"I have my period. So I mustn't have an eating disorder."
For years I thought that if a woman was menstruating regularly, she was displaying one of the ultimate signs of health.
I thought that if a woman had a regular period she must be well nourished. That the moment her caloric intake dipped below her requirements, her body would stop ovulating and periods would disappear.
That Mother Nature never lets our bodies grow babies - a highly energy intensive endeavour that demands massive amounts of resources - in a perceived famine.
For years, I was wrong.
In my time as an eating disorder dietitian, student naturopath, and having lived through an (undiagnosed but still very harmful) eating disorder, I have learnt a thing or two about periods and under eating. Here I'll attempt to bust some common myths around periods, fertility and disordered eating.
For years I thought that if a woman was menstruating regularly, she was displaying one of the ultimate signs of health.
I thought that if a woman had a regular period she must be well nourished. That the moment her caloric intake dipped below her requirements, her body would stop ovulating and periods would disappear.
That Mother Nature never lets our bodies grow babies - a highly energy intensive endeavour that demands massive amounts of resources - in a perceived famine.
For years, I was wrong.
In my time as an eating disorder dietitian, student naturopath, and having lived through an (undiagnosed but still very harmful) eating disorder, I have learnt a thing or two about periods and under eating. Here I'll attempt to bust some common myths around periods, fertility and disordered eating.
Myth #1: Anorexic women can't fall pregnant
To give myself some credit, it is generally accepted in the eating disorder community that the more severe or prolonged a woman's eating disorder is, the more significant the medical, gynaecological, and obstetrical complications (1).
In other words, eating disorders and disordered eating increase the chance that you won't ovulate normally, and therefore your period will be scanty, irregular, or absent.
There is plenty of research showing that many women who have an active eating disorder or disordered eating (whether diagnosed or not) struggle to get pregnant due to ongoing nutritional and psychological stressors that impair their ovulation and fertility*.
BUT... there are also plenty of women who, despite being in a significant calorie deficit, still have their periods and still fall pregnant.
Having a period is NOT a reliable indicator of optimal health and nutrition status.
Some of us have a genetic makeup that is incredibly sensitive to our environment: the moment a prolonged drop in caloric intake is detected, the hormones that keep our reproductive functions afloat will shut down and periods will stop.
Others, however, will continue to menstruate after months or even years of restrictive eating. For these women, their genetic blueprint dictates that despite significant malnutrition their reproductive function continues, although other body systems (such as brain function, immune status or digestion) may suffer.
By the way, all of this can happen regardless of what a woman weighs. People can be anywhere on the BMI scale and still be malnourished. Women (including folks suffering from anorexia nervosa) can be of ANY body size and still lose their periods due to malnutrition. That only visibly emaciated folks are malnourished is a myth.
So to bust this myth, underfed women of all body sizes CAN still have a period, ovulate, and fall pregnant. They can also lose their periods altogether, or sporadically.
*Eating disorders also increase the risk of problems with pregnancy and birth, including miscarriage, developmental abnormalities, preterm delivery, and lower birth weight leading to more difficult, intervention-heavy births. But for this article I'm going to focus on periods and ovulation in relation to eating disorders, rather than pregnancy and birth.
In other words, eating disorders and disordered eating increase the chance that you won't ovulate normally, and therefore your period will be scanty, irregular, or absent.
There is plenty of research showing that many women who have an active eating disorder or disordered eating (whether diagnosed or not) struggle to get pregnant due to ongoing nutritional and psychological stressors that impair their ovulation and fertility*.
BUT... there are also plenty of women who, despite being in a significant calorie deficit, still have their periods and still fall pregnant.
Having a period is NOT a reliable indicator of optimal health and nutrition status.
Some of us have a genetic makeup that is incredibly sensitive to our environment: the moment a prolonged drop in caloric intake is detected, the hormones that keep our reproductive functions afloat will shut down and periods will stop.
Others, however, will continue to menstruate after months or even years of restrictive eating. For these women, their genetic blueprint dictates that despite significant malnutrition their reproductive function continues, although other body systems (such as brain function, immune status or digestion) may suffer.
By the way, all of this can happen regardless of what a woman weighs. People can be anywhere on the BMI scale and still be malnourished. Women (including folks suffering from anorexia nervosa) can be of ANY body size and still lose their periods due to malnutrition. That only visibly emaciated folks are malnourished is a myth.
So to bust this myth, underfed women of all body sizes CAN still have a period, ovulate, and fall pregnant. They can also lose their periods altogether, or sporadically.
*Eating disorders also increase the risk of problems with pregnancy and birth, including miscarriage, developmental abnormalities, preterm delivery, and lower birth weight leading to more difficult, intervention-heavy births. But for this article I'm going to focus on periods and ovulation in relation to eating disorders, rather than pregnancy and birth.
Myth #2: Having a period means you musn't have an eating disorder
Lack of menstruation (or amenorrhoea) is one possible symptom of an eating disorder, but it doesn't work the other way around: having a period does not rule out the presence of an eating disorder.
That was important so I'll say it again: Having a period does not prove that you are well. If you or others close to you are concerned you have issues with your eating, the presence of a period does not give you the all clear to brush these concerns aside. Doing so can prolong your time to getting treatment. Unchecked, disordered eating patterns can wreak havoc on your physical and mental health.
You can have an active eating disorder or disordered eating and still have a regular period. You can also be years into recovery and not be getting your period. This is due to something called individual variability.
(By the way, many other things can cause amenorrhoea that have nothing to do with disordered eating, including PCOS, pregnancy, lactation, thyroid and other hormonal abnormalities. These are topics for another day).
That was important so I'll say it again: Having a period does not prove that you are well. If you or others close to you are concerned you have issues with your eating, the presence of a period does not give you the all clear to brush these concerns aside. Doing so can prolong your time to getting treatment. Unchecked, disordered eating patterns can wreak havoc on your physical and mental health.
You can have an active eating disorder or disordered eating and still have a regular period. You can also be years into recovery and not be getting your period. This is due to something called individual variability.
(By the way, many other things can cause amenorrhoea that have nothing to do with disordered eating, including PCOS, pregnancy, lactation, thyroid and other hormonal abnormalities. These are topics for another day).
Individual variability is a thing
Yes, you can be getting your period (and fall pregnant) even if you're undernourished. You can also not have your period long after resuming normal eating and being at a weight your body naturally wants to be at. Check out these real life cases of some female clients I have known and/or worked with:
1. Bethany* age 28, with a long history of severe anorexia nervosa and no period in six years, assumes she is infertile. She falls pregnant after having unprotected sex.
2. Mian* age 31, is mother to a toddler. She has an undiagnosed restrictive eating disorder. Despite numerous signs of malnutrition she is still lactating. A year after her child is born her period returns. Mian wishes to fall pregnant again as quickly as possible. Despite advice from her GP to first address her restrictive eating and restore her weight, Mian starts having unprotected sex in the hope she will fall pregnant.
3. Camille* age 35, wants to start a family. She lost her menstrual cycle five years ago after battling through several cycles of restrictive eating and bulimia. Despite being fully recovered, nutritionally rehabilitated and at a healthy weight for the last two years, she still has no period.
4. Faiza* age 22, is a chronic restrictive dieter and has not had a period for the past year. She went to see a naturopath who prescribed herbs that made her period come back. She continues to eat very little, over-exercise and worry about her weight.
1. Bethany* age 28, with a long history of severe anorexia nervosa and no period in six years, assumes she is infertile. She falls pregnant after having unprotected sex.
2. Mian* age 31, is mother to a toddler. She has an undiagnosed restrictive eating disorder. Despite numerous signs of malnutrition she is still lactating. A year after her child is born her period returns. Mian wishes to fall pregnant again as quickly as possible. Despite advice from her GP to first address her restrictive eating and restore her weight, Mian starts having unprotected sex in the hope she will fall pregnant.
3. Camille* age 35, wants to start a family. She lost her menstrual cycle five years ago after battling through several cycles of restrictive eating and bulimia. Despite being fully recovered, nutritionally rehabilitated and at a healthy weight for the last two years, she still has no period.
4. Faiza* age 22, is a chronic restrictive dieter and has not had a period for the past year. She went to see a naturopath who prescribed herbs that made her period come back. She continues to eat very little, over-exercise and worry about her weight.
Mo' menses, mo' problems?
This is a kinda serious and heavy topic so to break the tension, I made a little pun above (you kids who grew up in the 90's will get where I'm coming from). Any excuse for a music video hey?
Ok, back to the topic at hand.
It's misguided to think that if you have a period, you can't possibly have an eating disorder. If you have a period despite your eating being somewhat restrained or restricted, don't be lulled into a false sense of security that all is well. You may fall into the camp where, due to genetic tendencies your body menstruates even when it is very malnourished.
If this is you, I implore you to get the help you need to heal your disordered eating.
Even if you're still having a menstrual period (i.e. you bleed), you may not be ovulating (more about that soon). And if you're not ovulating, you face the same hormonally-based health risks as women who don't get periods at all. The ramifications of not ovulating (and the attendant lack of monthly oestrogen peaks) become evident as we age in the form of osteoporosis and increased risk of bone fractures, depression and cardiovascular problems.
Conversely, if you are NOT menstruating and you suspect you have some form of disordered eating or an eating disorder, please seek help. It is possible to restore your fertility. Even if you never want to have children, regular ovulation has many health benefits including protecting your long term cardiovascular, brain and bone health.
If this is you, I implore you to get the help you need to heal your disordered eating.
Even if you're still having a menstrual period (i.e. you bleed), you may not be ovulating (more about that soon). And if you're not ovulating, you face the same hormonally-based health risks as women who don't get periods at all. The ramifications of not ovulating (and the attendant lack of monthly oestrogen peaks) become evident as we age in the form of osteoporosis and increased risk of bone fractures, depression and cardiovascular problems.
Conversely, if you are NOT menstruating and you suspect you have some form of disordered eating or an eating disorder, please seek help. It is possible to restore your fertility. Even if you never want to have children, regular ovulation has many health benefits including protecting your long term cardiovascular, brain and bone health.
Myth #3: You can take herbs or meds to bring your period back (and forget the food part)
Doctors may prescribe oestrogen medications to increase levels and bring on a period. Naturopaths may prescribe herbs such as Chaste tree (Vitex agnus-castus) in women with hypothalamic amenorrhoea, a condition which often arises when women under eat.
These treatments can be of immense help for some women; I have personally experienced their value as temporary solutions. For years I had disordered eating behaviours (which at a certain point morphed into an undiagnosed eating disorder). My restrictive eating and exercise obsession lead to the cessation of my periods (in the form of hypothalamic amenorrhoea) for nearly a year. I then saw a naturopath who prescribed herbs and after a short time on herbal treatment my period returned.
The problem with these treatments is that the return of a period can lead some women into complacency regarding their disordered eating. It may discourage them from seeking help to treat the underlying disordered eating behaviours which caused their periods to stop in the first place. I have seen this in many women, and I have experienced it first hand.
From my personal experience with disordered eating and using herbs, I continued to somewhat restrict my food and over-exercise after the herbs "made" my period come back. It was only years later that I discovered intuitive eating, began to nourish myself properly and finally achieved hormonal restoration without needing to rely on herbs to have a normal menstrual cycle.
By the way, this is why I strongly believe that natural health practitioners should be trained in the recognition and management of eating disorders, which I discuss at length here.
These treatments can be of immense help for some women; I have personally experienced their value as temporary solutions. For years I had disordered eating behaviours (which at a certain point morphed into an undiagnosed eating disorder). My restrictive eating and exercise obsession lead to the cessation of my periods (in the form of hypothalamic amenorrhoea) for nearly a year. I then saw a naturopath who prescribed herbs and after a short time on herbal treatment my period returned.
The problem with these treatments is that the return of a period can lead some women into complacency regarding their disordered eating. It may discourage them from seeking help to treat the underlying disordered eating behaviours which caused their periods to stop in the first place. I have seen this in many women, and I have experienced it first hand.
From my personal experience with disordered eating and using herbs, I continued to somewhat restrict my food and over-exercise after the herbs "made" my period come back. It was only years later that I discovered intuitive eating, began to nourish myself properly and finally achieved hormonal restoration without needing to rely on herbs to have a normal menstrual cycle.
By the way, this is why I strongly believe that natural health practitioners should be trained in the recognition and management of eating disorders, which I discuss at length here.
Myth #4: Having a period means you're ovulating
It's important to understand that it is possible to have a period yet not be ovulating (and therefore not be able to conceive). This is called an anovulatory cycle and it happens when none of your follicles reach full maturity.
You do not ovulate, so you do not form a corpus luteum, and you do not make progesterone. But you still bleed because your growing follicles still make oestrogen, which is the hormone that thickens your uterine lining - and at some point that lining has got to be shed (2).
When a woman is under eating, her cycles may become anovulatory even if she still has a menstrual period (bleed).
You can also get anovulatory bleeds with certain conditions including PCOS, perimenopause, or if you have an implant or injection methods of hormonal birth control (but NOT the pill - in which case you have no cycle at all, and the bleed is not a true period but a drug withdrawal bleed) (2).
There are ways to check to see if you are ovulating including tracking your temperature (as in the Fertility Awareness Method) and/or tracking changes in your cervical mucus.
You do not ovulate, so you do not form a corpus luteum, and you do not make progesterone. But you still bleed because your growing follicles still make oestrogen, which is the hormone that thickens your uterine lining - and at some point that lining has got to be shed (2).
When a woman is under eating, her cycles may become anovulatory even if she still has a menstrual period (bleed).
You can also get anovulatory bleeds with certain conditions including PCOS, perimenopause, or if you have an implant or injection methods of hormonal birth control (but NOT the pill - in which case you have no cycle at all, and the bleed is not a true period but a drug withdrawal bleed) (2).
There are ways to check to see if you are ovulating including tracking your temperature (as in the Fertility Awareness Method) and/or tracking changes in your cervical mucus.
In summary
Women of all sizes who under eat can lose their periods, or keep them. They may ovulate or not ovulate. They may be able to conceive or they may not. Regardless of your period status, if you have issues with food, body or eating, please be gentle with yourself and seek the professional help you need. You deserve to get better.
*names have been changed.
*names have been changed.
References
(1) Gaudiani, JL (2019). Sick enough: a guide to the medical complications of eating disorders. Routledge, New York.
(2) Briden, L (2017). Period repair manual: natural treatment for better hormones and better periods. Second edition. Lightning Source, UK.
(2) Briden, L (2017). Period repair manual: natural treatment for better hormones and better periods. Second edition. Lightning Source, UK.
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