An Ignored Epidemic

The latest study shows that one out of four female athletes in your care experience amenorrhea. And the ramifications for their health are truly frightening.

By Shelly Wilson

Shelly Wilson is an Assistant Editor at Training & Conditioning.

Training & Conditioning, 12.8, November 2002,

Most of us envision student-athletes as the picture of health—lithe, muscular, and hardy. But imagine intercollegiate competitions where 80-year-old women perform intricate dismounts off the balance beam, septuagenarians strain to run the 400-meter hurdles in under a minute, and 65-year-old grandmothers fall to the basketball court to wrestle over loose balls.

It sounds inconceivable, but some of the female student-athletes on your teams who appear young and strong on the outside are actually as frail on the inside as these imagined elderly athletes. And the reason is secondary amenorrhea, a condition of more and more concern to medical professionals.

A recent study by Michelle Cameron, MD, orthopedic surgeon and spokesperson for the American Academy of Orthopedic Surgeons, found that the prevalence of amenorrhea in collegiate female varsity athletes to be 28 percent, compared to two to five percent in the general population. Older studies estimate that at least 10 to 20 percent of all female athletes have the condition.

But why does the incidence appear to be growing? What are the long-term ramifications of skipping one’s period? How do you detect such a discreet condition? And what should the athletic trainer do if an athlete in his or her care is experiencing amenorrhea?

Defining Dysfunction
A woman’s cycle is regulated by two hormones in the pituitary gland—luteinizing hormone and follicle-stimulating hormone. The pituitary gland is, in turn, controlled by a gonadotropin-releasing hormone (GnRH), which is released in intervals by the hypothalamus, the part of the brain that controls reproduction, among other things. When the body is working normally, this sequence of hormonal activity signals a woman’s ovaries to produce mature eggs, ovulate, and make estrogen. When the hypothalamus stops releasing GnRH, the delicate hormonal balance is disrupted and irregular periods ensue.

Technically, any missed periods constitute amenorrhea. Some medical studies define amenorrhea as missing a year’s worth of periods after menarche has taken place. Other physicians feel three months or more without a cycle is cause for concern. But more and more professionals are pointing to menstrual dysfunction of any kind as a substantial warning.

“If a female misses a period, there’s an indication that there’s something going on that should be cause for alarm,” says Bill Evans, PhD, Director of the Nutrition, Metabolism, and Exercise Laboratory at the University of Arkansas for Medical Sciences. “Evidence shows that if a woman is irregular, or even inovulatory, she potentially has other health problems.”

Until recently, scientists believed that amenorrhea was a result of low body fat. But research over the last 15 years indicates that this is not the case. Rather, amenorrhea appears to be multi-causal. Among the factors that bring on amenorrhea are congenital abnormalities of the reproductive tract, metabolic or endocrine disorders (including malnutrition), stress, tumors or cysts, or combinations of the above.

In athletes, however, the vast majority of cases of amenorrhea stem from an imbalance between activity level and nutritional intake. For example, a female student-athlete who menstruates during her off-season may lose her periods once preseason training begins because she increases her activity level without correspondingly increasing her nutritional intake. Her body can’t sustain all functions without adequate calories and nutrition, and so reproductive mechanisms are among the first to shut down.

The Dangers
Among the most widely known health risks associated with amenorrhea is the early onset of osteoporosis—the crippling disease of low bone mass and bone fragility. Because amenorrhea, like menopause, affects the body’s estrogen levels, bone development is compromised.

A 1997 article in The Physician and Sportsmedicine states that decreased estrogen levels in young women can leach away as much as two to six percent of total bone mass per year. And the results of a University of Arkansas study released in July 2002 show that two percent of college-age women already have osteoporosis and a further 15 percent have sustained significant losses in bone density and may be on their way to developing the disease.

Why is estrogen so important to bone mass? Contrary to popular belief, estrogen doesn’t actually build bones. Rather, its role is to ensure that one’s bones absorb calcium, which they need to stay strong. Also, estrogen conserves the calcium in bones by encouraging other body systems to make more efficient use of the calcium available in one’s diet. For example, muscles need calcium to contract, blood needs calcium to clot, and nerves require calcium to send impulses. Without estrogen to keep other cells using calcium efficiently, those functions would borrow calcium from bone stores and speed bone loss.

Estrogen also helps maintain a balance between the rate of bone destruction and bone reformation. In a normal-functioning human, osteoclasts, or bone-destroying cells, continually dissolve old bone while osteoblasts, bone-rebuilding cells, continually replace it. When estrogen is low, too many osteoclasts gather at one site and destroy bone faster than osteoblasts can replace it. Generally, children and teens grow new bone faster than they destroy old, which is why their bones grow in thickness and length. Amenorrheic adolescent athletes, however, lack the estrogen to stave off osteoclasts.

“You build bone and fill your bone bank until you’re about 25,” says Jill Thein-Nissenbaum, MPT, SCS, ATC, Faculty Associate at the University of Wisconsin. “After that, you slowly start to lose bone. But amenorrheic athletes fail to fill their bone bank optimally, so they’re really setting themselves up for significant problems later in life.”

“Girls think they need bone for height, and once they reach their height, what does it matter?” adds Heidi Skolnik, MS, CDN, FACSM, President of Nutrition Conditioning, Inc., in Fort Lee, N.J.. “But it’s not just the length of bone that matters, it’s the density of your bone. And you lay down all the density you will ever have in your lifetime in your teenage years. If a female athlete misses that window, she can’t make it back.”

The toll amenorrhea can take on a young athlete’s bones can also be felt immediately. For those still competing, low bone density often compromises their participation in the form of stress fractures.

“We did a survey years ago with women runners,” says Evans. “And it turned out that the women who were amenorrheic had a much higher incidence of stress fractures than the women who were regularly menstruating. So it’s not just an issue of, ‘I’ll develop osteoporosis when I’m 70 years old.’”

Other effects of early bone loss can pop up only a few years after an athlete’s competing days end. “I know a patient who [was amenorrheic, and when she got older and] wanted to have a baby, she couldn’t because her bones were too weak to support a pregnancy,” says Nancy Clark, MS, RD, Director of Sports Nutrition Services at Sports Medicine Associates in Brookline, Mass.

And amenorrhea may have a more direct impact on a woman’s fertility. Some healthcare professionals, like Thein-Nissenbaum and Skolnik, believe long-term amenorrhea may prevent regular, reliable, ovulation even after menstruation has returned.

“Women who continue to have bouts of amenorrhea are eventually going to discontinue ovulating periodically, and that’s going to make it much more difficult for them to get pregnant,” says Thein-Nissenbaum.

Others believe once an athlete is back on track and menstruation is reinstated, fertility resumes as normal. But the obstacle to definitive scientific information is the relatively short time doctors have been examining the condition.

“Unfortunately, this condition has only been defined in the last 10 or 15 years, and those women are just now starting to have children,” says Thein-Nissenbaum.

Another potentially serious health implication of amenorrhea that is on now being looked into is heart disease. Although not widely researched yet, the increased risk in post-menopausal women for cardiovascular disease led the Medical College of Wisconsin’s Cardiovascular Research Center to undertake a study of amenorrheic female runners in 2000. It was presented to the American College of Sports Medicine last year.

The Center studied two groups of women, all of whom ran at least 25 miles per week, were at least 18 years old, and were not on oral birth control. One group, of 11 women, had normal periods. The other group consisted of 10 women, all of whom had missed their periods for more than six months. Because a loss of blood vessel dilation is believed to be the first precursor to the development of heart disease, each participant’s blood vessels were examined using ultrasound to measure their ability to dilate under different conditions. The women with amenorrhea had the vasculature of 50-year-old postmenopausal women.

Battle Cry
With so much more to be learned about the effects of the condition, many physicians would like to see amenorrhea taken more seriously by the athletic population. The problem, they say, is that many of the known major health problems associated with amenorrhea will not set in in earnest for years to come, making it easy for athletes to disregard them.

“There’s not a real good appreciation for the magnitude of the problems and what amenorrhea is caused by,” says Evans. “And athletes aren’t as concerned as they should be.”

But these same experts say athletic trainers can play a big part in limiting the damage done by stepping up as the first line of defense against amenorrhea. “The athletic trainer should be the advocate for the athletes’ overall health, whether physical or mental,” says Thein-Nissenbaum. “And they’re the perfect people to detect amenorrhea, because they see the athlete day in and day out. The ATC may even be the person the athlete comes to first, because he or she is someone the athlete trusts.”

As with many things in athletic training, an ounce of prevention is worth a pound of cure, and the key to preventing amenorrhea is communication and education. For some athletic trainers, the first step is going to be overcoming the discomfort of discussing women’s periods. Evan’s advice is to just get over it.

“Ask the questions, so your women athletes at least understand that amenorrhea is a concern,” says Evans. “If you completely ignore it, the female athlete will as well.”

One of the first groups to educate about the condition is coaches. Because of the direct and indirect influence they have on the habits that can lead to amenorrhea—like increases in activity, diet, and body image—it’s important that they be informed about the condition and its negative effects. Doctors have witnessed cases, for example, where amenorrheic athletes refused treatment that could cure the condition because their coaches told them it was normal for elite athletes to miss their periods.

“The coach controls an athlete’s life, and sometimes coaches at the high school and college levels don’t have a clue about important health issues,” says Evans. “So a coach’s lack of information can be a huge problem for a female athlete.”

Skolnik suggests hosting a seminar to go over the coach’s role in building a healthy athlete. In it, an athletic trainer could cover amenorrhea as well as things like the coach’s part in athlete hydration, overuse injuries, healthy eating on the road, and the female athlete triad.

Thein-Nissenbaum agrees. “Offering to do in-services is a great strategy to educate coaches,” she explains. “You can provide them information on how the healthy athlete does so much better than the chronically injured athlete, and how a positive nutritional status is important.”

A similar tactic might also be useful with female athletes. An annual workshop could help athletic trainers set the record straight on a number of topics relevant and specific to the female athlete, including amenorrhea, and dispel the bad information athletes may have learned from former coaches and even uninformed family doctors. Particularly powerful are presentations from or stories of formerly amenorrheic athletes. Postings on bulletin boards or handouts can also work well.

But, in all formats, athletic trainers must work to counter menstruation’s image as a burden and promote it as an asset necessary for overall health. They must also be quick to dispel its myths and its status as something only women discuss.

“When I go talk to athletes,” says Skolnik, “it becomes evident that not everybody working with the athletes is as informed as they should be, never mind the athlete or the athlete’s parents. Part of that is because talking about periods is not common. And athletes need to know that you’re not seeking this information to penalize them. It’s to help them stay as healthy as they can be throughout their season, career, and lives.”

According to Skolnik, parents are another group that should be addressed. “One of the things we do at the School of American Ballet is send out a letter at the beginning of the year informing parents about amenorrhea and letting them know that it’s something we look for, what we do if we find it, why it’s important, and that it’s something for them to pay attention to,” she says.

Making some minor adjustments in the athletic training room can also play an important part in preventing amenorrhea. One suggestion is to change how and when weight scales are used with athletes.

“Some coaches are very concerned with the numbers on the scales,” says Thein-Nissenbaum. “And that makes the athlete a victim of everyone else’s mindset. But there are more and more teams that aren’t doing weigh-ins weekly. Or if they are, they’re not having athletes weigh in in front of everyone. And more athletic trainers are looking at body composition as a whole and body mass index or underwater weighing. Then they adjust strength training and conditioning programs, as well as nutrition, accordingly. So dismissing the numbers game can help.”

And because amenorrhea can result from exercise that outpaces nutritional intake, or from rapid weight loss, Thein-Nissenbaum reminds athletic trainers to proceed cautiously when weight loss is required for optimum athletic performance. “One or two pounds per week is ideal,” she says. “You don’t want to lose more than two pounds a week, or the athlete is probably going to get dehydrated and lose muscle mass. And athletes shouldn’t try to lose weight in the peak of the season, because it’s too much stress on the body.”

Early Detection
Since amenorrhea is vastly under reported by sufferers, medical professionals would also like to see educational efforts coupled with earlier detection of the condition in order to minimize health risks. For athletic trainers, carefully timed and worded questions throughout the year can go a long way in uncovering amenorrhea in female student-athletes.

The obvious time for making inquiries into athletes’ menstrual cycles is during preparticipation exams. In fact, the American College of Sports Medicine is in the process of rewriting the questions on its preparticipation form surrounding menstruation. Until the new form is issued, athletic trainers can include questions such as the following:

• When did you first get your period?
• Are you regular?
• If you’re not very regular, how regular are you?
• How long is your typical cycle?
• Do you often skip your period?
• How many times a year do you miss a period?

“Amenorrhea should be on the list just like everything else,” says Skolnik. “‘Do you sneeze, do you cough, do you have weak ankles, and do you get your period?’”

Also, don’t accept vague answers. A reply of “normal” to the question “What’s your menstrual cycle like?” can mean very different things to different athletes. It might be normal in her mind to miss her period for the six months of preseason and in-season training.

If during the preparticipation screening an athlete states that she is on the pill or another form of chemical contraception, athletic trainers should push for more information as to why. “I often ask patients, ‘If you weren’t on the pill, would you have regular menstrual periods?’” says Clark. “And often they say, ‘That’s why I went on the pill.’”

Also note that a student-athlete using oral birth control, a contraceptive patch, or Lunelle (a monthly birth control shot) isn’t immune to developing amenorrhea, despite the estrogen they contain. “The dose of estrogen a woman gets from the pill is very small compared to her loss of estrogen as a result of amenorrhea,” says Evans. “And the studies that have treated women with estrogen to cure amenorrhea have used much larger doses than are found in birth control pills.”

Athletic trainers should also question female athletes periodically throughout the year about any changes they’ve experienced in their cycles. “If an athlete is returning after summer and is answering preparticipation exam questions, she may be able to say she has her period,” says Skolnik. “But by Christmas time, she may not.”

Questions on amenorrhea should also automatically arise whenever a female athlete suffers an injury. “When you do not get your period, you have an increased risk for stress fractures,” says Skolnik, “so I’d absolutely investigate menstrual history anytime an athlete has a stress fracture. You can have a stress fracture and still be getting your period, but very often, an athlete won’t have been.”

“Prolonged delayed healing is another good thing for athletic trainers to look for if they suspect an athlete has amenorrhea,” adds Thein-Nissenbaum. “These are the athletes who get the stress fractures that take double the time to heal. They have chronic strains and sprains from their muscles not being provided adequate nutrition. And their healing rate for overuse injuries such as tendinitis is significantly longer as well.

“But amenorrhea can affect performance even before injuries appear,” she continues. “These are the people who are chronically fatigued because they have a negative energy balance. These are the gymnasts who are so tired that they fall off the balance beam because they don’t have enough endurance in their muscles to hold themselves upright. So I think even before a stress fracture comes on, there are certain signs that an athlete might be headed toward trouble.”

The causes of amenorrhea can vary widely, so athletic trainers who know of or suspect student-athletes with amenorrhea should always refer the patient to a physician or gynecologist who’s sensitive to the needs of student-athletes. Sometimes amenorrhea can’t be corrected by simply cutting back training or increasing nutritional consumption, and athletic trainers who try to cure it on their own delay proper diagnosis and put the student-athlete at risk.

“There are lots of reasons why you don’t get your period,” explains Skolnik. “I had one athlete who looked like it was caused by the female athlete triad, but she really had polycystic ovarian syndrome. And it took a good work-up from a doctor to figure that out.”

The best thing you can do, say experts, is to make sure your student-athletes are aware of the condition, understand the health problems associated with losing one’s period, and learn to come to you whenever their cycles seem irregular. “A woman should understand that losing her period is not natural,” says Evans. “It’s not something that should be desired or emulated. It comes with a number of health consequences and should be dealt with as soon as possible if she wants to continue with her athletic career. Because by the time they stop menstruating, even intermittently, it means there’s a problem already.”

SIDEBAR: Appetite For A Cure
Today, the most favored treatment of exercise-related secondary amenorrhea comes not in the form of estrogen supplementation, but through changes to an athlete’s diet under the guidance of a licensed nutritionist. And while athletic trainers should never attempt to treat amenorrhea themselves, there are nutritional recommendations you can make that may help prevent the onset of amenorrhea in the first place.

“Amenorrhea frequently stems from over-exercise and under-eating,” explains Heidi Skolnik, MS, CDN, FACSM, President of Nutrition Conditioning, Inc., in Fort Lee, N.J. “It’s an energy deficit thing. A female athlete may think she is eating healthfully but may be 500 calories shy of what she needs. She may not be anorexic or even losing weight, but she’s not giving her body what it needs to sustain itself at an optimum healthy level. So athletes need to make sure that when they step up their training that they also step up their food intake. Their calories in need to be equivalent to their calories out.”

One survey on the dietary habits of female runners showed that only 40 percent of the subjects questioned were eating more than 2,000 calories a day, despite running an average of 10 miles per day. The average daily caloric intake for the amenorrheic runners in the study was 1,600 calories, whereas menstruating runners in the survey consumed 2,500 calories per day on average.

One dietary way to prevent amenorrhea is to insist on the inclusion of fat in your players’ diets. “Athletes confuse eating fat with getting fat,” explains Nancy Clark, MS, RD, Director of Nutrition Services at Sports Medicine Associates, in Brookline, Mass. “But that’s not true. Fat is a part of the body’s nervous system, it’s a component of hormones, and it’s important in allowing certain vitamins to get absorbed. At least 20 percent of an athlete’s calories should come from fat. Nuts, peanut butter, salmon, and olive oil are all healthy fat options. And female student-athletes should try to include a little fat at each meal. That could mean using two-percent milk on cereal or substituting a light salad dressing for a fat-free one.”

Another important nutritional defense is adequate protein. “Insufficient protein has been linked with amenorrhea in conjunction with low calorie intake,” explains Clark. “Amenorrheic athletes tend to eat less protein than their regularly menstruating counterparts. And when calories are low, the body’s protein needs actually increase.”

Keeping red meat in the athlete’s diet is one sure way to incorporate protein, but even for vegetarians, it’s possible to provide the body with plenty of the crucial nutrient. Clark recommends peanut butter, tofu, and beans as good protein options for vegetarians, and adding cottage cheese and yogurt for those who eat dairy.

Calcium and Vitamin D are also important, not only because the foods they often come in add needed fat to an athlete’s diet, but also because of the positive role they play in the prevention of osteoporosis and the minimization of bone-density damage should a female athlete suffer amenorrhea. “I would look for some dairy with each meal, so they have at least three dairy items a day—like milk on cereal, yogurt at lunch, milk with dinner, or low-fat cheese on a sandwich,” Clark says.

Calcium supplementation is also recommended by the National Institute of Child Health and Human Development (NICHD). In 1997, an NICHD-supported study found that calcium supplementation of diets in girls ages 12 to 16 resulted in a 14 percent increase in bone density. It sounds insignificant, but for every five percent of increase in bone density, the risk of fracture declines by 40 percent.

Sidebar: Dispelling the Myths
Educational efforts should concentrate on dispelling some of the popularly held beliefs that surround women’s menstrual cycles. Among them are:

Skipping periods is normal. It might be common among female athletes they know, but what’s common and what’s normal are very different things. Once a female begins menstruating in her teens, she should continue to get her period every month. Her cycle may fluctuate in length, but to not have a period at all is not normal.

It’s hassle-free birth control. Wrong, say experts. Although an athlete may not have had her period for months, and thus believes she is not ovulating, there’s no telling when her body might resume ovulation and menstruation. Amenorrheic women have found themselves pregnant as a result of this misguided method of contraception.

It’s a sign of success. For some athletes, amenorrhea is celebrated as a sign that they’re a real athlete. “In some sports and on some teams, amenorrhea is looked upon as evidence that they’re doing an appropriate amount of training,” says Jill Thein-Nissenbaum, MPT, SCS, ATC, Faculty Associate at the University of Wisconsin. “If you still have your period, the perception is that you’re not training hard enough. But using amenorrhea as a bar to measure effective training is completely inappropriate.”

It’s no big deal. The physical toll amenorrhea can exact on one’s body are genuine and a concern. Among the least serious are stress fractures and delayed healing from injuries. More frightening is its documented influence on the early onset of osteoporosis, its suspected ties to early heart disease, and its still uncertain impact on a woman’s long-term fertility.