Have you ever met someone who lost their period and thought they were lucky? Or have you ever lost your period and were happy because you thought you wouldn’t have to deal with the hassle anymore? Think again. Getting your period is a sign that your body is functioning if you’re biologically female. Even if you don’t want to get pregnant or have children, getting your period until the age of menopause is very important for your health.
What is amenorrhea?
When someone who is biologically female hasn’t menstruated in 90 days or more, or the equivalent of 3 consecutively missed cycles, it is characterized as amenorrhea. There are 2 types of amenorrhea – primary amenorrhea and secondary amenorrhea (7).
- Primary amenorrhea is when someone who is biologically female doesn’t get their period when they reach puberty.
- Secondary amenorrhea is when someone who is biologically female got their period at puberty but stopped menstruating due to underlying health conditions.
What causes amenorrhea?
When people go on a calorie-restricting diet, their intake is generally insufficient to fuel their bodies and respond to their needs. The fact that caloric restriction could lead to amenorrhea shows how negatively it affects your body. When we restrict calories, our body senses starvation, and when this caloric restriction is long-lasting, the body stops sending energy to the organs and parts of our body that are the least vital to conserve as much energy as it can.
We could say that it goes into survival mode since it doesn’t know when it will have access to food again. When in survival mode, the body’s last priority is to make reproduction possible. It is trying to protect itself and knows that it can not care for and nurture another human being when it’s barely capable of protecting and nurturing itself (2) (4).
Exercising can be beneficial for mental and physical health. However, too much of it could be very dangerous and life-threatening. Both male and female athletes are at risk of low energy availability (LEA)(when energy expenditure is superior to energy intake) for several reasons:
- Difficulty meeting the energy demands of their sport
- Intentional restriction due to body image pressures
- Restriction of certain food groups due to misinformation
- Improper fueling for their sport
One of the symptoms of LEA is amenorrhea. As previously mentioned, when the body has low energy availability, it stops the reproductive axis to focus on survival and keep the energy for the organs that are fundamental to vital functioning. Therefore, it’s extremely important that athletes and individuals engaging in physical activity understand their energy needs and plan strategies to adequately fuel their sport. If you’re worried about this, working with a sports nutrition dietitian who practices through a Health at Every Size ®(HAES) lens can be helpful (2) (4).
At times, individuals may be consuming enough energy but may restrict a specific macronutrient. Restricting carbohydrates causes a starvation response in the brain. Eating enough carbs facilitates and contributes to the communication between our neurons and our hormones that regulate the menstrual cycle. We won’t get into the cascade of events impacting this, but stay tuned for a follow-up blog post about how carb restriction impacts specific hormones in our menstrual cycle. What’s important to remember is that carbohydrates contribute to the regulation of several extremely important hormones and without them, our body may go into a starvation state, impacting ovulation and menstruation (6).
What are the physical effects of amenorrhea?
HOW LEA IMPACTS ESTROGEN
LEA has multiple health consequences: it affects hormones, bone health, menstrual function, as well as mental health. LEA also decreases estrogen levels which can lead to amenorrhea. Estrogen plays different roles in a woman’s health: it keeps the bones healthy and impacts mood regulation as well as cognitive function (8) (9).
IMPACT ON BONE
Because estrogen inhibits bone resorption, it’s obvious that lower estrogen levels can suppress bone production and increase bone resorption markers. Therefore, when someone experiences amenorrhea, bone health is impacted and the risk for bone stress injury is increased because of brittle bones. LEA and RED-S (Relative Energy Deficiency in Sports) also contribute to impaired bone health in athletes, especially in individuals who are biologically female. This explains why amenorrheic athletes experience loss of bone mass and loss of bone formation markers, also known as osteopenia, which could lead to severe osteoporosis after menopause if left untreated. If amenorrhea is a result of caloric restriction, the brittle bones could result from a lack of nutrition, specifically the lack of calcium and vitamin D, two primordial nutrients for healthy bones (1) (3) (5).
LONG TERM CONSEQUENCES
Amenorrheic adolescents are at higher risk of developing lifelong bone complications because that’s when 60% of the skeletal mass is attained. Therefore, it is hard and even impossible to compensate and regain all the bone mass during adulthood, even if menses are regained and calcium and vitamin D levels are increased. That is why it is essential to focus on prevention in this population or to treat amenorrheic adolescents quickly. Otherwise, they will have an increased risk of fractures during adulthood. Restrictive diet patterns also lead to muscle mass reduction and loss of strength, and this is why they should be treated right away, thus avoiding any long-term consequences (3). Finally, amenorrhea could cause trouble with ovulation and pregnancy if left untreated for long periods because of permanent menstrual and hormonal irregularities (8).
What are the mental effects of amenorrhea?
Impacts of limited energy availability on mental health
Limited energy availability has as much impact on mental health as on physical health. In fact, LEA in athletes correlated negatively with multiple psychological well-being aspects: bulimic tendencies, higher depressive traits, social insecurity, introversion, mood disturbances, and decreased ability to manage stress (5). Additionally, LEA could cause amenorrhea, which means that it could also decrease estrogen levels. However, estrogen secretion is what leads to serotonin secretion, a happiness hormone. Therefore, low estrogen leads to low serotonin levels which can subsequently lead to depression (8).
Seeking professional help
Amenorrhea can have very severe consequences. Therefore, it is very important to treat it and address any harmful behaviors that may be contributing to the onset. Doing so is possible by increasing energy availability, increasing energy intake, or decreasing energy expenditure. We strongly recommend seeking professional help and guidance if you’re currently suffering from amenorrhea or believe that you may have low energy availability. Seek guidance and support from a Registered Dietitian who specializes in sports nutrition and eating disorders, consult a psychologist and a medical doctor and if you’re an athlete, inform your coach about what you’re experiencing as they may be able to refer you to trusted professionals (7). Finally, try holding on to some hope! It may seem overwhelming, but most of the problems related to amenorrhea are treatable and reversible if the underlying problem is addressed.
By: Mia El-Eid, Digital Marketing Coordinator, in collaboration with Annyck Besso, Registered Dietitian
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- Myers, V. (2021, April 20). Nourishing Women Podcast: 256: Why Carbs Are Essential for Amenorrhea Recovery. Nourishing Women Podcast. https://nourishingwomenpodcast.libsyn.com/episode-256-why-carbs-are-essential-for-amenorrhea-recovery
- SCAN registered dietitian nutritionists (RDN) (2016). The Female Athlete Triad. Sports, Cardiovascular and Wellness Nutrition (SCAN). www.scandpg.org
- Shufelt, C. L., Torbati, T., & Dutra, E. (2017, May). Hypothalamic amenorrhea and the long-term health consequences. Seminars in reproductive medicine. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6374026/
- © USOPC Sport Nutrition Team. Low Energy Availability. United States Olympic & Paralympic Committee. https://www.teamusa.org/