By Dr. Elissa Rosen, MD, CEDS

Before we delve into addressing the common myths surrounding amenorrhea in athletes, let’s start by defining some medical terminology. Amenorrhea means the absence of menstruation, or a period as we say colloquially. Menstruation occurs when an egg is released, called ovulation, but never fertilized (which would be the start of pregnancy). The thick lining built up in case of pregnancy is then shed when pregnancy does not occur, resulting in the blood loss seen monthly.

Amenorrhea can be classified as either primary or secondary. (1) Primary amenorrhea is when a female has not menstruated by the age of 15 and has otherwise shown signs of puberty. Secondary amenorrhea is the absence of menstruation for 3 months in a female who previously had regular menstrual cycles OR 6 months in a female with previously irregular cycles. The distinction between primary and secondary amenorrhea is made because the causes of primary amenorrhea are often due to genetic or anatomic abnormalities. Those who have menstruated before generally have functioning female anatomy and so some of these causes of amenorrhea can be excluded just by the presence of previous menstruation.

The most common cause of amenorrhea in athletes is what is known as functional hypothalamic amenorrhea (FHA). The hypothalamus is a regulatory center in the brain that releases hormones, which control multiple bodily systems, including the reproductive system.

In FHA, the hypothalamus is ‘silenced’ from releasing hormones that ultimately allow for ovulation and a normal menstrual cycle. FHA is caused by low energy intake, exercise, weight loss, stress, or a combination of these factors. (2,3) There are many other causes of amenorrhea so one should always be seen by a knowledgeable physician to rule out other causes before receiving the diagnosis of FHA.

Now let’s focus on some of those myths.

Myth 1: It is normal for an athlete to stop menstruating during periods of heavy training.

It is NEVER normal for an athlete to stop menstruating. Yes, you read that right. Amenorrhea should never be considered an acceptable consequence of any level of athletic or fitness training. Amenorrhea is a red flag that the body is not functioning to its full potential. Amenorrhea again can be due to exercising too much for your body, under-fueling, high stress, or a combination of these factors.

Myth 2: Amenorrhea in athletes is unique to only endurance or high-level athletes.

Amenorrhea can be seen in females from any sport and at any level from recreational to elite. Even those without sport specific goals and that exercise for health/fitness/enjoyment can develop amenorrhea. It is likely true that higher intensity and frequency of exercise might make someone more prone to FHA than those who exercise at a lower intensity, frequency. 

Myth 3: You have to be a certain body size to develop FHA.

 FHA can affect females of all shapes and sizes. That being said the lower someone’s body weight is, the higher the likelihood that they will develop FHA, but this does not mean FHA is exclusive to those at a lower body weight. Weight loss, even when remaining within what society defines as a ‘normal’ weight, can still trigger FHA. (3)

Myth 4: Amenorrhea is nothing to worry about.

It is estimated that for every year without a menstrual cycle, females can lose more than 2% of their bone density. This bone loss can be irreversible. Low bone mineral density increases the risk of fractures including those pesky stress fractures that can plague and sideline athletes for weeks to months. All female athletes with amenorrhea for 6 months or more should undergo formal bone density testing by getting a DXA (dual energy x-ray absorptiometry) scan.  

Myth 5: If you have amenorrhea, you should start oral contraceptive pills (OCPs) to induce a period and keep your reproductive and skeletal system healthy.

OCPs can play a role, outside of pregnancy prevention, in the treatment of select menstrual related conditions. FHA is not one of them. The bleeding caused by OCPs is completely artificial because the hormones in the pills are inducing the bleeding. In someone with hypothalamic amenorrhea, OCPs mask when a natural menstrual cycle resumes. Studies have also shown that OCPs are also not protective of the bones. (2) There is some exciting new research that a patch with lower dose estrogen can prevent bone loss stemming from amenorrhea, so this can be an option for treatment of low bone mineral density in athletes. (4) OCPs are certainly a good choice purely for birth control purposes, but if you are only taking them for reproductive or bone health purposes they aren’t really doing anything to help either one.

Myth 6: Amenorrhea means that you cannot get pregnant.

Amenorrhea should never be used as the only form of birth control. While it is much less likely that an athlete with FHA will be able to get pregnant, ovulation (egg release) can happen especially as someone is further along in the process of recovery from FHA.

Any athlete that is sexually active, even if they have amenorrhea, should take some form of birth control if they are not actively seeking to become pregnant.

Myth 7: There is nobody to help me if I develop FHA. 

What causes FHA is going to be unique for each person. A multidisciplinary team approach is often the most effective to delve into the individual factors at play. A sports dietitian can analyze your diet to see if there is insufficient energy intake and work with you to make changes to fuel better. A therapist can help with stress management, behavioral change, and accepting results of behavior change (i.e., weight gain, decreased exercise). They can also work on any potential underlying body image or disordered eating behaviors. A physician can be helpful for bone density monitoring and treatment of low bone mineral density.

Myth 8: As soon as I make changes like eating more, modifying exercise, and reducing stress my menstrual cycle should resume right away.

As frustrating as it may be, amenorrhea can persist for as long as 6 to 12 months, according to some studies, after making the changes to your lifestyle that were felt necessary to resume menstruation. (2) It can be really hard to be patient, but just remember that you are doing the right thing to heal your body and in due time you will see the results.

References:

1.     Welt CK, Barbieri, RL. Epidemiology and Causes of Secondary Amenorrhea. Up to Date. Waltham, MA: Up to Date, Inc. www.uptodate.com. (accessed on August 29, 2018)

2.     Gordon CM, Ackerman KE, Berga SL, Kaplan JR, Mastorakos G, Misra M, Murad MH, Santoro NF, Warren MP. Functional Hypothalamic Amenorrhea: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab. 2017 May 1;102(5):1413-1439.

3.     Rinaldi, N. No Period Now What. Factors in a Missing Period Part 1. http://www.noperiodnowwhat.com/hypothalamic-amenorrhea-info/factors-in-hypothalamic-amenorrhea. (access on August 30, 2018).

4.     Misra M, Katzman D, Miller KK, Mendes N, Snelgrove D, Russell M, Goldstein MA, Ebrahimi S, Clauss L, Weigel T, Mickley D, Schoenfeld DA, Herzog DB, Klibanski A. Physiologic estrogen replacement increases bone density in adolescent girls with anorexia nervosa. J Bone Miner Res. 2011 Oct;26(10):2430-8.