Low Bone Density And Hypothalamic Amenorrhea

Loss of bone density is one of the most profound and scary long-term health effects associated with Hypothalamic Amenorrhea. In this post I explain why this is, and more important, what you can do in order to reverse your Low Bone Density caused by Hypothalamic Amenorrhea.

Many tend to believe, that the bones of the body and their density is something static formed once and then remains. This is not the case. You can think about the density of your bones as a pile of sand. If you add more sand than you remove, the pile (in your case bone density) will increase. If you take away more sand than you add, then the pile (in your case bone density) will decrease. Lets take a closer look at this process, and the role estrogen plays.

The role of estrogen in osteogenesis (bone formation)

The metabolism in the skeletal system is foremost driven by two cell types:

• osteoblasts are cells that form bone tissue and drive bone-building activity. Referring to the analogy above, they are the ones adding sand to the pile.

• osteoclasts are cells that degrade bone tissue and mediate bone loss. Referring to the analogy above, they are the ones removing sand from the pile.

The hormone estrogen serves as a key factor in regulating adequate bone metabolism in the skeletal system. Estrogen stimulates the osteoblasts in their bone-building activity. In absent of estrogen, bone production is suppressed due to osteoblast cell death (apoptosis). Further, the absence of estrogen promotes osteoclast (bone degradation) activity which leads to bone deterioration.

Breakdown of bone in Hypothalamic Amenorrhea

How come Low Bone Density is seen in Hypothalamic Amenorrhea? As just explained, your sex hormone estrogen plays a key role in bone strength, repair and health. If you suffer from Hypothalamic Amenorrhea, you will be very low in estrogen, since this hormone is associated with your menstrual cycle (in this post you see how). The loss of estrogen resulting from Hypothalamic Amenorrhea is thus a serious risk for developing osteopenia or osteoporosis at an early age and over a lifetime. A profound loss in bone density can be seen already after after six months without a period. One study showed that the more severe osteopenia was found in the women with prolonged amenorrhea, but that the most profound decline in bone density occurred early after onset of amenorrhea.

Besides estrogen deficiency, it is worth mentioning that both high levels of cortisol and low level of thyroid hormone (for all low T3 and T4, TSH is often normal), both strongly associated with Hypothalamic Amenorrhea, may also have a negative impact on bone heath.

There is no way to see from the outside if you have weakened bones, osteopenia or osteoporosis. The only way to confirm this is by taking a DEXA scan. Since there are minor variations in result between machines, I advice you to do the scan on the same machine every time. Around every second or third year is a good rhythm to perform a scan to follow the development.

Bone density set point

It is never too late to start reversing your bones! I have seen it in clients and experienced it myself, if you recover from Hypothalamic Amenorrhea and your period returns, your bone health will improve! I know that for example doctor in Endocrinology Izzy Smith argues that our bone density has a set point (similar to weight set point), to which it will return if given the right conditions. For this hypothesis speaks observations in pregnant and breastfeeding women. To bake a baby requires a lot of calcium, which is taken from the bones of the mother. The bone density decreases with about 3-5 % during pregnancy and breast feeding (this is seen even if the calcium intake is adequate). Within 12 months after weaning, the bone density goes back to where it was prior to the pregnancy.

Actions to reverse osteopenia and/or osteoporosis

Regain your period

So what can you do to reverse the breakdown of your bones? Well the first, most obvious and most important thing you need to do is to recover from Hypothalamic Amenorrhea and regain your period. This means making changes to your lifestyle (eat enough, rest more, exercise less) so that your body feels that it is safe enough to become pregnant (and ovulate) again. By doing so your estrogen levels will return to normal.

Make sure you get enough calcium and vitamin D

Calcium works alongside Vitamin D to maintain bone health and achieve peak bone mass. Therefore it is important that you have adequate levels of calcium in your diet to avoid deficiency states and facilitate bone repair. In this post you can get more specific advice on sources and amounts.

Don't overdo the fiber

It is crucial in recovery that you eat enough, and that you eat enough carbs. Fiber is also a kind of carb, however your body can’t use or store it as energy. A high fiber intake has been associated with low estrogen level throughout the menstrual cycle and higher risk of anovulatory cycles. It may bind to estrogen, causing the estrogen to be excreted instead of absorbed recirculated, which in turn leads to lower estrogen levels. So don't overdo it with the fiber.

Engage in strength training

First a big DISCLAIMER. Strength training will only contribute to build up of bones in the present of estrogen. This means, if you start strength training while still lacking your period, you will only do further damage to your bones. That being said, once you have regained your period, strength training is a good way of supporting the reformation of your bones. Some things to think about in your strength training routine:

• make sure you train with multi-directional force and a lot of variation

• lift heavy weights

• strive after progressive overload

It might be beneficial to reach out to an expert who can give you advice on personal training for clients with osteoporosis since the program ideally should be individualized and dynamic.

Bone density, pregnancy and breastfeeding

Lastly, since many of my clients work towards pregnancy I wanted to quickly talk about some information to think about with regards to bone health. As explained, the pregnancy itself is a shot-term burden on the bones also for someone entering the pregnancy with normal bone density. It requires resources to create the baby skeleton, and these resources are taken from you and your skeleton. This is normal and reversible and has nothing to do with low levels of estrogen. In fact estrogen levels increase steadily during pregnancy and reach their peak in the third trimester. Breastfeeding is an even bigger challenge on your bones. The baby (and its skeleton) is growing and requires even more resources. This is paired with low estrogen levels. Given that you regain your period upon weaning, the estrogen levels will then reach normal levels again.

With this in mind, I think it is reasonable to take these facts into consideration when deciding how you wish to do with breastfeeding. Some blanket advice for those diagnosed with osteopenia and/or osteoporosis is of course difficult to give. But a rule of thump* is to keep the period of breastfeeding rather short (about 3 months), and to give the body at least 12 months to recover before becoming pregnant again after regaining the period.

Again, I am not saying you need to follow this. I did not, and my DEXA values still improved. I had my first DEXA scan in 2018 with osteopenia as a result. I regained my period (and by that normal levels of estrogen) in spring 2019. December 2019 I became pregnant. I then breastfed my child for seven months. In August 2021 I regained my period, and in December 2021 (three months later) I became pregnant again. In September 2022 my second child was born. In October 2022 I took my second DEXA scan. And my values had improved since the scan in 2018, despite two pregnancies and a total of nine months of breastfeeding.

The first and most important action to take in order to start recovering your bone health in Hypothalamic Amenorrhea is to regain your period. I am here to help you with that. Feel free to reach out to me, then we can start working recovering your period, your fertility, your bone health and your quality of life.

Further reading

Bone Density Loss (Osteopenia & Osteoporosis https://open.spotify.com/episode/7dcTXDyyiQayHlmk3HGDuJ?si=RtqApPclTcq0oIS10ejY3A

*All content is for informational purposes only. It is not intended to be a substitute for professional medical advice. Always seek the guidance of your doctor or other qualified health professional with any questions you may have regarding your health or a medical condition.