Myth: Periods Mean You’re Perfectly Fine
A visit from Aunt Flo, on the rag, time of the month, women’s troubles, moon time, riding the crimson wave, the painters are in, bloody Mary, defrosting the steak, shark week, red wedding, Carrie…
Believe it or not, these are just a handful of the euphemisms people around the world use to refer to periods or menstruation. This normal female bodily function has been a taboo subject in many cultures for centuries, shrouded in mystery and shame. The monthly bleed which begins in puberty and lasts until menopause has disrupted women’s lives, caused embarrassment, rage and discomfort and, for many, excruciating pain since the dawn of time, yet many of us still find it hard to discuss menstruation, even with our closest friends.
It’s time for some straight talking about periods, though. Because menses, or the lack thereof, have played a large part in the medical literature about anorexia nervosa over the years, and this has not always been helpful.
It’s true that in women and girls one of the first signs that someone is in trouble with anorexia might be the absence of menses, or amenorrhea. After embarking on a ‘healthy’ diet, both my daughters lost weight, and that was a big worry, but the change in shape wasn’t dramatic initially. Neither looked abnormally thin. I’d seen their bodies go through multiple changes since they were born, so this loss of weight was not initially terrifying. Perhaps it was just their age, although I had also noticed an anxiety around food which was new.
But when I learned they’d both lost their periods for several months, I knew that something was up, and that’s what prompted me to talk to our GP.
I took one of my daughters to see the doctor, who weighed her and said that she was within the healthy BMI range for her height, at the low end. But, she added, she should try to eat more and should put on a bit of weight because loss of periods could permanently damage her bones and reproductive health.
It was a big deal then, this loss of blood loss.
And when I think about it now, the cessation of periods is an extremely dramatic reaction for the body to have. The brain has lost trust that this body it’s in is suitable for motherhood. Nature no longer wants this body to carry a child. And for Nature, which is, let’s face it, all about reproduction — the continuation of the species — this is huge.
So, what is going on in the body and brain for it to react in such an extreme way to dietary restriction?
Functional hypothalamic amenorrhea (FHA) — or loss of periods — occurs after weight loss or excessive exercise, among other things. This results in suppression of the hypothalmic-pituitary-ovarian axis (HPOA), the tightly regulated system that controls female reproduction. This then leads to impaired production of a hormone called estradiol, which is responsible for the regulation of the female reproductive system. When there isn’t enough estradiol, in a female body of reproductive age, the system grinds to a halt.
It’s possible that this systemic reaction to dietary restriction, though extreme, is in fact protective. The brain sees that the body is not getting sufficient nourishment. It senses famine. Removing the means of getting pregnant — stopping the monthly release of eggs — would ensure that there are not too many mouths to feed. The species can’t survive if there isn’t enough food to go round. Limiting the numbers by disallowing reproduction is Nature’s pragmatic solution.
Now, let’s rewind and look in more depth at the hypothalmic-pituitary-ovarian axis. What is it exactly, and what does its response to malnourishment mean, in general, in anorexia nervosa?
Hypothalamic refers to the hypothalamus, an area deep within the brain, and pituitary refers to the endocrine gland the size of a chickpea which sits underneath it. The hypothalamus functions as the main link between the endocrine system and the rest of the body. Simply speaking, the endocrine system is a messenger system giving the body messages in the form of hormones, which it does in this case via the pituitary gland. The hormones tell the ovaries when it’s that time of the month to release an egg and also signal when there is no pregnancy and a period should occur.
The hypothalamus is a pretty busy part of the brain. It also helps to manage, among other things, body temperature, thirst and sleep. Another of its functions is to maintain energy balance through coordinated homeostatic regulation of food intake and energy expenditure. Insufficient food or too much movement is likely, then, to play havoc with the hypothalamus. And it’s surely no coincidence that all these functions can be affected by anorexia nervosa.
What’s intriguing to me is how rapidly the brain reacts to restricted eating, that this early warning system of amenorrhea is frequently sounded after a surprisingly small amount of weight has been lost. In this study, loss of periods occurred at a ‘normal’ BMI for 38.5 per cent of the participants. Some appear to be a healthy weight but have a body that’s in energy deficit, that is expending more energy that it’s holding on to. This imbalance is enough for the hypothalamus to react by putting the entire reproductive system on hold.
Of course, if the brain reacts so rapidly and so dramatically to insufficient food, is it any surprise when thinking — another major function of the brain — is also impacted? As I saw in both my daughters, with a small loss of weight and a little restriction of their diet brain functioning changed catastrophically. Decision making became impaired and rationality around food and body shape was lost. In other words, they developed anorexia nervosa.
But is it safe to use amenorrhea as a marker of how ill someone is, or indeed when diagnosing anorexia nervosa? Up until the latest edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM), published in 2013, the absence of at least three menstrual cycles was listed as one of the diagnostic criteria for anorexia nervosa in women and girls.
I believe that this was dangerous because — and this is important —not every female who is malnourished loses her periods. Yes, many do but many don’t. This was something that physiologist Ancel Keys noted in his book The Biology of Human Starvation as long ago as 1950:
Although anorexia nervosa is frequently accompanied by amenorrhea there are still a sufficient number of severely emaciated women who maintain regular menstruation to make any categorical statement hazardous.
It was unfortunate that the DSM recommended that a woman or girl of reproductive age should have lost her periods for a diagnosis of anorexia nervosa to be made for so long. How many were never diagnosed, and never treated, because they didn’t meet this crude requirement? How many did not receive treatment, and were left to suffer, simply because their hypothalamus made the judgement that, on balance, it would rather take its chances with reproduction in a famine than risk the wipeout of the entire species?
Period loss alone, while highly significant and potentially damaging, should not define whether or not someone has anorexia nervosa. The main test should always be whether or not someone is having negative thoughts around food and/or an inexplicable desire to lose weight. These thoughts and feelings are the main markers of this illness. If you are a healthy weight but still have the urge to restrict, you have an eating disorder. If you have your period but have a desire to eat an insufficient amount or feel that you have to exercise in order to allow yourself to eat, you have an eating disorder.
At present one of my daughters is a lower weight than she was when I first became concerned for her health. And she clearly struggles with eating, picking at her food and making excuses for why she can’t eat certain things. But right now she also has her periods. I know because she talks about it. A lot. I suspect this is an attempt to reassure me that all is well, or to convince herself perhaps that she is eating enough. She sees menstruation as an indication that she’s in good health. Her periods have convinced her brain that all is well in her body. This is a classic trick of anorexia, of course, which will use anything at its disposal to persuade the person who has it that they’re not all that sick or not sick at all. My daughter remains very unwell with anorexia.
So remember: losing your periods means you’re not okay but retaining them or regaining them doesn’t mean that you are. It’s the brain function that counts. Period.
Summary
Loss of periods is significant and is a major sign that something is wrong, whatever weight that person happens to be.
Not every female with anorexia nervosa loses their periods.
Having a period doesn’t mean you don’t have anorexia.
Regaining your periods after losing them doesn’t mean you no longer have anorexia.
Men and boys can develop anorexia and so can pre-pubescent girls and post-menopausal women. Amenorrhea is just one indicator of a problem, but it’s certainly not the only one.