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Menstruation - athletic amenorrhoea

Amenorrhoea means absence of the menstrual period. Female athletes or women who perform considerable amounts of exercise on a regular basis are at risk of developing athletic amenorrhoea. It is suspected that low body fat levels and exercise related chemicals (such as beta endorphins and catecholamines) disrupt the interplay of the sex hormones oestrogen and progesterone. Long term complications of untreated athletic amenorrhoea include susceptibility to broken bones and premature ageing. Diagnosis of athletic amenorrhoea requires eliminating all other possible causes, such as diseases of the reproductive system. Treatment options include reducing the amount of exercise performed or hormone replacement therapy, in severe cases.

Symptoms
Symptoms of athletic amenorrhoea may include:

  • No menstrual period for at least three months
  • Irregular and heavy menstrual periods that only occur four times or less per year.
High risk sports
Athletic amenorrhoea is more common in certain sports and activities, including:
  • Ballet
  • Basketball
  • Cycling
  • Gymnastics
  • Long distance running
  • Swimming.
The menstrual cycle
The hypothalamus and pituitary glands in the brain interact with each other to control the menstrual cycle. The pituitary gland produces chemicals that stimulate the ovaries to produce the two female sex hormones – oestrogen and progesterone. These hormones thicken the lining of the womb (uterus) to prepare for a possible pregnancy. When pregnancy doesn't occur, hormone levels drop and the lining of the womb falls away. This is called a period, or menstruation. The cycle then repeats. Disorders of the hypothalamus, pituitary gland or ovaries can disrupt menstruation and bring about amenorrhoea.

Causes of athletic amenorrhoea
The sex hormones can be disrupted by a number of events, including:
  • Low body fat levels – the female body won't menstruate below a certain percentage of body fat.
  • Exercise – physical exertion prompts the release of certain hormones, such as beta endorphins and catecholamines, and high levels of these hormones seem to interfere with the interplay of oestrogen and progesterone.
  • Emotional stress – strong, debilitating emotions are known to affect the hypothalamus, the brain structure that oversees the menstrual cycle.
  • Disordered eating – such as crash dieting and skipping meals may be indicative of eating disorders, producing weight related amenorrhoea.
Long term complications
The long term complications of untreated athletic amenorrhoea include:
  • Infertility – a woman is unable to conceive whilst she is amenorrhoeic, but athletic amenorrhoea has no effect on long term fertility once menstruation recommences.
  • High blood cholesterol levels – caused by an oestrogen related slump in the ratio of 'good' cholesterol (high density lipoprotein or HDL) to 'bad' cholesterol (low density lipoprotein or LDL).
  • Osteoporosis – a disease characterised by brittle, honeycombed bones that break easily.
  • Premature ageing – loss of skin elasticity due to insufficient levels of oestrogen.
Diagnosis
Diagnosis of athletic amenorrhoea requires eliminating all other possible causes, such as diseases of the reproductive system. Tests may include:
  • Pregnancy tests – either urine or blood tests.
  • Physical examination – to determine overall health and the presence of secondary sexual characteristics.
  • Medical history – including gynaecological history and contraceptive methods.
  • Hormone tests – to check the functioning of the hypothalamus, pituitary gland and ovaries.
  • Other scans – including CT scans and ultrasounds of the reproductive system.
Treatment options
Treatment options for athletic amenorrhoea depend on the individual, but may include:
  • Reducing the amount and intensity of exercise.
  • Allowing a small increase in body fat levels, such as two or three kilograms.
  • Dietary adjustments, such as increased calcium and additional daily kilojoules.
  • Calcium supplements to bolster bone strength and prevent osteoporosis.
  • The oral combined contraceptive pill or equivalent hormone replacement therapy, if dietary changes and reduced exercise don't prompt spontaneous menstruation.
  • Counselling may be helpful if eating disorders are suspected.
Where to get help
  • Your doctor
  • Family planning clinic
  • Gynaecologist.
Things to remember
  • Amenorrhoea means absence of the menstrual period.
  • Female athletes or women who perform considerable amounts of exercise on a regular basis may be at risk of developing athletic amenorrhoea.
  • Causes include low body fat levels and the effects of exercise related hormones on the menstrual cycle.

    Related articles:

Menstrual cycle.
Menstruation - amenorrhoea.
Menstruation - dysmenorrhoea.
Premenstrual syndrome.
Premenstrual syndrome - treatment options.
Reproductive system.
Vaginal bleeding - irregular.


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Article publication date: 27/04/2001
Last reviewed: 30/06/2004

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