Can you have normal periods in cases of estrogen deficiency?

Can You Have Normal Periods with Estrogen Deficiency?

No, you cannot have truly normal, spontaneous menstrual periods in the presence of estrogen deficiency—estrogen is essential for endometrial proliferation and the physiologic menstrual cycle. 1, 2 However, withdrawal bleeding induced by exogenous hormones (such as combined oral contraceptives) can create the false appearance of "normal periods" despite underlying estrogen deficiency. 3

Understanding the Distinction: True Menses vs. Withdrawal Bleeding

True Menstrual Periods Require Adequate Estrogen

• Physiologic menstruation depends on adequate estradiol production to stimulate endometrial proliferation during the follicular phase, followed by progesterone-induced secretory changes and subsequent withdrawal. 2
• Estrogen deficiency disrupts the hypothalamic-pituitary-gonadal axis, leading to decreased LH pulsatility, which fails to stimulate adequate ovarian estradiol production, resulting in amenorrhea (absence of periods). 1, 4
• When estrogen levels are aberrantly subphysiologic, normal ovulatory cycles cannot occur, and women develop oligo-amenorrhea (irregular or absent periods). 3, 2

The Deceptive Nature of Contraceptive-Induced Bleeding

• Combined oral contraceptives create an exogenous ovarian steroid environment that produces withdrawal bleeding, which mimics menstruation but does not represent restoration of spontaneous menses. 3
• This withdrawal bleeding provides a false sense of security and does not indicate that the underlying estrogen deficiency has been corrected. 3
• Contraceptive therapy does not restore spontaneous menses or normalize the metabolic factors that are impaired by low energy availability. 3

Clinical Context: When Estrogen Deficiency Occurs

Functional Hypothalamic Amenorrhea (FHA)

• Energy deficit from inadequate nutrition, excessive exercise, or psychological stress suppresses GnRH pulsatility, preferentially reducing LH secretion while FSH remains relatively preserved. 1, 4
• The LH:FSH ratio typically falls below 1 in approximately 82% of FHA patients, which is diagnostically useful. 1, 4
• This results in decreased estradiol and progesterone levels, not elevated gonadotropins, distinguishing FHA from primary ovarian insufficiency. 1, 2, 4

Female Athlete Triad and RED-S

• Low energy availability (below 30 kcal/kg fat-free mass/day) disrupts LH pulsatility, causing menstrual dysfunction manifesting as oligo-amenorrhea with low estrogen. 3, 2
• Approximately 47.3% of female athletes aged 15-30 years are at risk for low energy availability, with estimates of disordered eating ranging from 6-45%. 3
• Amenorrhea in athletes is associated with systemic reductions in estradiol levels, not excess estrogen. 2

Critical Pitfall to Avoid

Do not mistake withdrawal bleeding from hormonal contraceptives for evidence of normal estrogen status or resolution of the underlying problem. 3 The presence of monthly bleeding while on combined oral contraceptives does not indicate:

• Restoration of spontaneous ovulation 3
• Normalization of endogenous estrogen production 3
• Resolution of metabolic abnormalities affecting bone health 3
• Adequate energy availability 3

Hormonal Changes in Estrogen Deficiency States

Reproductive Hormones

• Decreased estradiol and progesterone are the primary reproductive hormone changes in conditions like anorexia nervosa and FHA. 2, 4
• LH is preferentially suppressed through disrupted GnRH pulsatility when energy availability falls below critical thresholds. 1, 4
• FSH levels remain relatively stable or show minimal changes during nutritional deficiency. 1

Metabolic and Other Hormonal Alterations

• Decreased leptin, increased ghrelin, and increased cortisol occur with low energy availability. 2, 4
• Decreased insulin and IGF-1 contribute to impaired bone health. 2, 4
• Decreased thyroid hormones (T3, T4) reflect metabolic adaptation to energy deficit. 2, 4

Treatment Implications

The primary therapeutic intervention for estrogen deficiency due to low energy availability is nutritional rehabilitation and weight restoration, not hormonal contraceptives. 3, 4

• The Endocrine Society recommends BMI should reach ≥18.5 kg/m² before ovulation induction is offered, as weight restoration is the primary therapeutic intervention. 1, 4
• Non-pharmacological treatment strategies should be prioritized, particularly focusing on achieving resumption of spontaneous menses, given the importance of normal estrogen status to bone health. 3
• Combined oral contraceptive therapy is not consistently associated with improved bone mineral density in amenorrheic athletes and may further compromise bone health through suppression of hepatic IGF-1 production. 3