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All About Exercise-Induced Amenorrhea

[Listen to an audio version of this blog HERE.]

I didn't have a single period for nearly five years. During this time, I was running competitively at the collegiate level and battling an eating disorder. Each year at my annual physical, my doctor would ask the date of my last menstrual cycle. "2 years ago," I'd answer. "3 years ago." "4."

Not having a period was convenient; I didn't have to remember to pack tampons when my team traveled to track meets. Never had to worry about getting my period at an inconvenient time or endure ugly menstrual cramps. Not getting my period, in hindsight, made me feel substantially less feminine, especially when coupled with my eating disorder. My boobs shrunk, my sex drive was nonexistent, and I was running faster than I ever thought possible (for a while, before my body broke down). In some ways, shunning my period was met with praise. My doctors said nothing was wrong; I'd lost my period because I was highly active. My coaches (all men) didn't know that the loss of a menstrual cycle was cause for concern. And I simply didn't want to talk about it. It was easier to believe my doctors when they said nothing was wrong. It was simpler to shut up about it, enjoy my time unencumbered by blood, and take care of any problems it might cause later.

Some people might be born with an ability to stand up for themselves in any situation. I may have been that person had the world not beaten it out of me. Not taught me that women should be small and silent. Not impressed upon me the notion that I should believe those in power, who just happened to be men, and who just happened to be wrong sometimes, like anyone. Much has been written about feminism-it's bastardization, it's necessity. Anecdotally, I know that the world is overwhelmingly sexist. Anecdotally, I have experienced being belittled and silenced and shunned. When you scream loud enough and nobody hears, you eventually stop screaming. It is exhausting to continually attempt to explain to men (and to some women) how critical the non-bastardized version of gender equality is. There are so many factors that add up to misogyny that any one story will not suffice to show the whole picture. This is just one story, but there are innumerable more. Most have never been told.

Twice, I asked my team doctor if it was bad that I hadn't experienced a menstrual cycle in 2, 3, 4 years. She was a doctor, but she was also overwhelmed with too much work and too little time. "It's fine," she said, "you're just very active, this happens sometimes." Because I didn't think my voice had any power or influence over my own body, I took her words as truth. Twice, my coaches told me to lose weight if I wanted to be a good runner, and I believed them. Twice, I starved myself thin only to peak and then burnout with injury. The ramifications of training so hard with inadequate fuel were multifaceted and complex. Constant fatigue, fucked up hormones, poor mental health, poor social health, and low self-esteem were just some of them. Losing my period was just one sign of physical decline, coupled with bad skin, thinning hair, low body temperature, and poor intestinal health. This is a story of internalized sexism, because I listened to other people instead of myself. It is a story many women can tell, but we don't have to.

I'm writing specifically about exercise-induced amenorhhea because that's what I experienced and it's also the most common cause. My biggest takeaway, however, is to advocate for your own health. I believed my doctor, but I could have gotten a second opinion, and should have. I'm going to break down the signs and complications associated with amenorhhea so you can *hopefully* catch it early.

What is Ammenorhea?

Amenorrhea (uh-men-o-REE-uh) is the absence of menstruation. Specifically, one or more missed menstrual periods. Women who have missed at least three menstrual periods in a row have amenorrhea, as do girls who haven't begun menstruation by age 15. Sometimes hormones are to blame for the loss of a period, and that's an entirely different conversation. The cause of exercise-induced ammenorhea is (obviously) too much exercise, paired with inadequate nutrition. Three specific factors combined greatly increase one's risk of amenorrhea:

  • Low body weight. Excessively low body weight interrupts many hormonal functions in the body and can potentially halt ovulation. Women who suffer from eating disorders often stop having periods because of these abnormal hormonal changes. Women need 10-12 percent body fat for essential functions, and perform best within 14-20 percent. When body fat is too low, some body systems that aren't entirely "necessary," such as menstruation, shut down.

  • Excessive exercise. Women who participate in activities that require rigorous training, such as ballet, swimming, running, or gymnastics, may find their menstrual cycles interrupted. Several factors combine to contribute to the loss of periods in athletes, including low body fat, stress, high energy expenditure, inadequate nutrition, and inadequate rest.

  • Stress. Mental stress can temporarily alter the functioning of your hypothalamus — an area of your brain that controls the hormones that regulate your menstrual cycle. Ovulation and menstruation may stop as a result. Regular menstrual periods usually resume after your stress decreases. For me, the stress of maintaining my GPA coupled with the stress of performing at a high level likely contributed to my amenorrhea.

Complications of Ammenorhea

By the time I saw a doctor who was concerned about my lack of period, I hadn't had one in roughly five years. She told me there are a few risks associated with not menstruating, the most immediate of which is infertility. Obviously, if you don't menstruate you can't become pregnant and even after regaining a menstrual cycle, some women have a hard time conceiving. She also told me that my risk for ovarian cancer may increase. Finally, if your amenorrhea is caused by low estrogen levels, you may also be at risk of osteoporosis and subsequent bone fractures.

Women who lose their periods are also at an increased risk of experiencing RED-S (relative energy deficiency in sport). RED-S is a syndrome in which disordered eating (or low energy availability), amenorrhoea, and decreased bone mineral density (osteoporosis and osteopenia) are present. The graphic to the left shows the many side effects of RED-S. What is typically known as the the "female athlete triad" is only a smart part of RED-S. A conversation about amenorhhea would be incomplete without mention of RED-S and the female athlete triad. If you notice multiple signs, talk to your doctor.

How to Avoid and Treat Ammenorhea

Treatment depends on the underlying causes, but in the case of exercise-induced amenorrhea, the best course of action is to dial back the exercise and increase nutrition/rest. My doctor also prescribed birth control,which didn't really work. The only thing that helped me regain my period (and not give up running) was consistently eating enough. Balance is difficult sometimes, especially for athletes who live and breathe the "all or nothing mentality." However, my performance only improved when I gave my body rest and fuel. If you lose your period for more than two consecutive months, talk to your doctor. If you doctor doesn't listen or shrugs off your concerns, talk to another doctor. It is not normal or healthy to stop menstruating, and the long-term effects can be damaging.

P.S. Read one of my earlier blogs about losing my period here. Read more about the female athlete triad here, or watch a video all about RED-S here.


Sarah Rose

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