormone (GnRH) is suppressed. GnRH is produced in the hypothalamus and works within the hypothalamic-pituitary-ovarian (HPO) axis. When GnRH is suppressed, this results in low levels of FSH and LH production from the being pituitary gland. 

This downregulation from the hypothalamus to the pituitary gland then further impairs this feedback loop down to the ovaries. The ovarian cells don’t receive the signal to produce estradiol. Without estradiol, the endometrial lining of the uterus does not thicken during the follicular phase of the menstrual cycle. Without endometrial thickening, there is no need for endometrial shedding, which occurs during the menstrual cycle. 

It’s important to address HA to avoid any health risks and long-term health implications that may arise. The hypothalamus is a key player in initiating a variety of hormone cascades that impact a whole host of body systems. 

Consider our hypothalamus as the starting point for the hypothalamic-pituitary-adrenal (HPA) axis, hypothalamic-pituitary-thyroid (HPT) axis, as well as the hypothalamic-pituitary-ovarian (HPO) axis. Untreated HA can result in fertility challenges, an increased risk for osteoporosis, and even cardiovascular health challenges, considering the widespread importance of estrogen in the body. 

Distinguishing the Cause of Your Period Irregularity

By considering the causes of PCOS compared to those of HA, you may have a better idea of which of these conditions is more likely the cause of your period irregularity. We can dive deeper and further distinguish between the two by looking at key differences in hormone levels.  

PCOS often involves elevated androgen levels (i.e. testosterone, DHEA, DHEA-S) and high LH. With HA we often see low androgens, as all reproductive hormones are suppressed, including FSH, LH, estrogen, and progesterone. 

Because the body is in an energy deprived state with HA, it is common to see high cortisol levels. Individuals with PCOS may also experience high cortisol levels, particularly if they are suffering from insulin resistance and blood sugar imbalance. Lab testing can provide insight to help to get to the bottom of your period irregularity. 

Key diagnostic testing for PCOS and PCOS-type more specifically includes blood sugar and insulin sensitivity markers, inflammatory markers and labs to help assess thyroid autoimmunity, androgen levels, cortisol levels, as well as LH and anti-mullerian hormone (AMH). Diagnostic lab testing for HA includes androgen levels, GnRH levels, FSH and LH, as well as cortisol levels. 

Similarities Between PCOS and HA 

Despite the significant differences between these conditions, there are also some similarities. For example, in both PCOS and HA, it’s common for individuals to have low levels of progesterone, and high levels of sex hormone binding globulin (SHBG) and prolactin. Progesterone plays a key role in hormone balance, fertility, bone health, and mood!

Inflammation and immune system activation is often at play with both conditions as well, particularly in the case of Inflammatory PCOS. There are major links between thyroid autoimmunity and PCOS inflammation, with thyroid peroxidase (TPO) antibodies present in 27% of PCOS patients, according to one study.

Additionally, the symptoms between PCOS and HA can often look similar, despite there being different reasons behind these symptoms. Beyond period irregularity, those with PCOS and HA may also experience acne, weight gain, depression and mood changes, as well as GI issues.

Differences in Nutrition & Exercise Considerations for PCOS and HA

Eating for PCOS

• Blood sugar balance: High insulin and blood sugar dysregulation are often challenges for those with PCOS. Apple cider vinegar and digestive bitters can help stimulate stomach acid and digestive juices, supporting digestion and blood sugar balance. Protein, fat, and fiber intake are critical to support blood sugar levels, slowing down the speed at which carbohydrates are digested and therefore how glucose enters the bloodstream.
• High androgens: Spearmint tea has exhibited powerful effects on lowering high androgen levels. 
• Vitamin and Minerals: Support thyroid, ovarian, and adrenal function by incorporating vitamin and mineral-rich food sources to replenish those B vitamin, vitamin C, vitamin E, magnesium, selenium, sodium, potassium, and zinc levels. We can find these micronutrients in foods such as grass-fed beef, citrus fruits, dark leafy greens, pumpkin and pumpkin seeds, Brazil nuts, potatoes, avocado, and unrefined salt.
• Meal timing: Consuming a balanced and protein-rich meal or snack every 3-5 hours helps maintain balanced blood sugar levels.
• Carbohydrate timing: We are naturally more insulin sensitive in the morning time and around exercise. Earlier meals and meals just following a workout are great times to incorporate more of your carbohydrates for the day.
• Anti-inflammatory and antioxidant-rich foods: Combat oxidative stress, or free radical formation, by consuming sufficient amounts of antioxidant rich foods. Leafy greens, dark berries, citrus fruits, olive oil and green tea are all potent antioxidant-rich foods sources that can help fight inflammation. Other anti-inflammatory foods include omega-3-rich salmon, flax, and chia, as well as bone broth, bone-in protein sources, turmeric and ginger.
• Liver support: The liver is responsible for our innate detoxification processes. By supporting detoxification we can prevent inflammation. Incorporate bitter foods, such as citrus fruits, beets, arugula, and dandelion to help stimulate bile flow from the liver. Highlight sulfur-rich cruciferous vegetables and alliums, such as onions and garlic, to provide the building blocks for liver enzymes!

Exercising for PCOS

Muscle is responsible for 70-90% of glucose disposal. This goes to show how important having adequate muscle mass is for maintaining balanced blood sugar levels! Resistance training is essential to support blood sugar and to help offset potential weight gain that is a common symptom of PCOS. 

Eating for HA

• Importance of energy availability: A major cause of HA is underfueling, or not consuming enough protein, fats, carbohydrates, and energy as a whole to fuel reproductive function. As a result, we see these reproductive hormones collectively suppressed.
• Carbohydrate intake: Chronic low carbohydrate intake can result in low insulin levels, which is quite different than in PCOS. Carbohydrates are important to support the adrenal glands and help bring down elevated cortisol levels, a common characteristic of those with HA.
• Adrenal support: The adrenal glands are responsible for cortisol production and heavily rely on having sufficient vitamins, minerals, and carbohydrates to function. Support your adrenal glands especially with sodium, potassium, and whole-food sources of vitamin C with citrus fruits, avocado, sweet potato, and a high quality unrefined salt.
• Nervous system support: We can support our nervous system and stress response by ensuring our blood sugar levels remain balanced, not dropping too low or spiking too high. To support morning blood sugar levels, thyroid hormone production, and circadian rhythms, try to eat a protein-rich meal or snack within 1-2 hours of waking. 

Exercising for HA

Various forms of stress are a significant cause of HA, whether that is the stress of underfueling, over-exercising, carbohydrate restriction, or the stress of chronic medical conditions. We want to ensure that exercise does not further exacerbate the stress response at play in those with HA. For that reason, it’s important to prioritize restorative movement. This could involve things like yoga, pilates, swimming, or zone 2 cardio such as walking, very light jogging, or bike riding.

We hope you find this information valuable to help you better understand the driving factors underlying your period irregularity. Check out our Hormone Potion as an additional period support tool, currently on sale this week through July 19th!

Written by Romana Brennan, MS, RDN