Female Athletes and Menstruation

What should athletes know about the menstrual cycle?

An athlete’s menstrual cycle can provide a lot of important information about their overall health, including whether they’re getting the proper nutrition, training too hard, and if their bones are getting what they need to be as strong as possible.

Some athletes, especially those in sports that emphasize leanness, may believe that getting to a state at which they’re not having periods (amenorrhea) will help them go from normalcy to excellence. In fact, amenorrhea can be a sign of relative energy deficiency in sport (RED-S), a syndrome of poor health and declining athletic performance that happens when athletes do not get enough fuel through food to support the energy demands of their daily lives and training.

What is a healthy, normal menstrual cycle?

Though menstruation may sometimes feel like a limitation, research shows that athletic performance stays about the same throughout the menstrual cycle, including during your period. Some small studies suggest that female track-and-field athletes land jumps slightly differently during certain phases of their menstrual cycles. However, good form and strength training can prevent problems from occurring.

In other words, most normal, healthy cycles don’t get in the way of competing, even at a high level. Some evidence even suggests that exercising during menstruation can soothe cramps and PMS symptoms.

When should you see a doctor about missed periods?

Missed periods (amenorrhea) may be caused by stress, under-nutrition, or over-exercise — all of which can lead to something called functional hypothalamic amenorrhea. Other causes of secondary amenorrhea include polycystic ovarian syndrome (PCOS), pituitary abnormalities, and thyroid dysfunction, among others.

The following circumstances are potential causes of concern and should be evaluated by a doctor:

a young woman has not gotten her period by the age of 15, or within five years of breast development
a young woman misses three or more consecutive cycles after her first menstrual cycle

How does energy availability impact bone health?

Quite simply, energy availability is what’s left of your dietary energy after exercise. For optimal performance in sport and daily life, athletes should eat enough nutritious calories to have energy for exercise, growth, and development. You also need energy for normal physiological functions, including a normal menstrual cycle.

How are bone health and menstrual cycles related?

Your menstrual cycle is closely tied to your bone mineral density. Healthy levels of estrogen and other hormones help build strong bones and keep them from breaking down.

When athletes don’t have enough energy for their body’s normal functions because of over-training or lack of proper nutrition, their hormones can become disrupted, which can ultimately harm their bone and reproductive health.

Without the proper energy balance, girls can experience menstrual irregularities and have an increased risk of stress fractures. Even with regular weight-bearing exercises, an amenorrheic athlete is two to four times more at risk for a stress fracture than an athlete who gets regular periods.

If the energy imbalance continues, athletes are at risk of RED-S. Over time, RED-S takes a toll on an athlete’s endurance, strength, health, and well-being.

How we care for female athletes at Boston Children’s Hospital

The Wu Tsai Female Athlete Program takes a comprehensive approach to diagnosing, treating, and managing sports injuries in female athletes and sees athletes of any gender with low energy availability. We start by assessing the whole athlete, including exercise habits, hormonal balance, and nutritional needs — not just symptoms and injuries — to ensure peak performance. We educate young athletes on proper nutrition and its importance in athletic performance. We also educate other clinicians, coaches, and parents on the signs of RED-S and how to intervene appropriately.

As the largest and most experienced pediatric and young adult sports medicine practice in the country, the Sports Medicine Division leads the way for innovation in the prevention and care of sports injuries. We work with athletes of all ages and abilities to help them train and compete at their best.