Exercise, Undernourishment, and Fertility: Understanding the Connection
6 minutes
It’s no secret that exercise is an important part of overall well-being. However, what most people don’t recognize is that exercise can go too far, leading to repercussions that are rarely discussed or addressed. Often, getting into an over-exercise mindset starts innocently, especially for those involved in sports from a young age. In fact, adolescents have better mental health outcomes if they participate in sports. Parents and grandparents generally also feel excited and positive about their child excelling in a sport, and rarely does anyone think a few steps ahead about what intensity in a sport could do down the line without proper guidance. This is not to say adolescents shouldn’t pursue sports and excel or aim high; this is to highlight that what isn’t addressed early on can and often does lead to unintended consequences down the road.
As an example, and what will set the stage for this piece, consider a young gymnast who demonstrates hard work, excels at her sport, and is admired for her talents and efforts. She likely experiences delayed puberty compared to her non-gymnast peers, which benefits her physically by keeping her body smaller. Additionally, if she were to begin menstruating and developing breasts, she might feel she isn’t working hard enough and isolated because most of her teammates would still be prepubescent. Having puberty delayed for a couple of years isn’t necessarily a huge cause for concern. However, prolonged puberty delay or participation in demanding physical sports into late adolescence and early adulthood can lead to secondary amenorrhea, where menstruation stops for three consecutive months, resulting in accumulating consequences.
Athletes aren’t the only ones affected by this issue. It also impacts individuals with a disordered relationship with their bodies who have restrictive food patterns and/or overexercise. To the average person and even to many doctors, these individuals may appear healthy unless they exhibit signs of severe malnourishment, such as extreme anorexia. These individuals often consume nutritious foods, possess strong bodies, and typically meet societal standards for thinness or being fit. However, beneath the surface, there are signs of compromised well-being and various concerns. This post, however, will concentrate on one specific marker that notably impacts female reproductive health.
Hypothalamic Amenorrhea: What’s happening in the brain?
I will try to avoid being too technical while providing enough information to help you understand the mechanism behind amenorrhea. There is a part of our brain called the hypothalamus (think of this part as the head of the entire operation), which sends signals to the pituitary gland. Based on those signals, the pituitary gland produces and releases hormones into the bloodstream. These hormones control various organs and glands in the body. To put it another way, the pituitary gland oversees and regulates the amount of hormone released throughout the body, directing other glands such as the thyroid, adrenal glands, ovaries, and testes to produce their own hormones.
When a female experiences hypothalamic amenorrhea (HA), it means her hypothalamus has informed the pituitary to cease or slow down the entire operation, which then signals other glands, including the ovaries, to pause hormonal release. To get a bit more technical, the release of gonadotropin-releasing hormone (GnRH), which regulates the follicle-stimulating hormone (FSH) and luteinizing hormone (LH), is slowed down. FSH is required to initiate egg development and increase estrogen levels, while LH aids in egg maturation, triggering ovulation and the release of the egg from the ovary.
When your body is under stress from excessive exercise or insufficient nutrition, the hypothalamus does its best to preserve energy and make sure you don’t become pregnant because if you can’t fully support yourself, it would be dangerous for you to also try to care for a growing fetus. Said another way, your brain decides that your body isn’t ready to support pregnancy and requires optimal health before you can conceive. As a result, ovulation doesn’t occur, making conception impossible…….Let that sink in. Your brain is protecting you, not betraying you (although if you are trying to get pregnant, it may not feel that way).
Previously, when this condition was seen along with lower energy availability (with or without an eating disorder) and decreased bone mineral density, it was referred to as the Female Athlete Triad. It has since been renamed Relative Energy Deficiency in Sport (RED-S). RED-S encompasses a broader range of health issues stemming from energy deficiency, namely effects on metabolic rate, menstrual function, bone health, immunity, protein synthesis, and cardiovascular health. It also includes males, making it more inclusive.
Secondary Amenorrhea and Birth Control: A Controversial Solution
Secondary amenorrhea, whether a result of HA or another cause, is the absence of menstruation for three months or more in someone who previously menstruated. This condition is predominantly treated with birth control pills and is not typically investigated further unless the patient advocates for herself, does her own research, or is trying to conceive. The rationale is that the estrogen in birth control pills can help maintain bone density, reducing the risk of osteoporosis. While the reasoning is sound, in some cases using this Band-Aid approach can backfire.
Recent research suggests that starting birth control pills during adolescence (ages 10-19) may lead to increased bone loss compared to those not taking birth control pills. This research is relatively new, and more studies are needed to fully determine the effects.
Besides that, one of the main issues with using birth control to induce regular menstrual cycles is that it doesn’t address the underlying issues of HA (or other potential reasons for secondary amenorrhea such as a pituitary tumor or Polycystic Ovary Syndrome (PCOS)). If a woman never takes breaks from her birth control, she won’t know if her body can naturally resume menstruation, even with improved nutrition and reduced exercise. For instance, perhaps the high school track star who was put on birth control to regulate her cycles has since graduated and is no longer running as much, but still maintains an exercise regime and, without realizing it, is under-fueling. She could be considered of normal weight and BMI, but her body is not in her unique homeostasis.
Reversing Hypothalamic Amenorrhea: Persistence is Key
The good news is that HA can typically be reversed by increasing caloric intake and reducing exercise. Although that sounds easy, and for some women it may be, as a therapist who works with disordered eating and body image issues, I know it’s incredibly difficult for some individuals to simply begin eating higher-caloric foods and decrease or cease all exercise, resulting in inevitable body changes. This process requires patience and consistency, often involving a therapist specializing in eating disorders, body image, and weight management, as well as a dietitian. While many women see improvements in their menstrual cycles with these lifestyle changes, the timeframe for recovery can vary. Some may notice changes within a few months, while others might take longer and need to continue making adjustments.
What if my Fertility Window is Closing?
For those desiring children and just learning about HA, you may feel you lack the time or discipline to quickly reverse the condition. Fertility treatments offer an alternative, though for the sake of future pregnancy, offspring, and your overall well-being, this should be combined with proper treatment for the underlying cause. The typical treatment pathway may include the following steps, though some stages could be bypassed based on individual circumstances:
Medications such as Clomid, Letrozole, or gonadotropins (e.g., Gonal-f, Menopur) are used to stimulate ovulation. Depending on the response, options may include:
Timed intercourse (the most natural of the treatments)
Intrauterine insemination (IUI), a procedure where sperm is placed directly into the uterus using a small catheter.
In Vitro Fertilization (IVF), a complex procedure involving fertilizing an egg with sperm in a laboratory dish and then transferring it back into your body. The process is much more in-depth, but that is the basics.
Conclusion
Understanding the impact of over-exercising and undernourishment on reproductive health is often overlooked or disregarded (typically unintentionally or due to the complexity of the condition) by doctors, coaches, parents, and individuals themselves unless they are ready to conceive. Many females resort to birth control believing it is in their best interest, only to confront the reality that their body may not cooperate when they decide to conceive. If this situation resonates with you and you still have time, consider seeking help before pursuing fertility treatments. If you are already undergoing fertility treatments or are past that stage of your life, you can still make changes that will benefit you in other ways. Ultimately, your hypothalamus is in protective mode right now, and wouldn’t it be better if your body operated without this threat?
My interview about this topic on the podcast I was supposed to have a baby
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