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Amenorrhea in Athletes

Female athletes with amenorrhea have an increased risk of osteoporosis

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Updated May 16, 2014

Female athletes running on race track
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What is Athletic Amenorrhea?

Amenorrhea is a term used to describe the lack of a menstrual period. There are two types of amenorrhea:
  • Primary Amenorrhea, in which a woman never started having regular menstrual periods.
  • Secondary Amenorrhea, in which a woman who has begun regular menstruation suddenly stops having a regular period.
Amenorrhea in athletes, sometimes called exercise-associated amenorrhea, occurs when a woman doesn't have a regular period either because she exercises too much, eats too few calories or both. In order to have regular periods women need to consume a certain number of calories and maintain around 16 percent body fat or more. If a woman has too little body fat the ovaries stop producing estrogen and the woman stops menstruating.

There are many causes of amenorrhea, but in athletes stopping your period is a warning sign that the body is under too much stress and has too little energy stores to support healthy functioning. Experts speculate that a woman stops ovulating and menstruating to protect against pregnancy during extreme physiological stress and to use any available energy to support her basic physiological processes. Intense exercise and extremely low body weight has also been linked with lower levels of the hormone estrogen which is necessary to maintain healthy bones.

Athletic Amenorrhea and Health Complications

One of the first researchers to identify the complications of athletic amenorrhea was Dr. Barbara Drinkwater. She found that female athletes with amenorrhea had significantly lower bone density than women athletes who had normal periods. When these women resumed regular periods by decreasing their training or increasing their calorie intake, they did regain a small amount of bone density, but never completely returned to normal mass density levels. It is now clear that exercise-associated amenorrhea leads to irreversible bone loss.

This was ground-breaking research because at the time it was thought that weight-bearing exercise would increase in bone density and protect women from bone loss. When athletes started to show low bone density because of the lack of regular periods, it sounded an alarm in the sports medicine community and kicked off much more research on the female athlete triad, a combination of:

The future health complications of loss of bone mass early in life can be devastating as a woman ages. The risk of stress fractures increases dramatically, but the long-term risk of severe osteoporosis that leads to bone fractures that may not heal properly as a woman ages is a real concern.

Treating Athletic Amenorrhea

Any female athlete who stops having a period should be very concerned about her health. Amenorrhea is not a normal part of training. It is dangerous and unhealthy. If you have stopped menstruating your first priority is to try to resume menstruation by:

  • Decreasing your training volume 10 to 15 percent
  • Increasing your calorie intake by 10 to 15 percent
  • Increasing your calcium intake
  • See your doctor, nutritionist or personal trainer
Women trying to overcome amenorrhea may need to gain from 2 to 5 pounds. Because body image and weight-related issues are often a part of this condition, it may be helpful for these athletes to work with a psychologist who specialized in athletes with eating disorders.

Seeing Your Doctor for Athletic Amenorrhea


If you are an athlete with amenorrhea, your doctor may do various tests to find out why your stopped menstruating. She will begin with a complete medical history, a physical examination and blood tests. She will ask about your training schedule and eating habits and may ask about any history of an eating disorder such as anorexia, bulimia or an exercise addiction. You may be asked to reduce your training intensity and duration and increase your calcium intake as well as your overall calorie intake. It is recommended that women with amenorrhea get at least 1,500 milligrams of daily calcium.

You may have a DEXA scan which is a type of x-ray that measures bone density. This helps determine your risk of developing osteoporosis.

If regular periods don't begin again within six months of making changes in exercise and diet, you doctor may consider using hormone replacement or oral contraceptives.

Even though women with amenorrhea are not menstruating or perhaps ovulating, it is still possible to become pregnant. Amenorrhea should not be considered a form of birth control.

Overcoming Athletic Amenorrhea


Amenorrhea is a serious health condition that can result in irreversible bone loss and devastating long-term health consequences. If you are an athlete who has stopped having regular periods, don't ignore it. By addressing and treating amenorrhea early, you may prevent the loss of bone and avoid serious fractures as you age.

Sources

The Female Athlete Triad, Position Stand, The American College of Sports Medicine, Medicine and Science in Sports and Exercise, 2007.

Warren MP, Chua AT., Exercise-induced amenorrhea and bone health in the adolescent athlete. Annals of the New York Academy of Sciences, 2008

Nattiv A, Agostini R, Drinkwater B, Yeager KK.,The female athlete triad. The inter-relatedness of disordered eating, amenorrhea, and osteoporosis. Clin Sports Med. April, 1994
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