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The rise of FHA: how workout culture is costing women their periods

Restrictive eating and daily exercise, fuelled by Instagram and TikTok, has become so normalised that an increasing number of people who menstruate are losing their periods

It’s no secret that society’s obsession with appearance is at the root of a growing number of physical and mental health risks. Toxic diet and workout culture has resulted in rates of eating disorders being at an all-time high, and Instagram itself has admitted that the unrealistic beauty standards promoted by its platform are damaging teens’ mental wellbeing

Less spoken about are the increasing numbers of people, like myself, who are losing their periods due the extreme dieting and exercise habits promoted by social media. FHA (functional hypothalamic amenorrhea) is when the body stops menstruating due to stress caused by a lack of fuel or over-exercise. The American Society of Reproductive Medicine reports that between one and two in every 100 women experience FHA, while another study found that 30 per cent of women who exercise frequently experience period loss. 

And these are numbers that are growing. “It’s the tip of an iceberg,” says Mr Narendra Pisal, consultant gynaecologist at London Gynaecology, who has seen a rise in FHA cases over the past five years. The issue is so widespread that a new genre of influencer content has arisen – advice videos on how to get your period back. The TikTok tag #periodloss, which has over 2.9m views, is full of young women offering advice and tips to their followers. 

FHA is often temporary, but if left untreated can cause a lifetime of health issues for those suffering, including infertility, osteoporosis, cardiovascular issues and an increased risk of anxiety and depression. “It's shocking to me to see how many women actually have FHA,” says Ximena Diz, a nutritionist specialising in period loss. “It’s a growing global fertility and mental health crisis that needs to be addressed immediately.”

Eating too little and exercising too much are the two main factors that cause the bodily stress response. This means athletes can get it (from over-exercising) and those with anorexia can get it (from under-eating), but people like me, who yo-yo diet or have binge eating disorders, can also get FHA from extended periods of eating very little, without ever actually becoming underweight. In my case, years of obsessing over food and exercise left me without a period, but my outwardly ‘healthy’ appearance prevented me from getting an FHA diagnosis until three years later.

Dr Husain, of the Royal College of Gynaecology, says she has noticed a rise in cases of FHA among women who are of a ‘healthy’ BMI (body mass index). “The pressures of two years of being locked away, with increased social media use, has made people very body-conscious”, explains Dr Husain. Society has found itself in a place where restrictive eating and daily exercise are so normalised that women are experiencing health issues usually associated with elite athletes. 

Mr Pisal says that other forms of stress could be exacerbating rates of period loss, too. “Relationships, anxiety, background anxiety from the lockdown and pandemic… and it’s not just Instagram, but also the Stravas of this world. A lot of women, as well as men, are trying to push themselves much harder,” he says. In a world where everything we do is tracked and measured, our bodies are having to pause normal bodily functions in order to have enough energy to perform.

For many sufferers, the issue begins online. Milly, who has since grown her 273k-strong Instagram following by sharing her weight gain and period recovery journey, says “social media had a huge impact on my relationship with food and exercise, which definitely contributed to me losing my period”. It was after her long-term eating disorder peaked during lockdown that Milly contacted a coach to help her lose more weight. But instead, the coach put her on a ‘reverse’ diet, a method used by bodybuilders to gradually increase calorie intake and boost metabolism, while gaining muscle and losing fat. Ten months and 20kg later, Milly had her first period in six years.

Many of the influencers promoting less restrictive attitudes to eating and exercise still conform to strict beauty standards

Grace*, a fellow FHA sufferer, has a similar story to Milly. “I was obsessed with this vision of wellness [that I saw online]: very beautiful young girls eating lots of fruit. To me, that’s what being healthy looked like”. Grace started to run daily and restrict her food intake in hopes of achieving the kinds of bodies she saw on social media, before coming off the pill with the aim of losing more weight. It was only then that she realised she didn’t have a period, and sought help from a coach. “The algorithm knew what I was doing. I was on TikTok and I kept getting these online fitness coaches… It’s like a whole community based around eating more or reverse dieting”.

Rather than sharing pictures of thigh gaps and acai bowls, this new breed of fitness influencer promotes weightlifting, sculpted abs and glutes, and ‘intuitive eating’ (specifically, eating more). In a lot of ways, it’s a more balanced lifestyle. Yet, as Grace points out, many of the influencers promoting less restrictive attitudes to eating and exercise still conform to strict beauty standards. “I probably only really listened to these people because they were eating 2000 calories a day, but still looked how I wanted to look.” ‘Reverse diet’ now has 78 million views on TikTok, with many advocates sharing how the technique helped restore their periods and give them an hourglass figure. But others, like coach Sarah Guerra, warn that reverse dieting is not another supposed hack to your dream body: while it can help you build muscle and lose some fat in desired areas, weight gain is inevitable, and should be normalised. 

With help from her coach, Grace cut her cardio, started lifting weights, increased her caloric intake, and got her period for the first time in three years. However, “I don’t think it is necessarily that healthy, because you’re still tracking everything [like calories, exercise and body measurements]. It’s still a complete obsession, but that change of obsession did give me back my period, my freedom. I wonder whether it’s a slight pivot rather than a complete change in how we view wellness”.

Health and fitness content, no matter how balanced, often still reinforces body image ideals and acts as a gateway to more extreme content. Yet it can also act as an important information source for many, particularly with the lack of medical resources for many in the US. Influencers like Milly and Liv, another online fitness coach who has made her own recovery from disordered eating and FHA, are working to educate young women about the risks of extreme eating and dieting. Social media “100 per cent” fuelled Liv’s eating disorder, she says, which in turn made her lose her period but she also believes “it can help massively if you’re following the right accounts”. 

It’s time we discussed the very real health risks posed by the pressures of modern life, the physical as well as the mental. The good news is that the medical community is more aware than ever of issues like FHA, and awareness is growing among the public, too. “The pandemic has definitely focussed people on mental health and how the mind can affect the body in different ways”, says Dr Husain. As awareness of issues like FHA grow, let’s hope that, finally, we might be on the right track.