Recovering From Hypothalamic Amenorrhea
  • August 22, 2023

Episode 26: Is Your Period Missing? Recovering From Hypothalamic Amenorrhea (HA) with Sarah Liz King

Today Meg and Kiah chat with Sarah Liz King about recovering from Hypothalamic Amenorrhea (HA).     Today we’re joined […]

Today Meg and Kiah chat with Sarah Liz King about recovering from Hypothalamic Amenorrhea (HA).



Today we’re joined by the wonderful Sarah Liz King, chatting all about recovering from hypothermic amenorrhea. 

Sarah is a Health at Every Size, exercise physiologist, health coach passionate about helping women recover from disordered eating, heal their relationships with physical activity, and successfully address hormonal challenges such as PCOS and hypothermic amenorrhea.

Through her own journey with an eating disorder, Sarah discovered Intuitive Eating which gave her the body freedom she had been searching for through endless other approaches. Sarah has invested countless hours learning and growing to become the best supporter of others that she can be, including becoming an Accredited Exercise Physiologist and personal trainer, qualified pilates mat and reformer instructor, and certified Intuitive Eating counsellor.

Sarah has over 10 years of experience helping people achieve full recovery so they can enjoy positive relationships with movement, food freedom and fall back in love with their bodies.

Q1: What is the one thing most people don’t know about you?

One piece of information people who may not follow me know about me is I am American. I was born in Southern California, and I only moved to Australia as a teenager. And now I am a dual citizen.

You’ll probably hear it in a very mixed accent as I speak now. And I basically flip-flop between the two accents kind of seamlessly, but people often kind of like turn their head when they first start talking to me and go, where are you from? And I’ve had so many different people say completely different countries. But yeah, I’m a blend, but I’m originally from America.


Q2: What hypothalamic amenorrhea is and how it’s diagnosed? Would you mind just chatting a bit about that?

Hypothalamic amenorrhea is the shortened abbreviation is HA or often in medical circumstances, FHA (functional hypothalamic amenorrhea). 

It is the absence of a menstrual period for three months or greater. Hypothalamic amenorrhea is caused by kind of three main things:

  • Under eating
  • Overtraining
  • And/or too much stress

It is a form of secondary amenorrhea. When we say that secondary amenorrhea means that a person has had their period previously, and that it has stopped as a result of something. In this case, it has resulted or stopped because your hypothalamus has gone, “Hey, it’s probably not really safe for us to reproduce right now, because things are a little bit stressful.” So it down-regulates a lot of the production of hormones that we have, which then cease that menstrual cycle.

In terms of diagnosis, it is actually quite tricky to get a diagnosis of hypothalamic amenorrhea. The reason being is there is a lot of crossover with other conditions that might lead to a missing menstrual cycle, which are more commonly known about and therefore more commonly diagnosed. Hypothalamic amenorrhea is a diagnosis of exclusion. 

If your periods have disappeared, going to your primary health care physician or your GP is the best place to start, they’ll often run some hormonal blood tests on you. Usually, the best place to get referred to when you’re having a problem with your sex hormones, or any hormones is to go and see an endocrinologist. They are experts in hormones, not just sex hormones.

Some of the things that we need to rule out in order to rule in hypothalamic amenorrhea are :

  • Thyroid issues
  • High prolactin levels
  • You might get set for an MRI or a scan just to ensure that there’s nothing else impeding the function of that hypothalamus, and basically, pituitary. This is because hormones are very complicated, and there are lots of things that can go wrong.

The really tricky thing is probably how many people get misdiagnosed as having PCOS as opposed to hypothalamic amenorrhea. Having someone that’s very well versed in the differences between the two is very important, because there is a lot of crossover between the symptoms. But the types of treatment required for each type of condition is completely opposite. So you really need to ensure that you do get that right diagnosis if you can.


Kiah: It’s so frustrating. Sometimes, as a health professional, you see clients that have gone on these big long journeys, and especially when misdiagnosis happens.

Q3: When I think of HA, I kind of think about you as the go-to person – especially in this social media space. Why are you so passionate about working in this area?

I went through hypothalamic amenorrhea myself, I had a missing period for over 10 years. I went to countless health professionals to figure out why this was missing. I got misdiagnosed as having PCOS, I got told there’s “Nothing wrong with me“, I got told “Don’t even worry about it.

When the time comes and you want to have children, they will just put you through IVF. However, I had diagnosed osteopenia, and I knew while I was studying that oestrogen was absolutely critical to my bone health. So I was like, well, someone needs to help me figure out why I have a missing period.

Eventually, it got to the point where I actually went to a talk with a gym that I used to go to, and a dietician showed up. She shared her story. And it was the first time I’d ever heard of this phrase, hypothalamic amenorrhea. And I was like, Oh, my God, this is what I have. How have I never heard of this before?

I ended up working with her for several months afterward to regain my period. And actually, it was interesting that I went back to my GP and I was like, “This is what I have.” And she was like, “Yeah, that’s probably right, I don’t know why I never thought of that.

I made it my life’s mission, probably not at the time, but a couple of years later to instigate education around different GP practices and different kinds of psychologists and dieticians to ensure that they knew that this could happen with a person at any body size. So it kind of became a passion out of necessity, and the fact that I never wanted someone to experience what I had, which was 10 years of feeling so lost and so confused.




Q4: For someone who is listening to the podcast, and thinks that this might apply to them, or maybe knows someone who maybe it might apply to, what are the steps to get started on an HA recovery journey?

In terms of the three main causes, those are the things that we’re trying to treat and look after when we are going on a recovery path and recovery journey.

So the first thing to be aware of is this mismatch between energy intake and energy output. As dietitians, you would be very aware of this phrase of energy availability. It’s basically when the energy and energy availability can be either optimal or suboptimal or low.

For women to be in a very healthy optimal stage, we want that optimal energy availability. Essentially, we have to help a person eat regularly and adequately enough to reach their body’s optimal energy availability. So that would take into account how much incidental movement they do and how much structured physical activity they do.

This is what signals to the brain, “Hey, there’s an abundance of energy around and now you can use some of those resources to start up-regulating the production of sex hormones again.”

So it really is this – eat more, be mindful of how much you’re moving, alongside also managing your stress.

There are very generic kind of recommendations that people often hear in the HA recovery space, such as eat 2500 calories a day, or don’t let your heart rate get above 100 beats per minute. And while it’s really lovely to have those kind of blanket recommendations, I’m always always always advocating for the fact that those recommendations are actually based on research. And when the broad blanket recommendations were given, they were literally just doing that equation for a “average female” or someone of a specific age.

So this advice needs to be tailored to you.

Eating enough will look different for you.

Managing and modifying your exercise will look different for you compared to the person next to you trying to recover from HA.

The other thing that people often miss out on is this proactive approach to managing your stress. And that is something we can’t brush over. So your brain has absolutely no idea whether stress is physical stress, or whether it’s psychological stress. It just knows that maybe your inbox exploding is absolutely the same am as being attacked by a sabre-toothed Tiger, it doesn’t know.

And obviously, if you’re being attacked by a sabre-toothed Tiger, or your inbox exploding, obviously isn’t a safe environment for your body to be prioritising sexual function. That’s where we get really interested in what people’s lives look like, and how we can fit in just small moments throughout the day of kind of lowering their stress levels and looking at both external sources of stress, as well as internal sources of stress.

This may look like maybe a bit of perfectionism, or that all-or-nothing mentality, whether that’s around food or other elements of their life. But those are the three key areas that you really need to get started with.


Q5: On the topic of stress, do you have any strategies that you’d like your clients to consider or people to consider – for stress management techniques they can try at home?

Often I say to a lot of my clients that our culture is in a place where you’re always ‘go, go, go’ all the time. Most people’s work environment requires them to be on all the time.

If you’re throwing in a workout at the end of that day, and maybe you’re trying to have like a really busy, flourishing social life, your nervous system, would always be on all the time.

There will be elements throughout the day where you probably be in that fight or flight kind of phase of your nervous system. So as much as we can, we have to think about well, how are we balancing that out with some slow rest and digest kind of moments throughout the day.

So I always like trying to tie something that you already do very frequently throughout the day, to something that is going to lower your nervous system down to a more calm and peaceful state. This is a really good thing that I often get people to do, and it helps for a multitude of different reasons.

Mostly, because oftentimes we’re working on helping people improve their relationship with food, at the same time we’re working on their stress management is to go, “Okay, before you sit down to a meal, I just want you to take three long, slow, deep breaths, and then start and it can help reduce that anxiety around the eating occasion, it can help lower your stress levels, it can help facilitate a little bit more muscle relaxation.

We know that deep slow breathing is one of the best ways to switch on your parasympathetic nervous system, which is that slow rest and digest state. So it’s just about figuring out small ways that we can kind of integrate all of that throughout the day.


Q6: Do you have any strategies to help someone cope with any of those body changes that they might experience?

Sarah: First and foremost, I think it’s really important for us to acknowledge that all changes are hard. But we live in an environment that is hypercritical to our physical bodies, and has incredibly unrealistic standards which you’ve been told for a really long time awe need to upkeep in order to be accepted, lovable, and attractive.

When you’re going through a period of renourish in your body, which might result in some changes, it can bring to the forefront a lot of these feelings and uncomfortable thoughts about who you are, how accepted you might be, how lovable you might be.

The first thing I want to say is, all of those feelings are so valid and you are not alone in thinking or feeling the way that you do.

In those moments, it’s really important to acknowledge that there is shared suffering in a lot of those experiences. So getting support whether that be from a qualified health professional that is very well trained in body image or disordered eating can be a really good place to go, or a really supportive community.

It takes a lot of the load off of people going through these transition periods in their lives. You can talk to someone and kind of go, “I don’t know what to do“, or “I don’t know how to navigate through the day“. And they can be like, “Look, I had a day like that too, and these are some of the things that helped me can make you feel less alone“.

The second thing to be aware of is to allow yourself time and space to grieve the loss of a body type that maybe you were praised for. Even though that body type might have been sub-optimal to your life and other ways – it might have caused you to miss out on a lot of social engagements. Or, it might have made you feel really, really sad, because you isolated yourself a lot. There are still moments where it did something for you, or the behaviours that you were doing at that time helped you cope in some way.

It’s really hard to let that go. And it’s okay to be sad about that. Give yourself time and days where you just want to curl up in a bowl, and maybe go back to how things were before and at the same time realise that that’s actually not what you truly want.

Reconnect to your values, and why this is important to you, in terms of your end goal and your healing process. Optimising your health and nourishing your body adequately and really reconnecting with why is so important. 

It can also be really helpful to have clothes that feel comfortable as your body changes. If we are forcing our bodies into clothes that are uncomfortable, and don’t serve us here, it only reminds us of the areas that feel quite uncomfortable. 

I know we’re going through a stage where things are quite expensive, and it’s probably the last thing someone wants to do, especially if they’re investing a lot of their time and money into seeking out professional help. This is where I would advocate for swapping clothes with other people who might be in a size or you might have sizes clothing that might be more comfortable to you going to thrift stores and having a bit of fun there

And when you do, allowing yourself to kind of sell those pieces of clothing on something like Depop or on Facebook Marketplace, so that you can actually use that money again to move forward and purchase what is going to be comfortable for you in those moments.


Kiah: I really liked what you said about just taking that time to really grieve the loss of a body that wasn’t serving us as well.

That’s really important, especially because we live in this society that unfortunately, values certain body types. It can be very difficult, especially if that’s all your life, you’re kind of told that looking a certain way makes you more valuable as a person or more. 


Sarah: Yeah, definitely. You got to let yourself grieve that body that no longer serves you because you get to move to a stage of life where there are endless possibilities, but you have to be open to them. And I think to be open to something sometimes we have to allow ourselves space to close the door behind us.


exercising on yoga mats


Q7:  How can someone safely reintroduce or increase exercise after that period comes back?

With movement, we never want to make it seem like you just need to shelve it and just don’t think about it and never move your body. For some people, there are legitimate reasons for taking a clean break from exercise to allow you to reset in terms of your mindset around it. 

You might have an accumulation of months or years where you may have pushed past physiological cues telling you to stop and slow down. Sometimes when you do finally stop and slow down, you’re very tired. That’s often a really triggering phenomenon for people going through the recovery process – is just how exhausted they can be, despite the fact that they might be nourishing themselves more adequately, and actually prioritising more moderate movement sessions or complete rest.

When we’re thinking about exercise and reintroducing it, we want to be really mindful that the body can be quite sensitive to these changes in energy, especially in those first few months where your period has come back. We really want to wait for around three menstrual cycles with three recurrent periods before we change too many variables. 

We want three periods that are roughly 28 to 35 days apart, that are of a relatively normal amount of bloodshed. So that can be quite a few teaspoons, not just spotting sometimes. We want to make sure that a person is in a good headspace, and wants to increase that exercise back for the right reasons.

Considering that you’ve ticked all of those boxes, the best place to start is by thinking about what kind of exercise you feel like doing, and only changing one variable at a time. For example, if you want to get back into riding you bike to work, great. Why don’t we try riding your bike to work one day a week and see how you feel? Then if all goes well, your periods are normal, maybe we increase either the frequency with which you’re riding your bike to work.

The best way to ease into it is to stay with that moderate-intensity exercise. High-intensity exercise is perfectly healthy, and definitely something that we don’t need to be afraid of. However, it should be sprinkled in instead of absolutely showered throughout your entire week.  


Q8: What would you say to someone trying to figure out that themselves about whether they’re actually including exercise because they want to and they’re at the right stage of their recovery, versus there’s wanting to change their weight or their body shape?

I often say to people, we’re usually motivated by one of two things, either running away from something or running towards something. A lot of times with people that have a history or background of disordered eating or HA, it’s often the running away from something. For example, running away from the fear of gaining weight or running away from becoming a bigger person.

You really have to tune into your intentions here and listen to not only the reasons that come up, but the tone of voice of that that you hear inside of your head.

Also knowing that you’re at a healthy enough place that even if you were to start your exercise one day, and you weren’t feeling it, you could just walk away. You wouldn’t beat yourself up about it, you wouldn’t change your eating habits as a result.

To summarise, it should be running towards things that are flexible, and inclusive, and have an element of fun. Or maybe there’s an element of performance that you want to work on. All of those are fine.



Q9: What would your top three tips for anyone who’s healing their relationship with food and exercise?

This is such a good one. So I’m going to give my top three tips, as they would potentially relate to HA recovery specifically.

When it comes to your relationship with food and fueling your body appropriately, yes, calories are important, but don’t get so stuck up on the number.

Carbs, people often think, “If I just hit the energy intake that I need, I don’t need to be mindful of how many carbohydrates I’m having”. Carbs have a huge role in the production of our hormones, and are really important to also our gut health as well. So that’s a really big one.

The third one is consistent eating – so not leaving big time gaps throughout the day where you’re not having food. Because if you’re only having like a couple of eating occasions throughout the day, it’s really difficult to get the energy intake that you need.

When it comes to exercise, I would be really encouraging you to try and find a mindful form of movement. So for a short period of time, you’re probably going to have to take a break from those really high-intensity exercises that might give you that euphoric high feeling that you’re so accustomed to after a workout.

Now’s the time to be really mindful and gentle with your movement, and allowing yourself to enjoy a different aspect of exercise that you may not have seen as beneficial before.

Try something different. Do a yoga class, go to Pilates, find a way to connect with your friends if you have lots of like gym friends, outside of the gym.

And then my last one with stress would be to find small ways to recoup your energy throughout the day. Those moments of deep breathing, or having better boundaries around switching off at work, or making sure that you’re getting enough sleep. Those are some really great ways that you can reduce your stress levels that don’t require you to become like a Zen Buddha, who does five hours of meditation a day, because we do not have time for that.


Q10: If people want to find you, where is the best place to locate you?

I am most active on Instagram. You can find me @sarahlizking and which has links to my website, which is . My podcast as well Holistic Health Radio which has a whole bunch of episodes around recovery for those who are interested in getting a little bit more free help and advice.



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