Missing or Irregular Periods (Amenorrhea)
In Brief
Dr. Sanika Kshirsagar at Soma Naturopathic in Kirkland, WA works up absent periods systematically — pregnancy, thyroid, prolactin, PCOS, and functional hypothalamic amenorrhea from under-fuelling or over-training — and treats the cause, rather than using hormonal contraception to create a withdrawal bleed that masks an ongoing problem with bone and hormonal health.
Amenorrhea is the absence of menstruation — primary when periods have never started by age fifteen, secondary when previously regular cycles stop for three months or more. It is not merely an inconvenience or a fertility issue. A cycle is a monthly signal about energy availability, thyroid function, pituitary signalling and stress load, and its absence usually means estrogen is low, which carries real consequences for bone density and cardiovascular health if it persists. Functional hypothalamic amenorrhea — the body suppressing reproduction because energy intake is inadequate relative to output — is among the most common and most misunderstood causes in otherwise healthy, active women.
Symptoms
- •No period for three months or more after previously having cycles
- •Never having started periods by age fifteen
- •Cycles that have become progressively longer and lighter before stopping
- •Low libido, vaginal dryness, and difficulty conceiving
- •Poor sleep, low mood, irritability and persistent fatigue
- •Frequent stress fractures or declining bone density
- •Feeling cold constantly, hair thinning, and dry skin
Causes & Risk Factors
- •Functional hypothalamic amenorrhea from low energy availability, over-exercise or psychological stress
- •Polycystic ovary syndrome, the most common cause of irregular rather than absent cycles
- •Thyroid dysfunction — both hypothyroidism and hyperthyroidism
- •Elevated prolactin, sometimes from a pituitary adenoma or medication
- •Primary ovarian insufficiency — loss of ovarian function before age forty
- •Recent discontinuation of hormonal contraception, with delayed return of ovulation
- •Significant weight loss, eating disorders, or rapid weight change
- •Structural causes including Asherman syndrome after uterine procedures
Naturopathic Approach
Diagnosis drives everything here, because the treatments for the common causes are almost opposites — a woman with functional hypothalamic amenorrhea needs more food and less exercise, while a woman with PCOS and insulin resistance often needs the reverse. Dr. Sanika works through a structured differential: pregnancy first, then thyroid function, prolactin, FSH, LH, estradiol, and androgens, with the LH-to-FSH ratio and androgen picture helping to separate PCOS from hypothalamic suppression, where both LH and FSH are typically low. Where prolactin is elevated or ovarian insufficiency is suspected, she refers for imaging and endocrinology input. For functional hypothalamic amenorrhea, treatment is direct and often uncomfortable to hear: energy availability has to increase. That means eating more, frequently substantially more, reducing training volume and intensity, restoring carbohydrate intake, and addressing the psychological stress load and the beliefs about food and body that commonly sit underneath. Clinical nutrition rebuilds intake in a structured way, and recovery of cycles typically takes several months rather than weeks. Where PCOS is the cause, the approach shifts to insulin sensitivity, inositol, and ovulation support. Throughout, Dr. Sanika is explicit that bone density is being lost while estrogen is low, which is why using hormonal contraception to produce a monthly withdrawal bleed is not a solution — it creates the appearance of a cycle without restoring the underlying hormonal signalling or reliably protecting bone. Functional lab testing tracks recovery through repeat hormone panels rather than relying on the return of bleeding alone.
Related Modalities
Frequently Asked Questions
I am healthy, athletic and lean. Why would my period stop?
This is the classic presentation of functional hypothalamic amenorrhea. The body suppresses reproduction when energy intake is insufficient relative to energy expenditure — it is a sensible adaptation, not a malfunction. It can happen at a completely normal body weight if training volume is high or intake is inadequate, and it often coexists with high achievement and high stress. The concerning part is that estrogen is low for as long as it continues, and bone density is quietly declining.
Will the birth control pill fix this?
It will produce a monthly withdrawal bleed, which looks reassuring, but it does not restore your own hormonal signalling and it does not reliably protect bone in hypothalamic amenorrhea. It also removes the single best signal you had that something was wrong. If the underlying cause is inadequate energy availability, the pill masks it while bone loss continues. There are situations where hormonal therapy is appropriate, but it should be a considered decision rather than a default.
How long does it take to get my period back?
Usually three to six months of consistently restored energy availability, sometimes longer if cycles have been absent for years. Recovery is rarely linear — cycles often return irregularly at first before settling. The changes required are typically eating meaningfully more and training meaningfully less, which many women find harder than any supplement protocol. Tracking hormone levels rather than waiting for bleeding gives earlier evidence that things are moving.
Does it matter if I am not trying to get pregnant?
Yes. Fertility is only one reason cycles matter. Estrogen protects bone density and cardiovascular health, and prolonged amenorrhea in your twenties and thirties can cost you bone you will not easily rebuild — it raises fracture risk decades later. Absent periods also frequently signal a treatable underlying condition such as thyroid dysfunction or elevated prolactin. It is worth investigating regardless of your pregnancy plans.
References
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Dr. Sanika Kshirsagar, ND
Doctorate of Naturopathic Medicine (ND)
Bastyr University, Kenmore, WA
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