Menses Requires Energy: A Review of How Disordered Eating, Excessive Exercise, and High Stress Lead to Menstrual Irregularities

Clin Ther. 2020 Mar;42(3):401-407. doi: 10.1016/j.clinthera.2020.01.016. Epub 2020 Mar 2.


Purpose: Functional hypothalamic amenorrhea secondary to low weight, excessive exercise, and/or high levels of stress is common among young women. Adolescence is a time in development that a positive energy balance is crucial for puberty, menarche, and regular menstruation. Disordered eating and eating disorders are the third most common chronic illness and tend to start during puberty. High-level athletes, specifically young girls participating in ballet, running, gymnastics, and figure skating, are at risk of developing hypothalamic amenorrhea from excessive exercise and inability to meet the energy needs of the body. Dysfunction of the hypothalamic-pituitary-ovarian axis leads to a hypoestrogenic state. Low levels of estrogen have a negative effect on bone health, sexual maturation, sexual function, and fertility. Puberty has the highest rate of bone accrual in a female's life. Adequate nutrition, physical activity, and estrogen are crucial for bone development and prevention of osteoporosis. Recognition and early intervention are necessary to limit the irreversibility of some of these effects.

Methods: A review of literature was completed to gather epidemiologic data, pathophysiology, diagnostic criteria, recommended laboratory/imaging, and approaches to treatment.

Findings: According to the American College of Obstetricians and Gynecologists, 16% to 47% of slender female athletes have disordered eating, which makes them at risk for functional hypothalamic amenorrhea (FHA). Most women present with previously regular menstrual cycles until there was a change in one or multiple factors, including weight, stress, and/or exercise. Athletes have a higher incidence, stemming from the synergistic relationship that exercise and low weight have on puberty and the menstrual cycle. FHA is a diagnosis of exclusion; therefore, eating disorders and other etiologies of menstrual irregularity need to be ruled out first.

Implications: Hypothalamic dysfunction leads to a hypoestrogenic state within the body. Low levels of estrogen manifest in multiple ways: amenorrhea, low bone mineral density, vaginal and breast atrophy, infertility, and dyspareunia. The goal of treatment of FHA and these downstream symptoms is weight gain with spontaneous resumption of menses, as this is the best indicator that the hypothalamic dysfunction and hypoestrogenic state have been resolved. In refractory cases of FHA, it may be necessary to replace hormones with physiologic dosing of transdermal estrogen and cyclic progesterone for the benefit of the young woman's bone health (Clin Ther. 2020;42:XXX-XXX) © 2020 Elsevier HS Journals, Inc.

Keywords: Adolescent gynecology; Amenorrhea; Functional amenorrhea; Menstrual cycle; Menstrual irregularity.

Publication types

  • Review

MeSH terms

  • Adolescent
  • Exercise*
  • Feeding and Eating Disorders*
  • Female
  • Humans
  • Menstruation / physiology
  • Menstruation / psychology
  • Menstruation Disturbances*
  • Stress, Psychological*