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

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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.

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