Summary
The enormous increase in participation by women in physical recreation and sport since the early 1970s, has seen a parallel increase in research into the effects of strenuous exercise on the female neuroendocrine and reproductive systems.
Oligomenorrhoea, primary or secondary amenorrhoea, altered pubertal progression, defective luteal phase, anovulation, and infertility may result, most frequently in those aerobic type activities associated with the lower bodyweight and fat percentages such as running, aerobics, and gymnastics. As well as body composition and sport specificity, intensity of training, previous menstrual history (in particular delayed menarche) and diet/eating disorders are all important associated factors.
The neuroendocrinological pathogenesis to this altered menstrual function is complex and controversial; however, the evidence for accelerated bone loss in these young women with chronic hypo-oestrogenaemia is substantial. Since the first studies released in 1982 when amenorrhoeic runners’ bone mineral content was measured and found equivalent to that predicted normal for 52-year-old women, further studies have proposed an association between this hypo-oestrogenaemia, reduced bone density and stress fractures.
Studies so far show that this bone loss continues to occur over time, but the most rapid rate of bone loss (approximately 4%/year) occurs early on cessation of menses, thus emphasising the importance of early management in preventing bone loss occurring in young amenorrhoeic athletes.
The role of calcium and oestrogen supplementation in management of the hypo-oestrogenic exercising female are unclear. The results of longitudinal studies currently under way assessing their benefits are awaited. Meanwhile an increased calcium intake to 1500mg per day should be advised and consideration of oestrogen and/or progesterone supplementation given.
It is important that other causes of amenorrhoea are not overlooked in this exercising population and the diagnosis of ‘athletic amenorrhoea’ should not be made until a full thorough history, physical examination and blood tests have eliminated other common causes. Full dietary history and assessment for eating disorders is an essential part of this assessment.
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References
Araham S, Beaumont PJ, Fraser IF, Llewellyn Jones D. Body-weight exercise and menstrual states among ballet dancers in training. British Journal of Obstetrics and Gynaecology 99: 507–510, 1982
Aickin DR, Donald RA. Amenorrhoea. New Zealand Medical Journal 96(724): 48–49, 1983
Aloia JF, Cohn SM, Babu T, Abesamis C, Kalici N, et al. Skeletal mass and body composition in marathon runners. Metabolism 27: 1793–1796, 1978
Anderson JL. Women’s sports and fitness programmes at the US Military Academy. Physician and Sportsmedicine 7: 72–80, 1980
Baker ER, Mathur RS, Kirk RF, Williamson HO. Female runners and secondary amenorrhoea. Fertility and Sterility 36(2): 183–187, 1981
Baker E. Menstrual dysfunction and hormonal status in athletic women: a review. Fertility and Sterility 36: 691, 1981
Barnes J. Lecture notes on gynaecology, 4th ed. p. 35, Blackwell, London, 1980
Berning J, Sanborn CF, Brooks SM, Wagner WW. Caloric deficit in distance runners. Medicine and Science in Sports and Exercise 17(2): 242, 1985
Bernstein L, Ross RK, Lobo RA, Hanisch R, Kraib MD, et al. The effects of moderate physical activity on menstrual cycle pattern in adolescence: implications for breast cancer prevention. British Journal of Cancer 55: 681–685, 1987
Boyden TW, Pamenter RW, Rotkis TC. Thyroidal changes associated with endurance training in women. Medicine and Science in Sports and Exercise 16: 243–246, 1984
Boyden TW. Prolactin responses, menstrual cycles and body composition of women runners. Journal of Clinical Endocrinology and Metabolism 54: 711–713, 1982
Bullen BA, Skrinar GS, Bertins IZ, Von Mering G, Turnbull BA, et al. Induction of menstrual disorders by strenuous exercise in untrained women. New England Journal of Medicine 312: 1349–1353, 1983
Bunt JC, Going SB, Westfall CH, Perry C, Pamenter R, et al. Impact of bone mineral content on body fat estimations in females. Abstract. Medicine and Science in Sports and Exercise 20: 357, 1988
Cann CE, Cavanaugh DJ, Schnurpfel K, Martin MC. Menstrual history is the primary determinant of trabecular bone density in women runners.Abstract. Medicine and Science in Sports and Exercise 20(2): S59, 1988
Cann CE, Martin MC, Genant HK. Detection of premenopausal women at risk for the development of osteoporosis. Abstract. Athletic Amenorrhoea Bulletin 1: 3, 1982
Cann CE, Martin MC, Jaffe RB. Duration of amenorrhoea effects rate of bone loss in women runners: implications for therapy. Abstract. Medicine and Science in Sport and Exercise 17: 214, 1985
Carlberg KA, Buckman MT, Peake GT, Reidesel ML. Body composition of oligo/amenorrhoeic athletes. Medicine and Science in Sports and Exercise 15: 215–217, 1983
Carlberg KA, Buckman MT, Peake GT, Reidesel ML. A survey of menstrual function in athletes. European Journal of Physiology 51: 211–222, 1983
Chow R, Harrison JE, Notarius C. Effect of two randomised exercise programmes on bone mineral of healthy post-meno-pausal women. British Medical Journal 295: 1441–1444, 1987
Christian JJ. Regulation of annual rhythms of reproduction. In Steinberger & Steinberger (Eds) Testicular development, structure and function, pp. 367–380, Rowen Press, New York, 1984
Clark N, Berning J. Nutritional guidance for low bodyweight athletes. Tutorial lecture, 35th Annual Meeting of the American College Sports Medicine Conference, Dallas, Texas, May, 1988
Clark N, Nelson M, Evans W. Nutrition education for elite female runners. Physician and Sports Medicine 16: 124–136, 1988
Cumming DC, Wall SR, Galbraith MA, Beicastro AN. Reproductive hormone responses to resistance exercise. Medicine Science in Sports and Exercise 19: 234–238, 1987
Dale E, Gerlach DM, Wilwhite AL. Menstrual dysfunction in distance runners. Obstetrics and Gynaecology 54: 47–53, 1979
Dalen N, Olsson KC. Bone mineral content and physical activity. Acta Orthopaedica Scandinavica 45: 170–174, 1974
Ding JH, Scheckter CB, Drinkwater BL, Soules MR, Bremner WJ. Higher serum cortisol levels in exercise associated amenorrhoea. Annals of Internal Medicine 108: 530–534, 1988
Drinkwater B. Cited in Munnings F. Exercise and estrogen in women’s health: getting a clearer picture. Physician and Sportsmedicine 16: 152–161, 1986
Drinkwater BL, Nelson K, Ott S, Chesnut CH. Bone mineral density after resumption of menses in amenorrhoeic athletes. Journal of the American Medical Association 256: 380–382, 1986
Drinkwater BL, Nelson K, Chesnut CH, Bremner WJ, Shainholtz SS, et al. Bone mineral content of amenorrhoeic and eumenorrhoeic athletes. New England Journal of Medicine 311: 277–281, 1984
Editorial. Information for authors. Medicine and Science in Sports and Exercise 16(3): i–iv, 1984
Editorial. Skeletal integrity: exercise and amenorrhoea, parts 1 and 2, (cassettes 85ACSM-F3A and F3B) Mobil Tape Company Inc., Glendale, California, 1986
Emans SJ. The athletic adolescent with amenorrhoea. Pediatric Annals 13(8): 605–612, 1984
Feicht CB, Johnson TS, Martin BJ, Sparkes KE, Wagner WW. Secondary amenorrhoea in athletes. Correspondence. Lancet 2: 1145–1146, 1978
Florsheim Y. The investigation and treatment of female sterility. Sandorama 1: 5–9, 1980–81
Frisch RE. Bodyfat, menarche, fitness and fertility. Human Reproduction 2: 521–533, 1987
Frisch RE. What does exercise mean for the menstrual cycle? Journal of the American Medical Association 243: 1699, 1980
Frisch RE, Gotz-Welbergen AV, McArthur JW, Albright T, Witschi J, et al. Delayed menarche and amenorrhoea of college athletes in relation to age of onset of training. Journal of the American Medical Association 246: 1559–1563, 1981
Frisch RE, McArthur JW. Menstrual cycles: fatness as a determinant of minimum weight for height necessary for their maintenance or onset. Science 185: 949–951, 1974
Gadpaille WJ, Sanborn CF, Wagner WW. Athletic amenorrhea, major affective disorders and eating disorders. American Journal of Psychiatry 144: 939–942, 1987
Genant HK, Ettinger B, Cann CE, Reiser U, Gordan GS, et al. Osteoporosis: assessment by quantitative computed tomography. Orthopedic Clinics of North America 16: 557–568, 1985
Gilchrist NL. Bone density estimation. New Zealand Medical Journal 101: 260, 1988
Glass AR, Deuster PA, Kyle SP, Yahiro JA, Vigersky RA, et al. Amenorrhoea in Olympic marathon runners. Fertility and Sterility 48(5): 740–745, 1987
Gonzales ER. Chronic anovulation may increase postmenopausal breast cancer risk, medical news. Journal of the American Medical Association 249: 445–446, 1983
Goulding A. Athletic amenorrhoea: a risk factor for osteoporosis in later life? New Zealand Medical Journal 99: 765–767, 1986
Hawlett TA, Tomlin S, Ngahfoong L, Rees LH, Sullen BA, et al. Release of β-endorphin and metenkephalin during exercise in normal women: response to training. British Medical Journal 288: 1950–1952, 1984
Heaney RP, Recker RR, Saville PD. Calcium balance and calcium requirements in middle aged women. American Journal of Clinical Nutrition 30: 1603–1611, 1977
Heaney RP, Recker RR, Saville PD. Menopausal changes in calcium balance performance. Journal of Laboratory and Clinical Medicine 92: 953–962, 1978
Heaney RP. The role of calcium in prevention and treatment of osteoporosis. Physician and Sportsmedicine 15(11): 83–88, 1987
Heath H. Athletic women, amenorrhoea and skeletal integrity. Annals of Internal Medicine 102: 258–260, 1985
Henderson BE, Ross RK, Judd HL, Krailo MD, Pike MC. Do regular ovulatory cycles increase breast cancer risk? Cancer 56: 1206–1208, 1985
Highet RM. Stress fractures. New Zealand Journal of Sports Medicine 15: 101–103, 1987
Hill P, Garbaczewski L, Helman P, Huskisson J, Sporangiosa E, et al. Diet, lifestyle and menstrual activity. American Journal of Clinical Nutrition 33: 1191–1198, 1980
Hutton JD. Effect of exercise on puberty, periods and pregnancy. New Zealand Medical Journal 99: 6–7, 1986
Jacobs HS. Amenorrhoea in athletes. British Journal of Obstetrics and Gynaecology 89: 498–500, 1982
Jacobson PC, Beaver W, Grubb SA, Taft TN, Talmage RV. Bone density in women: college athletes and older athletic women. Journal of Orthopaedic Research 2: 328–332, 1984
Kanders BS, Lindsay R. The effect of physical activity and calcium intake on the bone density of young women aged 24–35. Abstract. Medicine and Science in Sports and Exercise 17: 284–285, 1985
Kirkendall D, Bergfield JA, Calabrese LH, et al. Isokinetic characteristics of ballet dancers and effects of a season of training. Journal of Orthopedics and Sports Physical Therapy 4(21): 207–211, 1984
Krolner B, Toft B, Nielson SP, Tondevold E. Physical exercise as prophylaxis against involutional vertebral bone loss: a controlled trial. Clinical Science 64: 541–546, 1983
Lane N, Bevier W, Bouxsein M, Wiswell R, Carter D, Marcus R. Effect of exercise intensity on bone mineral. Abstract. Medicine and Science in Sports and Exercise 20: 303, 1988
Lindberg JS, Fears WB, Hunt MM, Powell MR, Boll D, et al. Exercise induced amenorrhoea and bone density. Annals of Internal Medicine 101(5): 647–648, 1984
Lindberg JS, Powell M, Hunt MM, Ducey DE, Wade CE. Increased vertebral bone mineral in response to reduced exercise in amenorrhoeic runners. Western Journal of Medicine 146: 39–42, 1987
Linnell SL, Stager JM, Blue PW, Oyster N, Robertshaw D. Bone mineral content and menstrual regularity in female runners. Medicine and Science in Sports and Exercise 16: 343–348, 1984
Loosli AR, Gillien DM, Benson J, Bourdet K. Inadequate nutrition and chronic caloric restriction among ballet dancers. Medicine and Science in Sports and Exercise 17(2): 201, 1985
Loucks AB. Athletic amenorrhoea. Research summary and evaluation. Athletic Amenorrhoea Bulletin 2: 1–12, 1983
Loucks AB, Horvath SM, Freedson PS. Menstruation and validation of body fat prediction in athletes. Human Biology 56: 383–392, 1984
Malina RM, Harper AB, Avent HH, Campbell DE. Age at menarche in athletes and non-athletes. Medicine and Science in Sports 5: 11–13, 1973
Marcus R, Cann C, Madvig P, Minkoff J, Goddard M, et al. Menstrual function and bone mass in elite women distance runners: endocrine and metabolic features. Annals of Internal Medicine 102(2): 158–163, 1985
Martin MC. Medical treatment for athletic amenorrhoea. Athletic Amenorrhoea Bulletin 4: 3–5, 1985
Massey JB, Reproductive effects of aerobic exercise in women. Journal of the Medical Association of Georgia 73: 457–479, 1984
McArthur JW. Amenorrhoeic athletes: at risk of developing osteoporosis. British Journal of Sports Medicine 18: 253–255, 1984
McArthur JW, Bullen BA, Betens IZ, Pagane M, Badger TM, et al. Hypothalamic amenorrhoea in runners of normal body distribution. Endocrine Research Communications 7: 13–25, 1980
Meerman R. Experimental investigation of disturbances of body image estimation in anorexia nervosa patients and ballet and gymnastic pupils. International Journal of Eating Disorders 2: 91–100, 1983
Nelson ME, Fisher EC, Catsos PO, Merdeith CN, Turksoy RN, et al. Diet and bone status in amenorrhoeic runners. American Journal of Clinical Nutrition 43: 910–916, 1986
Newsholme EA, Leech AR. Biochemistry for the medical sciences, pp. 357–368, John Wiley & Sons Ltd, 1983
Nilsson BE, Westlin NE. Bone density in athletes. Clinical Orthopaedics and Related Research 77: 179–182, 1971
Parker Jones K, Ravniker VA, Tulchinsky D, Schiff I. Comparison of bone density in amenorrhoeic women due to athletics: weight loss and premature menopause. Obstetrics and Gynaecology 66: 5–8, 1985
Pearson RM. Bionic ballerinas. Lancet 1: 481–482, 1985
Prior JC. Absence of molimina: a clinical orself diagnosis of anovulation. Abstract. 7th Conference of theSociety for Menstrual Cycle Research, Ann Arbor, June, 1987c
Prior JC. Annual trabecular bone density change in ovulatory premenopausal women is related to luteal length and family history of osteoporosis. Clinial Research 36: 102a, 1988
Prior JC. Exercise in women. Medicine North America/Sports (Fall): 16–23, 1987a
Prior JC. Physical exercise and the neuroendocrine control of reproduction in Bailliere’s. Clinical Endocrinological Metabolism 1: 299–317, 1987b
Prior JC, Cameron K, Yuen BH, Thomas J. Menstrual cycle changes with marathon training: anovulation and short luteal phase. Canadian Journal of Applied Sport Sciences 7: 173–177, 1982
Recker R. The relationship between calcium nutrition and bone health. 35th Annual meeting of the American College of Sports Medicine Conference, Dallas, Texas, May, 1988
Recker R. The relationship between calcium nutrition and bone health. Tutorial lecture (tape F9), 35th Annual Meeting American College Sports Medicine, Dallas, Texas, 27 May, 1988
Riggs BL, Milton III J. Involutional osteoporosis. New England Journal of Medicine 314: 1676–1686, 1986
Riggs BL, Wahner HW, Dunn WL, et al. Differential changes in bone mineral density of the appendicular and axial skeleton with aging. Journal of Clinical Investigations 57: 328–333, 1981
Ronkainen M, Pakarinen A, Kirkimen P. Physical exercise-induced changes and seasonal associated differences in the pituitary-ovarian function in runners and joggers. Journal of Clinical Endocrinology and Metabolism 60: 416–422, 1985
Sanborn CF, Albrecht BH, Wagner WW. Athletic amenorrhea: lack of association with body fat. Medicine and Science in Sports and Exercise 19: 207–212, 1987
Sanborn CF, Martin BJ, Wagner WW. Is athletic amenorrhoea specific to runners? American Journal of Obstetrics and Gynecology 143: 859, 1982
Schwartz B, Rebar RW, Yen SSC. Amenorrhoea and long distance running. Abstract. Fertility and Sterility 34(3): 306, 1980
Schweiger U, Laessle R, Schweiger M, Hermann F, Riedel W, et al. Caloric intake, stress and menstrual function in athletes. Fertility and Sterility 49(3): 447–450, 1988
Selye H. The effect of adaption to various damaging agents on the female sex organs of the rat. Endocrinology 25: 615, 1939
Shangold MM. How I manage menstrual disturbances. Physician and Sportsmedicine 14: 113–120, 1986
Shangold MM, Freeman R, Thysen B, Gatz M. The relationship between long distance running, plasma progesterone and luteal phase length. Fertility and Sterility 31(2): 1390–133, 1979
Shearman RP. Secondary amenorrhoea. In Dewhurst (Ed.) Integrated obstetrics and gynaecology for postgraduates, Vol. 6, pp. 53–72, Blackwell, London, 1972
Sinning WE, Little K.D. Body composition and menstrual function in athletes. Sports Medicine 4: 34–45, 1987
Sinning WE, Little KD, Wilson JR, Bowers BM. Body composition and menstrual function in women athletes. Abstract. Medicine and Science in Sports and Exercise 17(2): 214, 1985
Speroff L, Redwine DB. Exercise and menstrual function. Physician and Sportsmedicine 8(5): 41–42, 1980
Warren M P. The effect of exercise on pubertal progression and reproductive function in girls. Journal of Clinical Endocrinology and Metabolism 51: 1150–1157, 1980
Warren M P. The effects of altered nutritional states, stress and systemic illness on reproduction in women. In Vaitukaitos (Ed.) Clinical reproductive neuroendocrinology, Elsevier Biomedical, New York, 1982
Warren MP, Brooks-Gunn J, Hamilton LH, Warren F, Hamilton WG. Scoliosis and fractures in young ballet dancers. New Engl and Journal of Medicine 314: 1348–1353, 1986
Wilmore JH. Disturbances in weight and eating problems in young athletes. Tutorial lecture, 35th American College of Sports Medicine Conference, Dallas, Texas, May, 1988
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This review is based on a dissertation for the 1985/86 Diploma Course in Sports Medicine, The London Hospital Medical College, Whitechapel, London
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Highet, R. Athletic Amenorrhoea. Sports Med 7, 82–108 (1989). https://doi.org/10.2165/00007256-198907020-00002
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DOI: https://doi.org/10.2165/00007256-198907020-00002