The Hidden Cost of Athletic Performance: Why Missing Your Period is Not Normal
Written by Jennifer Dreke
For many female athletes, the loss of their menstrual cycle, also known as amenorrhea, is often dismissed as a normal consequence of intense training. Some even see it as a sign of dedication to training. But a missing period is more than just an inconvenience. It is the body signaling that it is under stress, under-fueled, and out of balance.
Menstrual dysfunction can manifest differently. Primary amenorrhea is defined as a delay in the onset of menstruation after age 15. However, secondary amenorrhea occurs when someone who previously had regular cycles goes three or more months without a period. Primary amenorrhea is rare in the general population, but within female athletes it is pretty common. By age 16, as many as 53.8% of rhythmic gymnasts, 20% of middle and long distance runners, and 19% of swimmers had still not had their first period. (Calcaterra et al., 2024) Even secondary amenorrhea occurs in over half of female runners and cyclists.(Gimunová M, et al., 2022). Also in our instagram community 45% had missed their periods for over three months.
Despite the clear health risks, many athletes do not report their missing periods, due to misconception and normalization of this problem. But the truth is menstrual health is a direct reflection of overall health. Without a regular cycle athletes risk bone loss, decreased performance, metabolic disruptions, and even long-term reproductive complications.
So why do periods disappear? What are the long-term consequences? And most importantly, how can female athletes restore their cycles and protect their health?
What leads to a missing period in athletes or active women?
The menstrual cycle is regulated by a balance of hormones. The most well known are estrogen and progesterone. In the first half of the cycle, before ovulation, in what is known as the luteal phase, estrogen levels rise to stimulate the thickening of the uterine lining in preparation for a potential pregnancy. Two other key hormones, follicle-stimulating hormone (FSH) and luteinizing hormone (LH), regulate egg maturation and ovulation.
After ovulation, progesterone increases to further support this process. If fertilization does not happen, both hormones drop and trigger menstruation. (Bernstein & Beringer, 2023).
The hormonal system is very sensitive and seemingly small changes in eating habits, training habits or metabolic changes can influence the menstrual cycle. Especially in female athletes one of the primary drivers of menstrual dysfunction is low energy availability (LEA). This describes a situation in which the body does not receive enough fuel to support training demands and basic physiological functions. Hence why the most common form of amenorrhea in athletes is functional hypothalamic amenorrhea (FHA). This occurs when an athlete’s energy intake is too low or their energy expenditure is too high due to overtraining. This causes the body to reduce hormone signals needed for ovulation, which in turn disrupts the balance of reproductive hormones and lowers estrogen levels (Calcaterra et al., 2024). Over time this hormonal imbalance can stop the menstrual cycle altogether.
This issue is very often experienced in athletes in endurance, aesthetic, and weight-specific sports. These athletes may face pressure to maintain a lean physique whether it be for aesthetic reasons, like for gymnastics or figure skating, or for purported performance benefits, e.g. in runners or climbers (Calcaterra et al., 2024). It is important to note however that menstrual dysfunction is not exclusive to underweight individuals. While a low body mass index (BMI, <18 kg/m2) increases the risk of menstrual dysfunction, studies have shown that women with a normal or high BMI can experience amenorrhea as well. If there is a history of LEA, disordered eating, or significant weight fluctuations, these dysfunctions can happen. One study by Aygun Ari, et al. found that 18% of individuals with atypical anorexia nervosa (AAN) (who have a normal BMI) experience secondary amenorrhea (Aygün Ari et al., 2024). This is in comparison with 21% of individuals with typical anorexia (who have a low BMI) who experience secondary amenorrhea. Another study by Walsh, et al. that surveyed people with AAN reported that 37.5% of individuals with AAN struggle with menstrual disturbances (Walsh et al., 2023). This highlights that menstrual dysfunction is driven by energy imbalance, not just weight.
No matter the reasoning behind missing your period, be it undereating, overtraining, or metabolic factors, losing your period is a signal from your body that it is not in an optimal state for health and performance. This is not a signal that you want to ignore.
Why is it important to have a regular menstrual cycle?
Not having a regular cycle can have an impact on your:
Bone Health: Estrogen is very important for your bone density. Women build most of their peak bone mass by the age of 30. Women experiencing prolonged amenorrhea have increased risk of osteopenia, osteoporosis, and stress fractures. (Mayo Foundation for Medical Education and Research; Birch, 2005)
Cardiovascular health: Estrogen helps to protect your heart. Women with low estrogen levels due to missing periods lose this critical heart protection , thus increasing their risk for cardiovascular diseases despite doing endurance training (which is cardio-protective). (Mayo Foundation for Medical Education and Research)
Fertility: A major consequence of prolonged amenorrhea is infertility. The disruption of normal ovulation can make it challenging for athletes to conceive. However, the good news is that fertility can be restored by reducing training intensity and increasing caloric intake (Nose-Ogura, 2023).
Overall health: As previously mentioned, a missing period is a sign of LEA and hormonal imbalance, which can disrupt metabolism, bone density, fertility, and cardiovascular health, ultimately affecting both long-term well-being and athletic performance (Verhoef, et al., 2021).
Why do female athletes not report missing periods?
Despite the serious problems that come with amenorrhea, many female athletes do not report missing their period to coaches and doctors. A study by Verhoef et al. 2021 identified five key reasons for this:
Normalization of the issue - Many athletes are told that missing their period is just part of being an athlete and nothing worrisome. By the way, 30% of our instagram followers reported having heard that it is normal losing your period as an athlete.
Lack of perceived problem - Some athletes believe that missing your period has no serious consequences, especially if their performance remains unaffected.
Experienced shame and taboo - In many sports environments, menstrual health is still a taboo topic, which leads to embarrassment or reluctance speaking up about it.
Prioritization of performance - It is common for athletes to prioritize competition and training over personal health, viewing periods as an inconvenience.
Denial and avoidance - Even if some athletes are aware that something is wrong, they fear the consequences of addressing it, which may mean changing their training regimen or gaining weight/ eating more.
The common underreporting and normalization of amenorrhea contributes to the continued prevalence of menstrual dysfunction among female athletes. This leaves many unaware of the long-term health consequences of missing their periods.
If you’re missing your period, how can you get it back?
Getting your period back requires addressing the root cause, which is usually low energy availability. However, each athlete's situation is unique. These are some general strategies to consider:
→ Increase Calorie Intake
A study by Cialdella-Kam et al. 2014 found that increasing daily calorie intake by 360 kcal, primarily from carbohydrates and protein, can improve energy status and support getting your period back. However, the exact needs vary for each individual. In general, consuming enough energy-dense foods to meet your training demands is crucial. This includes a balanced intake of healthy fats, proteins, and carbohydrates to properly fuel the body and restore hormonal balance.
→ Modify Training Load
Adjusting your training days to lower the amount of high-intensity training and incorporate more rest and recovery days can aid in restoring hormonal balance.
→ Manage Stress and Sleep
Being in constant stress and having poor and irregular sleep habits can contribute to hormonal imbalances. Try to incorporate mindfulness strategies, yoga, and prioritize rest to help you manage stress.
→ Rethink Birth Control
Contrary to the belief that birth control is helpful for a regular cycle, it is more of a quick fix solution that does not address the root cause of amenorrhea. While taking hormonal birth control, the body is not ovulating, meaning the female body does not release an egg to prepare for fertilization (Catlett, T.; 2024). Instead, the experienced bleeding is known as “withdrawal bleeding” and does not result from natural hormonal fluctuations. It is not a true menstrual cycle. Hence why it is more important to regulate your hormonal cycle through nutrition and lifestyle changes before considering birth control.
→ Seek Professional Help
Reach out to a team of professionals including Registered Dietitians, doctors, and sports psychologists that can provide guidance tailored to help you get your period back. A multidisciplinary team can help support your recovery from all sides. (Is this you? Peak to Peak Nutrition can help. Fill out an application for 1:1 nutrition support here.)
Conclusion
Losing your period is not a sign of peak performance. It is a serious health concern that signals hormonal imbalance, low energy availability and potential long term health concerns.
Athletes, coaches, and health professionals should stop normalizing menstrual dysfunction and treat a normal period as a sign of health and performance.
If you know someone that might struggle with menstrual dysfunction or are affected by it, speak up about it and seek help. Your future self will thank you for it.
About the Author
Hi, I am Jenny!
I am a graduate student in nutrition and dietetics from Germany with a focus in sports nutrition. I am committed to helping athletes and active individuals fuel their bodies in a way that enhances performance and well-being. My passion for outdoor activities and integrating mind-body connection through yoga helped shape my approach for a balanced and sustainable nutrition counseling. My goal is to open a private practice as an RDN and guide people through the complex world of proper fueling.
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