If you’re like most women, it’s something to count on once a month. Or, to be more specific, every 28 days. Your period. Between the menstrual cramps, the bloating, the mood swings and the general “Ehh…” feeling, you might feel more likely to camp out on the couch until Aunt Flo’s visit comes to an end and less likely to hit the gym.

There’s something to be said for breaking a sweat when it comes to your cycle. One medical study¹ reported women who engaged in aerobic exercises experienced fewer painful cramps, increased energy and even lighter periods. It’s not uncommon that weight loss can lead to a lighter period to begin with, but some women have reported their exercise routine contributed to a lighter flow. In addition, exercise during your period can lead to increased energy and a much-needed boost in endorphins (those feel-good hormones responsible for relieving and reducing pain). If you’re still wondering does working out delay your period? Let’s look at the facts.

So…what’s the problem? 

If you’re a woman with a normal regular exercise practice and a regular cycle, no problem at all, right? Right. But women who participate in intense exercise over a long period of time are at a heightened risk to have their period late, or for their periods to go away completely. The absence of a period for 3-6 months is called amenorrhea.

Amenorrhea can be caused by many factors, but “secondary amenorrhea” or “female athlete triad,” as it’s known in the exercise world, are the terms commonly used to describe menstrual cycles that are delayed or missed altogether due to strenuous physical activity.

Is amenorrhea dangerous?

Amenorrhea isn’t a disease in itself, but it is a glaring red flag that something in your body is not working right. 

When you experience several missed periods in a row, your body believes it’s in a “starvation state.” When that happens, your body begins to automatically shut down functions and systems of the body that are not essential for survival. 

Long term effects² of amenorrhea can be scary and include:

• Increased risk of broken bones, stress fractures and osteoporosis (it’s estimated that for every year without a menstrual cycle, a woman can lose up to 2% of her bone density)
• Heightened cholesterol
• Higher risk for cardiovascular disease
• Inability to carry a pregnancy / infertility (However, when regular periods are restored, women without other underlying fertility issues should be able get pregnant).

What’s going on in my body in amenorrhea?

For many athletes experiencing amenorrhea, it all starts in the hypothalamus. The hypothalamus is the part of the brain (located directly above the brainstem at the base of the brain) responsible for releasing hormones. Those hormones control many of the body’s systems, including the reproductive system. 

When an athlete exercises at strenuous levels for an extended amount of time, the hypothalamus stops releasing the hormones that trigger ovulation and a regular period. Sidebar: this also means the body isn’t getting the estrogen needed to promote strong bone development and keep good cholesterol in check either, among other issues.

How much exercise does it take to lose a period?

There’s no specific amount or threshold of exercise or type of exercise associated with amenorrhea, but women’s health experts agree that these are intense workouts by elite athletes. Sports medicine experts have reported that the highest number of athletes experiencing amenorrhea include ultramarathon runners, cyclists, rowers and swimmers. Since loss of a period can often go hand in hand with unhealthy weight loss, amenorrhea unsurprisingly has been reported more frequently in sports where thinness is prized – such as dancing (namely ballet), cheerleading and gymnastics. 

Amenorrhea may be more common in intense athletes, but women who exercise recreationally can also develop it. However, it is much less likely.  

Can I just correct it with birth control pills?

Birth control pills can help regulate a menstrual cycle for period-related conditions, but not in this case. Menstrual cycles kick-started by birth control pills are artificial because the pills are inducing the bleeding, not the hypothalamus. It might mask the problem, but it doesn’t correct the deficient hormone levels. Plus, birth control pills generally do nothing to help out with the trauma experienced in the bones.

Getting your period back

As with all serious health concerns, a trip to the doctor is in order, pronto. Your doctor will go through your medical history (including a general gynecological questionnaire and listing of birth control methods used in the past). They will also likely run a battery of tests to make sure all possible causes of the missed periods are identified. Some of these tests might include:

• A general pregnancy test (unsurprisingly, pregnancy is the most common cause of a missed period)
• Hormone tests to check the hypothalamus, pituitary gland and ovaries
• A dual energy x-ray absorpiometry (DEXA) scan to measure bone density (this is typically done with women with amenorrhea lasting at least six months).

Following a diagnosis, doctors will work to reestablish your menstrual cycle. If strenuous exercise is indeed the root of the problem, it’s time to cut down. Your doctor may recommend working out 10 to 15 percent less than the current intense exercise routine. If you want to continue to exercise regularly, your doctor might also suggest picking new, less strenuous, workouts. And of course, taking a day off (or days off) from exercising to rest, recover and get into the treatment plan isn’t a bad idea.  

Oftentimes athletic amenorrhea can go hand-in-hand with eating disorders, significant caloric deficiencies or extreme attempts to lose weight. If that is the case, the doctor might suggest radical dietary changes to raise caloric intake.This will circle around nutritious foods high in calcium to build back bone density and prevent osteoporosis (think milk, cheese, and yogurt). Foods rich in Vitamin D (fortified milk, fatty fish like salmon, and egg yolks) can also assist in this process, though a multivitamin will suffice. Healthy fats, like those found in peanut butter, avocado and olive oil, should also be part of this balanced diet. In order to make sure you are eating enough calories, the doctor may suggest a goal of gaining weight, usually around 0.5 to 1 lb every week³, until the goal weight is achieved. 

This is a great time for a mental health check. Many women report high levels of stress, anxiety or depression either before losing their periods or when their periods stopped. Your doctor might recommend regular talk therapy to deal with stress management and behavioral change (as well as accepting the results of that behavior change, like weight gain or decreased energy, which might be very difficult for some athletes to handle). They can also help work through any underlying body image or disordered eating behaviors (like anorexia nervosa or bulimia) that can sometimes affect athletes. Other stress relief measures, like yoga, meditation or journaling, can also be helpful.

But don’t expect your menstrual cycle to return quickly after starting these new measures. Doctors say it can take a few months even up to a year for menstruation to return to normal. And, as previously stated, women who regain their periods following amenorrhea, should be able to get pregnant.  

OK…maybe it wasn’t the exercise after all

If cutting back the intense workouts hasn’t brought your periods back to normal, it’s time to look at what else could be going on.

Amenorrhea can be caused by many factors, and these other causes should be discussed with your doctor. A few other causes of amenorrhea include:

• Pregnancy (if you’re already expecting, amenorrhea is natural)
• Contraceptives (yes, sometimes birth control pills can delay periods depending on the type)
• Certain medications (antidepressants, blood pressure meds and allergy medicines, to name a few)
• A hormonal imbalance (like PCOS or a thyroid malfunction)
• Structural problems with sexual organs, including uterine scarring or a structural abnormality in the vagina.
• High levels of stress

How can I prevent female athlete triad, or secondary amenorrhea, from happening to me?

Getting in a great workout, even if it is an intense workout, can be very beneficial for your body, mind and spirit. But when it leads to menstrual dysfunction, it goes from being something really good for you to being something potentially dangerous for you.

Remember, your body is great at telling you when something is wrong. So if you’re exercising strenuously several days a week and you experience late periods or missed periods (or really, any abnormal menstrual symptoms), cut back and call your doctor. 

Sports experts predict that amenorrhea has occurred in nearly two-thirds of women athletes⁴, and often occurs alongside negativity – like societal pressure for the “ideal body image” and pathogenic weight control behaviors (like weighing in frequently and pressuring athletes to lose if they’ve gained weight or body fat). So, it may sound simple, but watch who you have around you in the gym, whether that’s your coach or just the people who exercise with you. See to it that they’re encouraging healthy behaviors and if not, move on to people who do.

Physical fitness has its place in a healthy lifestyle. Do everything you can to make sure it stays that way.   

Citations

1: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2662100/
2: https://www.betterhealth.vic.gov.au/health/conditionsandtreatments/menstruation-athletic-amenorrhoea#high-risk-sports-for-athletic-amenorrhoea
3: https://www.aafp.org/pubs/afp/issues/2000/0601/p3357.html
4: https://www.aafp.org/pubs/afp/issues/2000/0601/p3357.html