Female Athletes Who Miss Their Period May Have Functional Hypothalamic Amenorrhea
Missing Period Due to Intense Training is Not Normal
Among some female athlete circles there exist a mythical belief that when the period suddenly stops during training, it is completely normal or even expected¹. In fact, along with the decreased time on the stopwatch, missing period is even sometimes used as an indicator for training ‘hard enough’.
Such belief, however, can not withstand a closer examination. When one’s hunger cue suddenly disappears without food intake or when one’s body temperature is out of regulation, it is natural to think that something is wrong with one’s health and should therefore seek help.
Along the same line, it is hard to follow the logic that a non-pregnant previously ovulating woman has reached an improvement to her fitness level when her period has suddenly ceased.
Making up for one-third of the athlete’s triad, functional hypothalamic amenorrhea, a top cause of secondary amenorrhea (missing >3 consecutive periods in women who had at least one period prior) besides pregnancy, does not just exist among professional athletes or dancers² ³.
In fact, you don’t have to exercise to a heavy extent to encounter secondary amenorrhea⁴ ⁵. It is estimated that secondary amenorrhea affects about 1.62 million women between 18–44 in the US and 17.4 million women worldwide⁶.
Some studies even estimate about half of the exercising females experienced subtle to severe menstrual disturbance⁷.
By now some may ask: “If I am not looking to get pregnant, why is my missing period a problem?”
To understand why functional hypothalamic amenorrhea (FHA) is problematic even if one is not looking to conceive a child, we will need to look into the mechanism of menstruation, and two hormones are at the center of the cascade of events that occur in a menstrual cycle. These two hormones are Follicle-stimulating hormone (FSH) and luteinizing hormone (LH).
FSH stimulates the ovarian follicle and facilitates the egg to grow and triggers the production of estrogen in the follicle. As estrogen level rises, it signals the pituitary gland in the brain to stop producing FSH and start to produce LH.
The rising level of LH facilitates ovulation (the release of an egg from the ovary). After that, LH and FSH level decreases and we enter the luteal phase. During the luteal phase, the ruptured follicle closes after the release of the egg and produces progesterone.
The rising level of progesterone and estrogen thickens the lining of the uterus and ensures the egg is in a fitting environment for fertilization. If the egg is not fertilized, both the progesterone and estrogen level decreases and the top layers of the uterus lining starts to shed, and this is the beginning of menstrual bleeding.
Like a conductor, Gonadotropin-releasing hormone (GnRH) secreted from the hypothalamus, orchestrates the production of LH and FSH, and the LH and FSH affect the subsequent menstrual cycle.
When there is very limited energy in the body that is readily available, the production of GnRH becomes suppressed⁸. In turn, the body stops ovulating due to the lack of LH and FSH, which subsequently results in decreased estrogen or more specifically estradiol.
Estrogen is not just a reproductive hormone. It is critical for bone health in both men and women⁹ ¹⁰. A decrease in estrogen level increases bone resorption and hinders bone formation¹¹. As a result of low estrogen levels, osteoporosis can occur. Additionally, the reduced estrogen level is also linked to cardiovascular disease, mental health problems(depression and anxiety), and other metabolism issues in women⁹.
Though FHA itself is reversible, its impact on other aspects of health, such as bone health may not be easily reversible. Therefore, it is important to recognize the sign of FHA and seek proper diagnoses as well as treatment early on to fully address the fundamental of the etiology⁸.
Currently, the most effective way found to fundamentally address the FHA is to ensure the body has enough available energy via increased calorie intake and reduced energy expenditure-eat more and exercise less⁸-¹⁶. Additionally, psychological stress can affect the pituitary gland similarly as low available energy does (when you are stressed, you are putting stress on your body as well)⁸ ¹².
It is also important to note that though oral contraception pills can produce a period when taking per its full cycle, it is not considered a fundamental treatment for FHA, since its artificial hormone is masking the actual underlying issue⁷ ¹² ¹⁶ ¹⁷.
In summary, if you are an athlete, a fitness lover, or someone who newly started exercising, and you noticed that your period suddenly disappeared, you may have FHA.
It is important to seek help from a health professional to avoid developing additional irreversible health issues as a result. Meanwhile, it can help you, in the long run, to listen to your body’s needs and allow it to rest so that it can further flourish.
References:
[1]:https://www.milesplit.com/articles/211759/dear-younger-me-lauren-fleshman
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[17]:Catherine M. Gordon, Kathryn E. Ackerman, Sarah L. Berga, Jay R. Kaplan, George Mastorakos, Madhusmita Misra, M. Hassan Murad, Nanette F. Santoro, Michelle P. Warren, Functional Hypothalamic Amenorrhea: An Endocrine Society Clinical Practice Guideline, The Journal of Clinical Endocrinology & Metabolism, Volume 102, Issue 5, 1 May 2017, Pages 1413–1439, https://doi.org/10.1210/jc.2017-00131
