No Period, No Problem, or Is It?
Thousands of athletic females of all ages do not have normal menstrual cycles and that is considered "normal" by their fellow athletes, and surprisingly by many of their doctors. However, while it may by common, it is not normal, and is definitely not healthy.
Why is it not healthy, what's the big deal ? After all, it can be super convenient to not have to worry with a menstrual cycle, monthly cramping, supplies, and all the other fun things that come with having a monthly period.
What Causes Amenorrhea ?
Amenorrhea is the clinical name for an absence of menstrual cycles. There are multiple reasons why a female may not have a regular monthly menstrual cycle, and the root cause should be determined. For athletes, the root cause is often times due to a lack of sufficient calorie consumption to keep up with all of their activity . In 1992, the phenomena was named, The Female Athlete Triad. It was originally defined by the 3 common denominators seen in athletic women who stopped having monthly menstrual cycles: an eating disorder, amenorrhea, and osteoporosis. But wait---the definition was revamped in 2002 to reframe the common denominators as energy deficiency (with or without an eating disorder), low bone mineral density, and menstrual dysfunction.
Did You Say Eating Disorder???? Keep Reading !
The mention of an eating disorder may sound very drastic, which is part of why the definition for the Female Athlete Triad was reworded. The definition from 2002 is MUCH MORE ACCURATE, because many athletes who don't consume enough calories and lose their period do not have an eating disorder at all, they just simply don't consume enough calories, which is what starts the cascade of menstrual dysfunction and bone issues. (On the contrary, some athletes do indeed have an eating disorder, which is why the newer definition from 2002 simply states, "energy deficiency, with our without an eating disorder").
What's the Big Deal for Bone Health ?
While talking about bone health may sound like something only old people talk about, it is extremely important for all ages. Bones do get thinner as one ages, and this lack of hormones that drive a monthly menstrual cycle to stop, also cause a young persons healthy bones to start to behave just like an older person with no monthly menstrual cycle. Many amenorrheac athletes end up in my office with stress fractures, sidelined, and unable to play the sport that they love. And oftentimes, no one ever connected the dots for them as to why they have a stress fracture ( and not all stress fractures are due to lack of menstrual cycles) . The issue that has to be corrected for the athlete who is not having menstrual cycles due to a lack of calories, is a need to consume more calories, period (no pun intended). When calories in can't keep up with calories expended, the intelligent amazing human body decides to shut down a factory somewhere, and this is the most easily expendable "factory " to turn off. I have seen post collegiate athletes suffering from bone problems as early as their mid 20's because they have gone years and years with no menstrual cycle.
What Should You Do ?
One of the most helpful things you can do is work one on one with a sports dietitian to help determine how many calories you do need to fuel all of your activities so you keep a monthly menstrual cycle. It is also very important to be evaluated by a sports medicine physician or an endocrinologist who works with athletes. It is so common for an athlete to tell me that their Doctor told them it was normal to not have a cycle, or that they were put on the birth control pill to restore their monthly cycle, but neither of these is the right course of action! The birth control pill does not fix the caloric need, and the hormones offered in the birth control pill do not simulate normal ovarian production . According to Dr Julia Warren, endocrinologist at Creedmoor Centre Endocrinology in Raleigh, North Carolina,
"Treatment has focused on oral contraceptive use, though this form of estradiol replacement, particularly in adolescents, is not optimal. Rather, an option that more closely simulates the normal ovary is preferable. Use of the estradiol patch allows for close monitoring of estradiol levels. Additionally, studies have shown the transdermal patch was shown to increase bone accrual in one study in adolescent females with anorexia nervosa. While the female athlete and the patient with anorexia nervosa may not be the same, the similarities suggest that estradiol replacement via the estradiol patch is better (more physiologic and can be measured) than the birth control pill.
Also, the patch allows for observing a patient’s recovery better than birth control pills, which may mask the problem by creating monthly menstrual cycles. Regardless of the form of estrogen replacement, the cornerstone of therapy remains optimizing caloric intake. If left untreated, the health consequences include lack of periods, infertility, attainment of low peak bone mass, and bone loss leading to stress fractures. The cause of amenorrhea and bone loss is multifactorial, involving hormones leptin and possibly ghrelin, which communicate the nutritional status of a person to the brain. Bone loss occurs due to nutritional deficiencies, possibly estrogen deficiency, and direct and indirect effects of leptin on bone".
How Long Does It Take to Reverse It ?
Once an athlete is consuming enough calories, it can still take up to 6 months to restore a normal, monthly, menstrual cycle. This is why it is so important to work closely with a sports dietitian who can determine and then educate and explain what the proper amount of calories are for each individual athlete. It is also important to work with a sports dietitian to help unravel the reasons behind the insufficient calorie consumption in th first place. There are numerous reasons why athletes may not eat enough, which can range from just not knowing what they needed, to hearing other adults talk about cutting back, to wanting to "eat clean" which just gets turned into not eating enough, or so often times, from reading incorrect information on social media.
Prevention is the Best
The ideal for all athletes is that they would have access to accurate sports nutrition training and be able to implement it easily and with confidence so they can fuel for their sport, stay healthy, strong and avoid preventable injuries. SaveSaveSave