Pregnancy isn't the only cause of missed or late periods. Weight loss or weight gain, stress and hormonal imbalances can affect your period, too. Another common cause is overtraining. Too much exercise may induce amenorrhea, which is why many female athletes stop having a period.
What Is Amenorrhea?
Amenorrhea is a condition characterized by the absence of menstruation. It can be primary — when the first menstrual bleeding doesn't occur until after age 15 — or secondary — when your period stops for at least three consecutive months. Teen girls and women can experience amenorrhea for various reasons, including but not limited to:
- An overactive or underactive thyroid
- Eating disorders
- Congenital disorders
- Being overweight or underweight
- Ovulation problems
Female athletes and regular gym-goers are more likely to develop secondary amenorrhea because of the hormonal changes caused by fat loss and overtraining. According to a September 2018 review published in The Lancet Child & Adolescent Health, this condition often results from low energy availability and may affect bone health and development — especially in teenage girls. Women with secondary amenorrhea are at a higher risk for osteoporosis and infertility.
In some cases, secondary amenorrhea is a symptom of the female athlete triad, according to a June 2017 research paper published by the American College of Obstetricians and Gynecologists (ACOG). This condition has three main components, including:
- The cessation of a woman's menstrual cycle for three or more consecutive months (sometimes in the form of functional hypothalamic amenorrhea).
- Low bone density.
- Low energy availability — which may be accompanied by eating disorders, such as bulimia or anorexia.
The ACOG suggests that all active females should be assessed for these symptoms. Without adequate treatment, they may cause complications and affect quality of life. Many women experience hair loss, unwanted hair growth, acne, headaches and pelvic pain in addition to the absence of menstruation.
Understanding the Female Athlete Triad
The female athlete triad causes a chain reaction in the body. Basically, it consists of three interrelated symptoms.
For example, if you're dieting and working out too hard or for too long, you'll lose body fat. As a result, your body won't have enough energy to function optimally. This energy deficiency can affect your hormone levels, leading to amenorrhea. Over time, menstrual irregularity can impact your bone mass and bone density, increasing the risk of fractures, sports injuries and osteoporosis.
As the American Fitness Professionals Association (AFPA) points out, up to 45 percent of female athletes experience secondary amenorrhea. Researchers believe that the female body ceases ovulation when its energy stores drop below 12 percent. Additionally, high-intensity exercise can raise a woman's testosterone levels, which further affects her menstrual cycle.
The AFPA states that high-protein, low-carb diets may lead to the absence of menstruation. Long-distance female runners, as well as those who engage in heavy weight training, are more likely to experience secondary amenorrhea. The same goes for women who start training before reaching puberty. Stress and anabolic steroids play a role, too.
According to the ACOG, dancers, gymnasts and other athletes who engage in sports that require low body fat levels are at the greatest risk of female athlete triad. These women often restrict their caloric intake and develop eating disorders that bring their body fat levels down to single digits.
A restrictive diet can deplete your body of calcium and other nutrients that support bone health while affecting your hormonal balance. In the long run, your bones may become weak and fragile. A July 2017 review published in Translational Pediatrics suggests that low energy availability can affect the skeletal, reproductive and cardiovascular systems.
What Is Functional Hypothalamic Amenorrhea?
According to another research paper in the Journal of Endocrinological Investigation in September 2014, a common form of secondary amenorrhea is functional hypothalamic amenorrhea, a condition caused by stress, weight loss or overtraining — it is actually one of the main components of the female athlete triad.
This disorder reduces the production of gonadotropin-releasing hormone and can have serious complications. It not only affects bone density but can also impair reproductive function and mental health. Anxiety, depression, mood disorders, sexual problems and cardiac events tend to be more common in women who develop this condition.
In a June 2017 interview with the Endocrine Society, Catherine Gordon, MD, MSc, pointed out that healthcare providers need to rule out other conditions that may stop menstruation before making a diagnosis of functional hypothalamic amenorrhea. In general, its underlying cause is an exaggerated approach to healthy eating and exercise, such as eating too few calories or spending long hours in the gym.
This problem, though, may also affect women with a balanced diet and workout regimen. In this case, stress is the culprit. According to a 2015 January review published in the Journal of Clinical Endocrinology and Metabolism, this condition may be caused by extreme emotional stress, which increases cortisol levels. Elevated cortisol affects your hormonal balance and disrupts endocrine function, increasing the risk of amenorrhea and fertility problems.
Get Your Period Back
The good news is that secondary amenorrhea is reversible in most cases. The sooner you do something about it, the higher your chances of success.
Try to determine what caused this problem in the first place. If you're underweight, put on a few pounds until you reach a healthy body weight. Forget about crash diets and skipped meals. As the Translational Pediatrics review notes, increasing your body weight by 5 to 10 percent may be enough to get your period back.
Gradually increase your calorie intake and fill up on nutrient-dense foods. Pistachios, walnuts, almonds, cashews, pumpkin seeds and whole grains are all an excellent choice. Almonds, for example, provide 164 calories per serving. If you eat two servings daily, that's an extra 328 calories.
Beware, though, that this isn't an excuse to indulge in chocolate, ice cream and junk food. Choose whole and minimally processed foods that nourish your body. You don't need empty calories, but a healthy balance of protein, carbs, fats and micronutrients. Consider taking calcium and vitamin D supplements for bone health.
The more active you are, the higher your energy requirements. A diet that's low in micro- and macronutrients can affect your health and physical performance — not just your period. Fatigue, low energy and hormonal imbalances are common side effects. According to a review published in Frontiers in Nutrition in May 2015, female endurance athletes should aim for about 1.6 grams of protein per kilogram of body weight per day and at least 45 calories per kilogram of lean muscle mass per day.
Your daily protein and calorie requirements will depend on your activity level and the type of exercise you perform. A female weightlifter, for example, has different energy requirements than a tennis player or a swimmer.
Also, you need to consider your current body weight and fitness goals. A dietician with experience in sports nutrition can develop a diet plan that suits your individual needs.
Avoid Excessive Exercise
Unless you're a professional athlete, you don't need to spend hours in the gym to reap the benefits. If you're an athlete, it's crucial to get plenty of rest and fuel your body so it can recover from training. Either way, excessive exercise can be detrimental to your goals.
The World Health Organization recommends adults engage in at least 75 minutes of high-intensity aerobic exercise or 150 minutes of moderate-intensity physical activity per week. Weightlifting, full-body circuit training and other types of resistance training should be performed at least twice a week. These guidelines should give you a rough estimate of how much exercise you need to stay lean and enjoy good health.
Too much exercise does a lot more than affect your menstrual cycle. Over time, it can lead to coronary artery calcification, according to a November 2017 study conducted on 3,175 people and published in the Mayo Clinic Proceedings. This condition causes calcium and plaque buildup in the arteries, which in turn, may increase your risk of cardiovascular disease.
Overtraining has been also linked to diminished performance, depression, fatigue, irritability, mood swings, poor mental focus and high blood pressure, among other problems. It can affect your mood and behavior as well as your heart, muscles, bones and immune system.
Talk to your doctor and get some blood tests done to determine the exact cause. In the meantime, try to get more rest and decrease your training volume. Keep track of how you feel before, during and after exercise — and adjust your workouts accordingly.
- University of Rochester: "Amenorrhea in Teens"
- NCBI: "Amenorrhoea in Adolescent Female Athletes"
- ACOG.org: "Female Athlete Triad"
- BMJ: "Amenorrhea in Elite Athletics Athletes: Prevalence and Associations to Athletics Injury"
- APFA Fitness: "Athletic Amenorrhea: Women at Risk"
- NCBI: "The Female Athlete Triad: Special Considerations for Adolescent Female Athletes"
- NCBI: "Functional Hypothalamic Amenorrhea and Its Influence on Women's Health"
- Cedars-Sinai: "The Why Behind Heart Disease and Young Women"
- USDA: "Raw Almonds"
- Frontiers in Nutrition: "Recommendations for Healthy Nutrition in Female Endurance Runners: An Update"
- WHO: "Physical Activity and Adults"
- Mayo Clinic Proceedings: "25-Year Physical Activity Trajectories and Development of Subclinical Coronary Artery Disease as Measured by Coronary Artery Calcium: The Coronary Artery Risk Development in Young Adults (CARDIA) Study"
- NCBI: "Diagnosis and Prevention of Overtraining Syndrome: An Opinion on Education Strategies"
- Endocrine.org: "No Easy Answers: New Functional Hypothalamic Amenorrhea Treatment Guidelines Released"
- NCBI: "Neuroendocrine Causes of Amenorrhea — An Update"