What to do if you’re a competitive athlete with a missing period?

Our hypothalamic amenorrhea / female athlete triad recovery book No Period. Now What? describes the causes of HA, many of the short- and long-term effects, and offers a Recovery Plan that has worked for hundreds of women. We also offer support throughout in the form of our own experiences, anecdotes from other women in similar situations, and advice we have gleaned over our years working with women to restore menstrual cycles.

There are two major components to recovery, both of which are covered in great detail in our book, but simply put, they are to eat more and cut out high intensity exercise.

Easy, right? Except, really, not at all. It is incredibly difficult for most of us to relinquish the food myths that we have been taught over the years, to let go of the rules that we have placed on ourselves, and particularly, to gain weight. For many it’s even more difficult to stop our cardiovascular exercise, whether it be running, biking, classes, or being a ‘gym rat.’ That’s why we spend more than a hundred pages on the rationale for the recommendations, ideas to implement them, and support for all the mental work that needs to happen.

While it’s hard enough for a recreational athlete to cut out high intensity exercise, for a competitive athlete this might truly be impossible. If you’re in high school and hoping for a college scholarship, or already in college being provided funds to attend, or a professional athlete – you might not be able to just quit for a few months. There is so much riding on your ability to perform.

relay Pole_vaulter Division’s_own_earns_Camp_Pendleton_Female_Athlete_of_the_Year,_runner_up_in_Marine_Corps_award_140313-M-PC317-003 Women 60 m final during Doha 2010 World Indoor Championships, by Erik van Leeuwen

(Photo credits, L to R: Erik van Leeuwen, Atitaya Kongkaew, Sgt. Timothy Lenzo (https://www.dvidshub.net/image/1189561), Erik van Leeuwen http://www.erki.nl/pics/main.php?g2_itemId=33469, all via Wikimedia Commons)

And yet.

If you’re not getting your period through your training, there are potentially serious short- and long-term health consequences. Short term, the most obvious consequence is stress fractures that could place your athletic career in serious jeopardy. But there are also other effects like difficultly recovering from other injuries, an immune system that struggles to keep you healthy, GI issues, a heart that has to work harder than necessary…

If this is the case for you, I strongly encourage you to read our book and use it to help motivate you to make the changes that you *can* make – namely eating more (both amount and variety) as well as reducing stress. It is well documented in the scientific literature that low energy availability (i.e. the energy available to your body to maintain normal functioning, after what you’ve expended on exercise) causes negative health outcomes like menstrual cycle abnormalities, bone, musculoskelatal, and cardiovascular effects, see this female athlete triad article for an excellent review. (Please note: if you are a recreational athlete we strongly recommend cutting out high intensity exercise for the time being, in concert with increasing fuel. By far the optimal path to recovery entails addressing both eating and exercise.)

You might think that you are fueling your workouts appropriately, but did you know that hunger signals do not adequately compensate for the exercise we perform? A study in which people were either sedentary or exercised for three 40-minute sessions per day found that when they were allowed to eat as much as desired, those who had exercised ate more than those who had not, but did not eat nearly enough to make up for all the calories burned. This led to a marked energy deficit and decrease in resting metabolic rate that was observed almost immediately.

Over the long term, such an energy deficit in a woman would lead to missing periods; in a man, significantly lowered testosterone levels. If this describes you; you think that you are consuming adequate fuel but your period is still missing (or as a man you experience symptoms of low testosterone), chances are that your energy intake is not in fact sufficient. It is incredibly important to appropriately fuel your training. It is hard to perform at your peak when at a caloric deficit that is not allowing your cells and body to be fully functional.

On top of the inadvertent energy deficits that can be created by hunger signals not adequately compensating for exercise, there is also the societal component to address, the idealization of the thin, buff, model-looking girl/woman. This is particularly difficult in sports like gymnastics or ballet where physical appearance is part of the package, but even in sports where thin-ness is not an overt requirement, there is still serious societal pressure to have body fat as low as possible and continue to push to be thin, thinner, thinnest.

The Female Athlete Triad Coalition strongly suggests that all athletes undergo a pre-season screening physical that includes questions designed to uncover potentially harmful habits so that they can be addressed before turning into serious issues. The questions mirror those we suggest in our book for determining whether you might be experiencing hypothalamic amenorrhea, including:

  • Missing period, or in the case of a teen athlete, not having started menstrual cycles by age 15
  • Recent significant weight loss (more than 10lb or more than 10% of body weight)
  • Low current BMI (in our experience, anything less than 21-22 can be a warning sign, although as we describe it is definitely possible to have HA at a higher BMI.
  • Low bone density and/or recent stress fractures
  • Restricting food intake or food groups
  • And another that we discuss in the book but do not mention explicitly: Worry about weight and/or having been told to gain or lose weight?

A yes answer to any of these questions could signify a potential issue that our book can help with, particularly in the area of letting go of food restrictions to allow adequate energy consumption to hopefully recover cycles. (We strongly recommend consulting with a dietitian familiar with the female athlete triad for assistance in determining adequate energy intake.) It might be difficult to accomplish the necessary increase in available energy during the active season (although we strongly encourage you to try), but during the off-season training can be cut back to allow for the body to recover. Continued fueling after period recovery can keep menstrual cycles going after that.

We also recommend that trainers and physicians who are treating athletes with symptoms of hypothalamic amenorrhea / Female Athlete Triad, along with parents, coaches, and others who are influential in an athlete’s life review the return to play guidlines in Tables 4 and 5 in the Female Athlete Triad Coalition consensus statement in order to guide athletes to their best performance AND health.

I’ll leave you with a quote from our book, from marathon runner Jen:

Jennifer: I’m still running, but at a nice, healthy weight and cycling regularly
on my own! Plus, I’m way faster than I was when I was at my lower
weight so it just goes to show you that some extra pounds won’t hurt you.
I’m done with having kids, but it’s awesome to know that I’m on the right
track (post-HA) with calories and body fat to be able to run and train as
much as I do and still get my period each month. I was a 3:38 marathoner
prior to trying to conceive. I gained weight, had two babies, and now I’m
at a healthy weight, cycling regularly, and ran a 3:03 marathon this spring.
You CAN train hard, still get your period, and be healthy!


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