Active Women without Monthly Menses: A Cause for Concern

Some active women feel relieved when they no longer get a monthly menstrual period. (Yes! More freedom, less dis- comfort, no more cramps.) They may believe having no period is a sign they are training hard, like a real athlete. Others believe they have stopped menstruating because they are exercising too much or have too little body fat. No. Many very thin athletes who exercise hard have regular menses.

Absence of periods (called amenorrhea) can be linked to serious health problems, including loss of calcium from the bones, almost a three times higher incidence of stress fractures today and long-term problems with osteoporosis in the not-too-distant future.

If you should want to start a family, amenorrhea interferes with the ability to conceive easily, and can also contribute to future problems with infertility (even though normal menses may have returned).

Amenorrhea is not sport-specific. Sports that emphasize lightness (ballet, running) have the highest prevalence. Up to 44% of these athletes may experience amenorrhea (as compared to 2% to 5% of women in the general population). The question arises: among a team of female athletes, why do some of the women experience menstrual problems and others don’t? The answer may relate to nutrition. Woman with amenorrhea commonly under-eat; their bodies have inadequate fuel to support the menstrual process, to say nothing of nurture a baby. Under famine-like conditions, menstruation can stop to conserve energy.

If you among the estimated 20% of active women who have missed three or more consecutive menstrual periods and are experiencing amenorrhea, please stop rejoicing and go see your gynecologist. Amenorrhea is abnormal. It can be a red flag for body image problems (i.e., claiming to feel fat even when emaciated), an intense fear of gaining weight or becoming fat, and restrictive eating. Amenorrhea is part of The Female Athlete Triad, along with low bone mineral density/stress fractures, and restrictive eating patterns/eating disorders. Amenorrhea can create undesired health issues.

Resolving the problem: If you no longer get regular menstrual periods and feel as though you are struggling to balance food and exercise, please get a nutrition check-up with a sports dietitian as well as a medical check-up with your doctor or gynecologist. To find a sports dietitian in your area, use the Academy of Nutrition and Dietetics referral networks at www.SCANdpg.org  or www.eatright.org.

The most important change required to resume menses includes matching your energy intake with your energy output, so you eat enough to support both exercise and normal body functions.

Historically, doctors gave the birth control pill to women with amenorrhea; this forced menstrual bleeding. But taking the birth control pill is a “Band-Aid approach” and does not resolve the underlying problem.

You are likely eating too few calories if you are hungry all the time and think about food too much. You can achieve energy balance by exercising a little less (add a rest day) and by eating a little more. Your goal is to consume about 15 calories per pound of body weight that you do not burn off with exercise. That means, if you weigh 100 pounds, you need to eat ~1,500 calories to maintain your weight PLUS another 500 to 800 calories to replace the fuel you burned while training. That totals 2,000 to 2,300 calories for the entire day, a scary amount of food for some women.

If eating this much sounds overwhelming to you, the following tips may help you get “back on the healthy track.”

1. Take a vacation from dieting. If you cannot let go of your compulsion to lose weight, at least be less restrictive. Cut back on your eating by only 100 to 200 calories at the end of the day, not by 500 to 1,000 calories during the active part of your Small deficits can result in losing excess body fat and are far more sustainable than the food chaos that accompanies starving-stuffing patterns.
2. Throw away the bathroom scale. Rather than striving for a certain number on the scale, let your body achieve a natural weight that is in keeping with your
3. Eat adequate protein. When you under-eat, your body burns protein for Some of the protein comes from your diet; for example, the protein in your omelet gets used for fuel instead of building and repairing muscle. Some of the protein comes from your muscles, hence, you experience muscle wasting and can lead to weaker bones and stress fractures. A 120-pound athlete should target 60 to 90 g protein/day. If you think your diet might be low in protein, track your food intake at www.supertracker.usda.gov.
4. Eat a calcium-rich food at each meal to help maintain bone Exercise alone is not enough. Enjoy milk on cereal, low fat cheese on a lunchtime sandwich, a decaf latte in the afternoon, and a yogurt after dinner.
5. Get adequate vitamin D, to help with calcium absorption and bone Sunlight on the skin helps make vitamin
6. If you are an “indoor athlete” (gym rat, ballet dancer, fig- ure skater) who gets little sunshine, be sure to choose foods fortified with D (milk, some breakfast cereals), fatty fish like salmon, eggs, and mushrooms. In the winter months, you may need to take a vitamin supplement.
7. Eat at least 20% of your calories from (healthful) fat. While excess calories from fat are easily fattening, a little fat at each meal (15 to 20 g fat/meal, or 45 to 60 g fat/day) is an important part of a sports diet. You won’t “get fat” by eat- ing Your body uses fat to absorb vitamins A, D, E and K; these vitamins are important for good health. To boost your intake of healthy fats, sprinkle slivered almonds on cereal, snack on a banana spread with peanut butter, enjoy salmon for dinner, drizzle olive oil on steamed veggies, and add avocado to your turkey sandwich.

Is there long-term damage? Loss of bone density can be irreversible and lead to early osteoporosis. The younger you are, the better your chances of recovery. Nip this problem in the bud now!

Article written by Nancy Clark, MS, RD CSSD (Board Certified Specialist in Sports Dietetics) counsels active people at her private practice in Newton, MA (617-795-1875). For more information, read her Sports Nutrition Guidebook and food guides for marathoners, soccer players, and cyclists. They are available at www.nancyclarkrd.com.