Tawnee recently featured the elite runner Tina Muir on Endurance Planet, where she shared her journey about getting her fertility back. As I was also dealing with HA (hypothalamic amenorrhea, aka no period because of over-exercise and under-eating), I found Tina’s story really inspirational.

Still, I’ve been feeling discouraged for having gone an eternity (cough, cough 8 weeks) without exercise and gaining an uncomfortable amount of weight without any certainty of when I’m going to get my period back. What motivated Tina through those dark patches was her goal of trying to conceive (TTC). But that’s not my goal. I don’t want kids in the near future. A loud part of me says, “Just keep doing Ironman, stay super lean, and you’ll sort this out when you actually want kids later.”

WRONG! This is so wrong! Ladies, no matter if you want kids or not, it is a major problem if you’re not menstruating regularly. Below is a list of some scary, scientifically-proven health consequences associated with HA:

  • Impaired heart health
    • Low levels of estradiol result in endothelial dysfunction and abnormal changes in the lipid profile. And you know what these irregularities lead to? Cardiovascular disease.
      • Not-so-fun-fact: Cardiovascular disease is the leading cause of death in women in developed countries. Numerous studies have shown that women with HA are higher at-risk for coronary artery disease than regularly menstruating women. 
  • Decreased bone mass density
    • In the short term, this increases the likelihood of fractures (every runner’s worst nightmare)
    • In the long term, this drastically increases the likelihood of osteopenia and osteoporosis, which are irreversible conditions.
  • Increased risk of early onset degenerative brain disease
  • Significantly higher rates of depression and anxiety
    • Estrogen plays a major role in regulating mood, so when your serum sex steroid levels are low, cue the breakdowns.

The heart health factor was the biggest wakeup call for me. Osteoporosis is debilitating, but a heart attack could kill you! The reason why many of us got into health and fitness in the first place was to maximize life expectancy and quality of life. But when you take health and fitness to the extreme and wind up with HA, you’re contributing to the exact opposite of that ideal. And osteoporosis is pretty terrible too. I want to be doing my sport for decades (qualifying for Kona or the Boston Marathon at 80 sounds like a pretty cool goal). You can kiss that dream good-bye if your bones are prone to stress fracture at the slightest stimulus. Also, let’s talk about early onset degenerative brain disease… you’re willing to risk your brain capacity so you can look hot in a sports bra and short shorts and podium at your next race?! I’m sorry to be harsh or slightly dramatic, but the fact is, this kind of hard, honest talk is necessary.

I’ve referenced almost ONE HUNDRED scientific studies below backing me up here. This is a highly studied problem with conclusive evidence that HA is seriously dangerous, way beyond causing infertility.

So next time you’re doubting yourself for going “all in” for recovery, think of these facts. Get real with yourself. This isn’t about having a baby. This is about living a long, healthy, functional life. Apply your superhuman capacity for discipline to hold strong to your purpose. Because here’s the really good news: if you recover from HA then all those wonderful hormones will repair the damage that’s been done! So eat, rest, and recover, ladies. I’m right there with you.

—Samantha Morse

 

References:

1. Berga SL, Mortola JF, Girton L, Suh B, Laughlin G, Pham P, Yen SS. Neuroendocrine aberrations in women with functional hypothalamic amenorrhea. J Clin Endocrinol Metab. 1989;68:301–308. doi: 10.1210/jcem-68-2-301. [PubMed] [Cross Ref]

2. Gordon MC. Functional hypothalamic amenorhea. N Engl J Med. 2010;363:365–371. doi: 10.1056/NEJMcp0912024. [PubMed] [Cross Ref]

3. Genazzani AD. Neuroendocrine aspects of amenorrhea related to stress. Pediatr Endocrinol Rev. 2005;2:661–668. [PubMed]

4. Meczekalski B, Podfigurna-Stopa A, Warenik-Szymankiewicz A, Genazzani AR. Functional hypothalamic amenorrhea: current view on neuroendocrine aberrations. Gynecol Endocrinol. 2008;24:4–11. doi: 10.1080/09513590701807381. [PubMed] [Cross Ref]

5. Harlow SD. Menstruation and menstrual disorders : the epidemiology of menstruation and menstrual dysfunction. In: Goldman MB, Katch M, editors. Women and Health. San Diego: Academic Press; 2000. pp. 99–113.

6. Practice Committee of the American Society for Reproductive Medicine Current evaluation of amenorrhea. Fertil Steril. 2006;86:S148. [PubMed]

7. De Souza MJ, et al. High prevalence of subtle and severe menstrual disturbances in exercising women: confirmation using daily hormone measures. Hum Reprod. 2009;25:491–503. doi: 10.1093/humrep/dep411. [PubMed] [Cross Ref]

8. Otis CL, et al. American college of sports medicine position stand. The female athlete triad. Med Sci Sports Exerc. 1997;29:1–9. [PubMed]

9. Valdes-Socin H, Rubio Almanza M, Tomé Fernández-Ladreda M, Debray FG, Bours V, Beckers A. Reproduction, smell, and neurodevelopmental disorders: genetic defects in different hypogonadotropic hypogonadal syndromes. Front Endocrinol (Lausanne) 2014;5:109. [PMC free article] [PubMed]

10. Berga SL, Daniels TL, Giles DE. Women with functional hypothalamic amenorrhea but not other forms of anovulation display amplified cortisol concentrations. Fertil Steril. 1997;67:1024–1030. doi: 10.1016/S0015-0282(97)81434-3. [PubMed] [Cross Ref]

11. Laughlin GA, Dominguez CE, Yen SS. Nutritional and endocrine-metabolic aberrations in women with functional hypothalamic amenorrhea. J Clin Endocrinol Metab. 1998;83:25–32. [PubMed]

12. Marshall LA. Clinical evaluation of amenorrhea in active and athletic women. Clin Sports Med. 1994;13:371–387. [PubMed]

13. Funes S, Hedrick JA, Vassileva G, Markowitz L, Abbondanzo S, Golovko A, Yang S, Monsma FJ, Gustafson EL. The KiSS-1 receptor GPR54 is essential for the development of the murine reproductive system. Biochem Biophys Res Commun. 2003;312:1357–1363. doi: 10.1016/j.bbrc.2003.11.066.[PubMed] [Cross Ref]

14. Roa J, Tena-Sempere M. KiSS-1 system and reproduction: comparative aspects and roles in the control of female gonadotropic axis in mammals. Gen Comp Endocrinol. 2007;153:132–140. doi: 10.1016/j.ygcen.2007.01.026. [PubMed] [Cross Ref]

15. Sills ES, Walsh AP. The GPR54-Kisspeptin complex in reproductive biology: neuroendocrine significance and im- plications for ovulation induction and contraception. Neuro Endocrinol Lett. 2008;29:846–851. [PubMed]

16. El Bahh B, Balosso S, Hamilton T, Herzog H, Beck-Sickinger AG, Sperk G, Gehlert DR, Vezzani A, Colmers WF. The anti-epileptic actions of neuropeptide Y in the hippocampus are mediated by Y and not Y receptors. Eur J Neurosci. 2005;22:1417–1430. doi: 10.1111/j.1460-9568.2005.04338.x. [PubMed][Cross Ref]

17. Pedrazzini T, Pralong F, Grouzmann E. Neuropeptide Y: the universal soldier. Cell Mol Life Sci. 2003;60:350–377. doi: 10.1007/s000180300029. [PubMed] [Cross Ref]

18. Kalra SP, Crowley WR. Neuropeptide Y: a novel neuroendo- crine peptide in the control of pituitary hormone secretion, and its relation to luteinizing hormone. Front Neuroendocrinol. 1992;13:1–46.[PubMed]

19. Meczekalski B, Genazzani AR, Genazzani AD, Warenik-Szymankiewicz A, Luisi M. Clinical evaluation of patients with weight loss-related amenorrhea: neuropeptide Y and luteinizing hormone pulsatility. Gynecol Endocrinol. 2006;22:239–243. doi: 10.1080/14767050600761992. [PubMed][Cross Ref]

20. Barreiro ML, Tena-Sempere M. Ghrelin and reproduction: a novel signal linking energy status and fertility? Mol Cell Endocrinol. 2004;226:1–9. doi: 10.1016/j.mce.2004.07.015. [PubMed] [Cross Ref]

21. Schneider LF, Warren MP. Functional hypothalamic ame- norrhea is associated with elevated ghrelin and disordered eating. Fertil Steril. 2006;86:1744–1749. doi: 10.1016/j.fertnstert.2006.05.051. [PubMed][Cross Ref]

22. Tolle V, Kadem M, Bluet-Pajot MT, Frere D, Foulon C, Bossu C, Dardennes R, Mounier C, Zizzari P, Lang F, et al. Balance in ghrelin and leptin plasma levels in anorexia nervosa patients and constitutionally thin women. J Clin Endocrinol Metab. 2003;88:109–116. doi: 10.1210/jc.2002-020645. [PubMed][Cross Ref]

23. De Souza MJ, Leidy HJ, O’Donnell E, Lasley B, Williams NI. Fasting ghrelin levels in physically active women: relationship with menstrual disturbances and metabolic hormones. J Clin Endocrinol Metab. 2004;89:3536–3542. doi: 10.1210/jc.2003-032007. [PubMed] [Cross Ref]

24. Considine RV, Caro JF. Leptin: genes, concepts and clinical perspective. Horm Res. 1996;46:249–256. doi: 10.1159/000185096. [PubMed] [Cross Ref]

25. Andrico S, Gambera A, Specchia C, Pellegrini C, Falsetti L, Sartori E. Leptin in functional hypothalamic amenorrhoea. Hum Reprod. 2002;17:2043–2048. doi: 10.1093/humrep/17.8.2043. [PubMed][Cross Ref]

26. Smith R, Nicholson RC. Corticotrophin releasing hormone and the timing of birth. Front Biosci. 2007;12:912–918. doi: 10.2741/2113. [PubMed] [Cross Ref]

27. Rivier C, Brownstein M, Spiess J, Rivier J, Vale W. In vivo corticotropin-releasing factor-induced secretion of adrenocor- ticotropin, b-endorphin, and corticosterone. Endocrinology. 1982;110:272–278. doi: 10.1210/endo-110-1-272. [PubMed] [Cross Ref]

28. Remorgida V, Venturini PL, Anserini P, Salerno E, De Cecco L. Naltrexone in functional hypothalamic amenorrhea and in the normal luteal phase. Obstet Gynecol. 1990;76:1115–1120. [PubMed]

29. Mellon SH, Deschepper CF. Neurosteroid biosynthesis: genes for adrenal steroidogenic enzymes are expressed in the brain. Brain Res. 1993;629:283–292. doi: 10.1016/0006-8993(93)91332-M. [PubMed][Cross Ref]

30. Genazzani AD, Luisi M, Malavasi B, Strucchi C, Luisi S, Casarosa E, Bernardi F, Genazzani AR, Petraglia F. Pulsatile secretory characteristics of allopregnanolone, a neuroactive steroid, during the menstrual cycle and in amenorrheic subjects. Eur J Endocrinol. 2002;146:347–356. doi: 10.1530/eje.0.1460347. [PubMed] [Cross Ref]

31. Hind K. Recovery of bone mineral density and fertility in a former amenorrheic athlete. J Sports Sci Med. 2008;7:415–418. [PMC free article] [PubMed]

32. Devoro E, Aravena L. Favorable reproductive and menstrual evolution in adult women, who presented in the adolescence, menstrual disturbances by hypothalamic dysfunction and lack of response to clomiphene. Rev Med Chil. 2002;130:745–752. [PubMed]

33. Juul A, Hagen CP, Aksglaede L, Sørensen K, Mouritsen A, Frederiksen H, Main KM, Mogensen SS, Pedersen AT. Endocrine evaluation of reproductive function in girls during infancy, childhood and adolescence. Endocr Dev. 2012;22:24–39. doi: 10.1159/000326625. [PubMed] [Cross Ref]

34. EasterA TreasureJ, Micali N. Fertility and prenatal attitudes towards pregnancy in women with eating disorders: results from the avon longitudinal study of parents and children. BJOG. 2011;118:1491–1498. doi: 10.1111/j.1471-0528.2011.03077.x. [PubMed] [Cross Ref]

35. BeckerAE GrinspoonSK, KlibanskiA HerzogDB. Eating disorders. NEJM. 1999;340:1092–1098. doi: 10.1056/NEJM199904083401407. [PubMed] [Cross Ref]

36. Shen ZQ, Xu JJ, Lin JF. Resumption of menstruation and pituitary response to gonadotropin-releasing hormone infunctional hypothalamic amenorrhea subjects undertaking estrogen replacement therapy. J Endocrinol Invest. 2013;36:812–815. [PubMed]

37. Clarke BL, Khosla S. Female reproductive system and bones. Arch Biochem Biophys. 2010;503(1):118–128. doi: 10.1016/j.abb.2010.07.006. [PMC free article] [PubMed] [Cross Ref]

38. Gordon MC. Functional hypothalamic amenorhea. N Engl J Med. 2010;363:365–371. doi: 10.1056/NEJMcp0912024. [PubMed] [Cross Ref]

39. Seeman E. Pathogenesis of bone fragility in women and men. Lancet. 2002;359:1841–1850. doi: 10.1016/S0140-6736(02)08706-8. [PubMed] [Cross Ref]

40. Meczekalski B, Podfigurna-Stopa A, Genazzani AR. Hypoestrogenism in young women and its influence on bone mass density. Gynecol Endocrinol. 2010;26:652–657. doi: 10.3109/09513590.2010.486452. [PubMed] [Cross Ref]

41. Khosla S, Oursler MJ, Monroe DG. Estrogen and the skeleton. Trends Endocrinol Metab. 2012;23:576–581. doi: 10.1016/j.tem.2012.03.008. [PMC free article] [PubMed] [Cross Ref]

42. Taes Y, Lapauw B, Vandewalle S, Zmierczak H, Goemaere S, Vanderschueren D, Kaufman JM, T’Sjoen G. Estrogen-specific action on bone geometry and volumetric bone density: longitudinal observations in an adult with complete androgen insensitivity. Bone. 2009;45:392–397. doi: 10.1016/j.bone.2009.04.198. [PubMed] [Cross Ref]

43. Mircea CN, Lujan ME, Pierson RA. Metabolic fuel and clinical implications for female reproduction. J Obstet Gynaecol Can. 2007;29:887–902. [PubMed]

44. Crandall CJ, Tseng CH, Karlamangla AS, Finkelstein JS, Randolph JF, Jr, Thurston RC, Huang MH, Zheng H, Greendale GA. Serum sex steroid levels and longitudinal changes in bone density in relation to the final menstrual period. J Clin Endocrinol Metab. 2013;98:E654–E663. doi: 10.1210/jc.2012-3651.[PMC free article] [PubMed] [Cross Ref]

45. De Souza MJ, Williams NI. Physiological aspects and clinical sequelae of energy deficiency and hypoestrogenism in exercising women. Hum Reprod Update. 2004;10:433–448. doi: 10.1093/humupd/dmh033. [PubMed] [Cross Ref]

46. Warren MP, Brooks-Gunn J, Fox RP, Holderness CC, Hyle EP, Hamilton WG. Osteopenia in exercise-associated amenorrhea using ballet dancers as a model: a longitudinal study. J Clin Endocrinol Metab. 2002;87:3162–3168. doi: 10.1210/jcem.87.7.8637. [PubMed] [Cross Ref]

47. Lawson EA, Donoho D, Miller KK, Misra M, Meenaghan E, Lydecker J, Wexler T, Herzog DB, Klibanski A. Hypercortisolemia is associated with severity of bone loss and depression in hypothalamic amenorrhea and anorexia nervosa. J Clin Endocrinol Metab. 2009;94:4710–4716. doi: 10.1210/jc.2009-1046. [PMC free article] [PubMed] [Cross Ref]

48. Guo LJ, et al. Relationship between serum omentin-1 level and bone mineral density in girls with anorexia nervosa. J Endocrinol Invest. 2013;36:190–194. [PubMed]

49. Davies JH, Evans BAJ, Gregory JW. Bone acquisition in healthy children. Arch Dis Child. 2005;87:2391–2394.

50. Podfigurna-Stopa A, Pludowski P, Jaworski M, Lorenc R, Genazzani AR, Meczekalski B. Skeletal status and body composition in young women with functional hypothalamic amenorrhea. Gynecol Endocrinol. 2012;28:299–304. doi: 10.3109/09513590.2011.613972. [PubMed] [Cross Ref]

51. Gordon CM, Bachrach LK, Carpenter TO, Crabtree N, El-Hajj Fuleihan G, Kutilek S, Lorenc RS, Tosi LL, Ward KA, Ward LM, Kalkwarf HJ. Dual energy X-ray absorptiometry interpretation and reporting in children and adolescents: the 2007 ISCD pediatric official positions. J Clin Densitom. 2008;11:43–58. doi: 10.1016/j.jocd.2007.12.005. [PubMed] [Cross Ref]

52. Misra M. What is the best strategy to combat low bone mineral density in functional hypothalamic amenorrhea? Nat Clin Pract Endocrinol Metab. 2008;4:542–543. doi: 10.1038/ncpendmet0925. [PubMed][Cross Ref]

53. Lambrinoudaki I, Papadimitriou D. Pathophysiology of bone loss in the female athlete. Ann N Y Acad Sci. 2010;1205:45–50. doi: 10.1111/j.1749-6632.2010.05681.x. [PubMed] [Cross Ref]

54. Mendelsohn ME. Protective effects of estrogen on the cardiovascular system. Am J Cardiol. 2002;89:12E–17E. doi: 10.1016/S0002-9149(02)02405-0. [PubMed] [Cross Ref]

55. Reckelhoff JF. Sex steroids, cardiovascular disease, and hypertension: unanswered questions and some speculations. Hypertension. 2005;45:170–174. doi: 10.1161/01.HYP.0000151825.36598.36. [PubMed][Cross Ref]

56. Ouyang P, Michos ED, Karas RH. Hormone replacement theray and the cardiovascular system lessons learned and unanswered questions. J Am Coll Cardiol. 2006;47:1741–1753. doi: 10.1016/j.jacc.2005.10.076. [PubMed] [Cross Ref]

57. O’Donnell E, Goodman JM, Harvey PJ. Clinical review: cardiovascular consequences of ovarian disruption: a focus on functional hypothalamic amenorrhea in physically active women. J Clin Endocrinol Metab. 2011;96:3638–3648. doi: 10.1210/jc.2011-1223. [PubMed] [Cross Ref]

58. Rickenlund A, Eriksson MJ, Schenck-Gustafsson K, Hirschberg AL. Oral contraceptives improve endothelial function in amenorrheic athletes. J Clin Endocrinol Metab. 2005;90:3162–3167. doi: 10.1210/jc.2004-1964. [PubMed] [Cross Ref]

59. Bairey Merz CN, Johnson BD, Sharaf BL, Bittner V, Berga SL, Braunstein GD, Hodgson TK, Matthews KA, Pepine CJ, Reis SE, Reichek N, Rogers WJ, Pohost GM, Kelsey SF, Sopko G. Hypoestrogenemia of hypothalamic origin and coronary artery disease in premenopausal women: a report from the NHLBI sponsored WISE study. J Am Coll Cardiol. 2003;41:413–419. doi: 10.1016/S0735-1097(02)02763-8. [PubMed] [Cross Ref]

60. O’Donnell E, Harvey PJ, Goodman JM, De Souza MJ. Long-term estrogen deficiency lowers regional blood flow, resting systolic blood pressure, and heart rate in exercising premenopausal women. Am J Physiol Endocrinol Metab. 2007;292:E1401–E1409. doi: 10.1152/ajpendo.00547.2006. [PubMed][Cross Ref]

61. Rickenlund A, Eriksson MJ, Schenck-Gustafsson K, Hirschberg AL. Amenorrhea in female athletes is associated with endothelial dysfunction and unfavorable lipid profile. J Clin Endocrinol Metab. 2005;90:1354–1359. doi: 10.1210/jc.2004-1286. [PubMed] [Cross Ref]

62. Friday KE, Drinkwater BL, Bruemmer B, Chesnut C, 3rd, Chait A. Elevated plasma low-density lipoprotein and high-density lipoprotein cholesterol levels in amenorrheic athletes: effects of endogenous hormone status and nutrient intake. J Clin Endocrinol Metab. 1993;77:1605–1609. [PubMed]

63. WISE Study Group. Ahmed B, Bairey Merz CN, Johnson BD, Bittner V, Berga SL, Braunstein GD, Hodgson TK, Smith K, Shaw L, Kelsey SF, Sopko G, WISE Study Group Diabetes mellitus, hypothalamic hypoestrogenemia, and coronary artery disease in premenopausal women (from the National Heart, Lung, and Blood Institute sponsored WISE study) Am J Cardiol. 2008;102:150–154. doi: 10.1016/j.amjcard.2008.03.029. [PMC free article] [PubMed] [Cross Ref]

64. McEwen BS, Akama KT, Spencer-Segal JL, Milner TA, Waters EM. Estrogen effects on the brain: actions beyond the hypothalamus via novel mechanisms. Behav Neurosci. 2012;126:4–16. doi: 10.1037/a0026708. [PMC free article] [PubMed] [Cross Ref]

65. Kormos V, Gaszner B. Role of neuropeptides in anxiety, stress, and depression: from animals to humans. Neuropeptides. 2013;47:401–419. doi: 10.1016/j.npep.2013.10.014. [PubMed] [Cross Ref]

66. Giles DE, Berga SL. Cognitive and psychiatric correlates of functional hypothalamic amenorrhea: a controlled comparison. Fertil Steril. 1993;60:486–492. [PubMed]

67. Lawson EA, Donoho D, Miller KK, Misra M, Meenaghan E, Lydecker J, Wexler T, Herzog DB, Klibanski A. Hypercortisolemia is associated with severity of bone loss and depression in hypothalamic amenorrhea and anorexia nervosa. J Clin Endocrinol Metab. 2009;94:4710–4716. doi: 10.1210/jc.2009-1046. [PMC free article] [PubMed] [Cross Ref]

68. Bomba M, Gambera A, Bonini L, Peroni M, Neri F, Scagliola P, Nacinovich R. Endocrine profiles and neuropsychologic correlates of functional hypothalamic amenorrhea in adolescents. Fertil Steril. 2007;87:876–885. doi: 10.1016/j.fertnstert.2006.09.011. [PubMed] [Cross Ref]

69. Bomba M, Corbetta F, Bonini L, Gambera A, Tremolizzo L, Neri F, Nacinovich R. Psychopathological traits of adolescents with functional hypothalamic amenorrhea: a comparison with anorexia nervosa. Eat Weight Disord. 2013;19:41–48. doi: 10.1007/s40519-013-0056-5. [PubMed] [Cross Ref]

70. Dundon CM, Rellini AH, Tonani S, Santamaria V, Nappi R. Mood disorders and sexual functioning in women with functional hypothalamic amenorrhea. Fertil Steril. 2010;94:2239–2243. doi: 10.1016/j.fertnstert.2010.01.012. [PubMed] [Cross Ref]

71. Berga SL, Loucks TL. Use of cognitive behavior therapy for functional hypothalamic amenorrhea. Ann N Y Acad Sci. 2006;1092:114–129. doi: 10.1196/annals.1365.010. [PubMed] [Cross Ref]

72. Marcus MD, Loucks TL, Berga SL. Psychological correlates of functional hypothalamic amenorrhea. Fertil Steril. 2001;76:310–316. doi: 10.1016/S0015-0282(01)01921-5. [PubMed] [Cross Ref]

73. Miller KK, Lawson EA, Mathur V, Wexler TL, Meenaghan E, Misra M, Herzog DB, Klibanski A. Androgens in women with anorexia nervosa and normal-weight women with hypothalamic amenorrhea. J Clin Endocrinol Metab. 2007;92:1334–1339. doi: 10.1210/jc.2006-2501. [PMC free article] [PubMed][Cross Ref]

74. B. Meczekalski, K. Katulski, A. Czyzyk, A. Podfigurna-Stopa, and M. Maciejewska-Jeske. Functional hypothalamic amenorrhea and its influence on women’s health. J Endocrinol Invest. 2014; 37(11): 1049–1056. doi:  10.1007/s40618-014-0169-3.

75.Prokai D, Berga SL. Neuroprotection via Reduction in Stress: Altered Menstrual Patterns as a Marker for Stress and Implications for Long-Term Neurologic Health in Women. Int J Mol Sci 2016 Dec 20;17(12). pii: E2147. doi: 10.3390/ijms17122147.