Menstrual Irregularities & Amenorrhea In Female Athletes Reducing Body Fat
In response to several requests, in 2007 I started writing an article on menstrual irregularities and amenorrhea in women who were able to achieve a high degree of muscularity and muscle definition by significantly reducing their body fat. At the time it was my experience working with female athletes that problems with their menstrual cycles were often an issue, and that there wasn’t that much in the way of literature that addressed the issues they were facing. There is sadly, mountains of male centric information with regards to getting into shape but even the magazines designed for women don’t always address certain topics. Perhaps it is a matter of certain health issues being almost taboo in our culture, but nonetheless, they do need to be addressed. I started this article relying on my own experience training women and getting them into contest level shape, and my experience with traditional Eastern medicine, however the more I wrote, the more I realized that my observations were still very limited, even though I trained a good number of women over the years. One of the problems with studies or observations of any kind is what is known as sampling error- which occurs when the number of subjects used to observe any particular effect or attribute is too small to represent a consistent aspect of the entire population. Think about getting some of your friends together and asking them all if they ever get headaches. If you have 10 friends and they all work in really high stress jobs and four of them say that they regularly get headaches, it would be erroneous to extrapolate that data to say that 40% of the population regularly gets headaches- the number is simply too small to represent the numerous variables of the general population. That being said, in my quest for a bit more universality, I put out a call to female physique competitors, fitness models and athletes to write in and share their experiences before I made any generalizations. It took two years to get over 50 detailed responses from mostly natural athletes and their coaches and the information collected was invaluable. Without their input I would not have been able to write this piece (which I finished originally in 2009) and I dedicate this updated version to each and every athlete and coach who was kind enough to share their experiences and I hope that it helps give some insight into the menstrual changes that can occur for female athletes.
Many women will have irregular or absent periods when subjecting themselves to the conventional methods of body fat reduction; usually high intensity resistance training coupled with extensive aerobic exercise and severely calorically restricted diets. Many competing in drug tested contest also employ over the counter fat burners, while many competing in non-tested events resort to prescription only thyroid medications, clenbuterol, anabolic steroids and diuretics. Whether using drugs or not many find themselves with irregular if not completely absent periods while training and dieting for their event. Lack of menstrual cycle is called amenorrhea.
About Amenorrhea In Female Athletes And Non Athletes
Amenorrhea is a menstrual condition characterized by absent menstrual periods for more than three monthly menstrual cycles. Amenorrhea may be classified as primary or secondary.
Primary amenorrhea – from the beginning and usually lifelong; menstruation never begins at puberty.
Secondary amenorrhea – due to some physical cause and usually of later onset; a condition in which menstrual periods which were at one time normal and regular become increasing abnormal and irregular or absent.
Human reproductive functions are exceptionally complex- and require a perfect synchronization of neurological and hormonal functions in order for the monthly menstrual cycle to occur.[ 1] An evolutionary failsafe of sorts designed to ensure that pregnancy does not occur under ideal circumstances. The hypothalamus is a gland responsible for regulating ovarian function and certain stressors affecting it can negatively affect the function of the ovary and induce amenorrhea.  Stressors can cause a lack of balance between eating patterns, overall energy consumption, physical and psychological stress. Stress induced amenorrhea is usually called hypothalamic amenorrhea and affect a consistent percentage of women, regardless of age.
(For the purposes of this article we will deal only with hypothalamic amenorrhea and all references to amenorrhea will refer only to this type.) While cessation of menses during pregnancy and lactation is normal, within the context of females striving for lower body fat it may be brought on by what the body sees as a form of malnutrition, or possible endocrine dysfunction brought on by the use of drugs. Most would argue that having low body fat levels are also a primary cause of amenorrhea, but as we will see- there wasn’t much solid evidence to support this common conclusion.
Menstruation is the process of changes in the endometrium, regulated by hormones from the hypothalamus, anterior pituitary gland and the ovary, and is very much a natural female monthly phenomenon. Birth control pills are often used by the general population as a way delaying, reducing or in some instances avoiding menses altogether. Athletes employ them as well so as to not interfere with performance during key competitions, and the same applies to several physique competitors wishing to ensure that they do not experience the painful cramping and increased water retention that can affect their physical appearance onstage.
Reported Female Athlete Experiences With Amenorrhea and Menstrual Irregularities:
That being said, here is a synopsis of the patterns, trends and experiences among those that I have worked with as well as those that shared their experiences.
- Most of the women who engaged in what they described as a severely restrictive diet, to reduce their fat levels did not menstruate for a month or more, with one third of respondents reporting clinically defined amenorrhea.
- Of those who experienced menstrual irregularities, all of them engaged in extensive exercise routines, with weight training and aerobic exercises for a group average of one and a half hours five times a week. (A smaller number trained more often, with one respondent reportedly training every day of the week for three hours to prepare for a contest).
- Almost all surveyed reported using over the counter fat burning supplements of some kind, however doses were not given. What was interesting is that all but one female who admitted using illegal drugs to increase their rate of body fat loss, experienced menstrual irregularities that continued well after their contests. One unfortunately reportedly that she had not resumed her menstrual flow and was seeking medical intervention as a result.
- Another unexpected and interesting occurrence was the account of one woman who experienced minor abnormalities while preparing for a contest, but stopped menstruating completely after gaining a total of 15 lbs over the course of two weeks after her contest. A result of binge eating after ending her rigorous pre-contest diet.
- Of those who did not suffer from any menstrual cessation while significantly reducing their body fat levels and increasing their muscle mass, all of the women who I worked reported a decrease in the intensity of their menses- less cramping, reduced blood flow and shorter periods overall. Which many saw as a positive occurrence.
- Of those who did not engage in calorie restricted, crash type diets, only one reported a full cessation, (she skipped one period immediately before the contest).
- Of those who did not severely restrict their fat intake during their diets, only one reported any cessation.
- Of those who trained an average of three to four times a week for less than an hour and without aerobic exercise, only two out of twelve reported temporary menstrual irregularities.
Some conclusions and thoughts:
From the information presented to me there are some observations that we can make- although I will preface any conclusions with the fact that this was not a scientifically conducted study and that there very well may be individuals whose personal experiences contradict what is published here, and I invite anyone with different experiences to share with me as well). However, there are some patterns that emerge that I would think are significant and worthy of consideration. Here are the conclusions:
Extreme Dietary Changes & Not Low Body Fat Levels As A Possible Cause of Menstrual Irregularities
In general, almost all the women who drastically reduced their energy intake while increasing their energy output through almost daily bouts of aerobic exercise experienced major menstrual irregularities. The ones who did extreme (one hour or more 5 times a week) amounts of aerobic exercise in addition to weight training were also the ones who restricted their calories the most and so it is difficult to know whether the restrictions alone brought on menstrual irregularities or if the high volume of aerobic exercise caused it- or if it was the combination of both. Without a control group doing only high volume aerobics and one doing only low calorie dieting it is hard to tell, but it is nonetheless useful to know that the combination seems to be associated (from this data) with amenorrhea. Menstrual cessation occurs early on for many of these women with the high volume cardio/low calorie regime, long before we can assume they attained their sought after low body fat levels. From this alone we can infer that low body fat may not be the reason for their menstrual irregularities. A study of long distance runners published in 1983 offers some insight into our finding, as two groups of runners with relatively equal body fat levels, fitness levels, age, training experience and aerobic exercise volumes. One group experienced irregular menstrual cycles while the other group with the same body fat percentages and training volumes did not. The conclusion was that low body fat alone cannot be considered a universal cause of athletic amenorrhea and that more research was needed to understand the causes. As insightful as the study was- it was limited in that it did not record caloric intake among individuals or the rate of change of calorie intake- which we see here may be a contributing factor.
Stress And Over Training As A Causative Factor For Athletic Amenorrhea
It is known that when the body is not properly nourished, as a preventative measure against a pregnancy that cannot be supported, menses will stop as a protective measure as both bringing a baby to term and lactation requires a significant amount of energy reserves. We also know from several studies that extreme stress brought on by exercise can cause cessations in menstrual flow.  In either case, I think it wise that many women reconsider their dietary habits, as many of the conventional calorie and macronutrient reduction methods used may very well be a cause of malnutrition. Also of note is the extreme amount of time exercising both with weights and cardiovascular type exercise, (to the point where one might begin to suspect exercise addiction.) In one respondent that was not at all a competitive athlete, but who had a similar exercise regime, she found that her periods would become erratic and eventually cease when she kept up her daily marathon sessions of hours of weight lifting followed by at least an hour and a half of aerobic exercise.
Overtraining As A Causative Factor:
Overtraining thus, can be figured in as a contributing factor in bringing about menstrual irregularities and cessation as only two out of twelve women who did not employ cardio as a part of their contest preparation suffered any changes in menstrual cycle. Of those two who did report changes one female athlete also trained six days a week and the overall finding was that the more often individuals trained, the greater the likelihood of some form of irregularities . This is underlined by the reports of those that did not have any menstrual abnormalities while reducing their body fat levels, which leads to a rethinking of the commonly accepted notion that menstrual cessation is an inevitable result of a woman significantly reducing her overall body fat.
Rate of Change In Body Fat As A Possible Cause Of Menstrual Irregularities
From my own experience working with female athletes and from the data collected, how long it takes to achieve muscle definition and reduce body fat levels appeared to be a common factor among those who reported no major irregularities. All but one woman weight training, who took five or more months to reduce their body fat reported any serious changes in menstrual cycles. Those dieting for 12 weeks or less had the highest incidence of amenorrhea and irregularities- except for those who lost only 8-10 lbs to get into onstage contest shape. One explanation being that those who lose weight gradually seem to be less likely to have menstrual irregularities as in the end almost all those reporting were in shape enough to win or place at local to regional level figure and bodybuilding contests. See also my article, Ultra Low Body Fat Is Not Healthy.
Fat Loss Without Menstrual Irregularities Or Amenorrhea In Female Athletes Is Possible:
To summarize, it is indeed possible for a woman to get into shape without any menstrual irregularities as having a low body fat percentage does not necessarily bring about problems with menstruation. However, it does require more time, and a more consistent and balanced approach that is a far cry from the usual protocols employed for contest preparation. It is my hope that there is more solid research done with women trying to reduce body fat levels to competitive levels as to date there isn’t much of anything addressing this population. Hopefully this article at least opens a dialogue about the need for more female issues being addressed and researched in the field of health and fitness. Again, my thanks to everyone who took the time to share what were very personal experiences and I hope that the article is useful for future female athletes and their trainers.
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References For Menstrual Irregularities & Amenorrhea In Female Athletes Reducing Body Fat:
- Marshall L.A. Clinical evaluation of amenorrhea in active and athletic women. Clin. Sports Med 1994
- Meczekalski B., Podfigurna-Stopa A., Warenik-Szymankiewicz A., Genazzani A.R. Functional hypothalamic amenorrhea: current view on neuroendocrine aberrations. Gynecol. Endocrinol. 2008
- Sanborn CF, Albrecht BH, Wagner WW Jr. Athletic amenorrhea: lack of association with body fat. Med Sci Sports Exerc. 1987
- Genazzani AD. Neuroendocrine aspects of amenorrhea related to stress.Pediatr Endocrinol Rev. 2005