We’re back again with another installment of the Stronger U Journal Club! Last month we took a deep dive into self-conscious emotions and how those emotions can impact someone sticking to an exercise program. This month we’re going over a topic that is familiar to a large number of our members: weight loss and menstrual irregularities.
Coach Erin Ferner and Dr. Jessica Bachman led the Stronger U staff through an awesome Journal Club meeting where we all got to learn more about how weight loss can play into menstrual irregularities, which, as we learned, is a highly nuanced topic.
This is a topic that’s highly relevant to Stronger U for a few different reasons. A large percentage of our members are female, and many of those members have gone through a significant weight loss phase at some point during their journey with Stronger U. That significant weight loss can, at times, lead to some irregularities in the menstrual cycle. If you don’t know that those irregularities can occur thanks to prolonged weight loss efforts, that could potentially be a confusing and alarming experience.
But on top of that, taking a deep dive into a topic like this is important for us as a staff, especially the males on our staff. As males, we don’t experience monthly menstruation, but we do work with clients that do. In order to be able to take the best care of our clients, we want to be as prepared as possible. Doing that includes an in-depth understanding of how a monthly menstrual cycle impacts a human body and how that cycle can be impacted by significant weight loss.
Weight loss and menstrual irregularities.
Inside the broader topic of weight loss and menstrual irregularities, we covered a few basic definitions that are important to understand and know when talking about menstrual irregularities:
- Primary amenorrhea: The absence of menarche (first occurrence of menstruation) by age of 15 in girls who have never menstruated.
- Secondary amenorrhea: The absence of menstruation in women for 3 or more months.
- Ovaries do not release an oocyte (egg) during a menstrual cycle.
- Women who menstruate fewer than 9 times out of a 12 month period (irregular periods).
- Heavy or prolonged menstrual bleeding.
- Bleeding or spotting between periods.
From here, what we talked about specifically was amenorrhea, the various causes of amenorrhea, and how those causes can be addressed so that someone gets back to normal ovarian function.
What are the general causes of amenorrhea?
- Anatomic Causes: Someone is now pregnant
- Ovarian Failure: Menopause, genetic abnormalities, immune dysfunction, etc.
- Chronic Anovulation: Hypothalamic (hormone related), Psychogenic (stress related), Exercise-associated, etc.
It’s important to know that the above isn’t anywhere close to a comprehensive list when it comes to explanations for amenorrhea. There is a multitude of reasons for amenorrhea, which is why we will always suggest you see a doctor if this is something you’re experiencing, as weight loss very well might not be a sufficient explanation for why someone is experiencing amenorrhea. From here, we’ll break down three causes of amenorrhea that typically have a nutrition/exercise component: exercise-associated amenorrhea, weight loss associated amenorrhea, and FHA.
Loss of period due to exercise volume compared to energy intake is one common component of what is referred to as Relative Energy Deficiency in Sport (RED-S)
RED-S was previously called the Female Athlete Triad because it was a blanket term that covered amenorrhea, loss of bone density, and disordered eating. We now refer to it as RED-S. The name was changed because the Female Athlete Triad included the requirement of someone exhibiting disordered eating behaviors. But in practice, many very active and athletic females that experience RED-S aren’t necessarily showing disordered eating behaviors. They’re typically just so active that they stay in a chronic calorie deficit and wind up losing their period because of it.
RED-S is associated with and presents more in women who partake in regular endurance exercise. That can show up as:
- Delayed periods, luteal dysfunction, and amenorrhea. This is typically something that happens in individuals who go from a sedentary lifestyle to a very intense exercise program.
- RED-S is typically more common in slimmer, lower-body-weight physique (middle/long distance runners, ballet dancers, gymnasts) for a number of reasons including but not limited to:
- Dietary changes
- Hormone effects of acute/chronic exercise
- Hormone metabolism (increased lean to fat ratio)
- Physical “stress” of exercise
Weight loss related amenorrhea:
Loss of menstruation does not typically happen before significant weight loss in women. Meaning that someone might have a normal cycle, go through significant weight loss in a short period of time and wind up losing their period. This loss of their period typically stems from undernutrition for an extended period of time, which is what happens during weight loss when you are purposefully trying to eat less than your body needs.
- Abnormalities in a cycle are minor and more easily reversed with weight gain.
- Evidence supports “normal” body weight to normal reproductive function.
- A BMI greater than 20 may be needed for optimal reproductive outcomes here, and research seems to suggest that a BMI somewhere between 20-30 is typically going to be the sweet spot for fertility.
Functional Hypothalamic Amenorrhea (FHA)
FHA, or Functional Hypothalamic Amenorrhea, is a form of chronic anovulation that is not due to other identifiable causes and is typically present with amenorrhea, or loss or period, of six months or longer. But for a specific diagnosis, there needs to be three consecutive months of no menstrual cycle, as well as getting hormones tested and “ruling out” other causes before FHA is diagnosed.
FHA is one of the most common reasons for secondary amenorrhea (behind pregnancy) and tends to impact around 1.62 million women between the ages of 18 and 44 in the United States, and 17.4 million worldwide. FHA can be corrected by identifying the behaviors that led to amenorrhea and correcting those behaviors. As we’ve mentioned, there are a number of different factors that can lead to FHA, but some of the most common and easily addressed behaviors include an intense calorie deficit, often and repeated bouts of intense exercise, or intense stress levels.
What are the short and long-term effects of FHA?
There are no major short-term side effects of FHA that someone typically experiences outside of the inability to get pregnant. Other than that, someone that has FHA will typically report not feeling any differently than normal, outside of their loss of menstrual cycle.
Long-term, FHA does seem to be associated with an increased risk of cardiovascular disease — which is the leading cause of death in women. So while someone who doesn’t have their normal period might feel okay, taking care of hormonal health and well-being so that they do get their cycle can be an important step for overall health and well-being. Additionally, long-term FHA can lead to loss of bone density, increases in depression and anxiety, and higher levels of stress.
The stress point here is especially important, as long-term FHA and high levels of stress can be things that play into one another. Someone might deal with higher stress levels and feel that stress be exacerbated by dealing with long-term FHA, essentially creating a stress-related feedback loop that can be hard to break out of.
What are some of the treatment options for FHA?
When treating FHA the goal is always to get back to re-establishing regular menstrual cycles. That can be accomplished a number of ways, some obvious and some not so obvious. Finding the right way to treating FHA does involve correctly identifying the cause of FHA. This, in particular, can be a challenge because many women dealing with FHA present more than one cause. This is why when working to address FHA. A few examples include:
- Lowering psychological stress levels (in one study nearly 90% of women resumed normal ovarian function after 20 weeks of cognitive behavioral therapy)
- If the cause is weight related:
- Leptin replacement therapy has become a common treatment (this should always be discussed with your doctor)
- Increasing calorie intake
- This involves stopping weight loss and even working to regain body fat
- A reduction in physical activity
It’s important as well to understand that even if someone starts eating more food and reduces their physical activity, regaining normal ovarian function can take months at a time. Just because someone has started eating more and resting their body more doesn’t mean that they’ll immediately get their period again the following month, this can take time.
What should your takeaway be?
Amenorrhea and menstrual irregularities are both highly common and highly nuanced things. Nearly every single coach at Stronger U has worked with a client who has had menstrual irregularities, and it’s a safe bet to say that a large percentage of our members who are pre-menopausal and have lost a significant amount of weight have dealt with menstrual irregularities at some point or another. If you’re going to come away from this with any sort of understanding about menstrual irregularities, this is it:
Menstrual irregularities are common and happen for a very large number of reasons, weight loss, high levels of physical activity, and stress being just a few. If you’re someone who is dealing with menstrual irregularities, it’s always recommended that you bring that up with your doctor, as it will be the easiest course of action to determine if there is some hormone-related cause that can be addressed.
On top of that, if you are someone who exercises often, has been chronically dieting, recently gone through a major weight loss phase, or are dealing with large amounts of stress in your life, it’s worth recognizing that those might be playing a role in the irregularity of your cycle. Bring those up with your coach and work to address any one, or all, of those causes. But understand that just because you’ve stopped dieting, started resting your body, or started working on your stress levels for a few weeks doesn’t mean that you will immediately regain normal menstrual function. That will take time, so patience will be key.