The Female Athlete Triad

Experiencing hypothalamic amenorrhea while competing in sports of any kind, or even just exercising a lot, is not talked about hardly at all and it really bugs me.

So many women are experiencing this and doctors shrug it off as if it’s not a big deal just because someone might look “healthy” on the outside. They might say “well, you exercise and eat well so you’re fine. It’s normal when you exercise a lot.” Just because it’s common doesn’t mean it’s normal in the slightest.

Female bodies are sensitive to stress! When we’re under loads of it, the first thing to go is our fertility.. because when you’re in that “fight or flight” mode all the time, the last thing your body wants to do is create a human lol.

I’m still dealing with it as a result of many years of competition, high stress workload, college, starting a business, and just any other stress. It compounds.

I’ve also taken some info from an amazing study from NCBI and pasted it below.

“The female athlete triad is an interrelationship of menstrual dysfunction, low energy availability (with or without an eating disorder), and decreased bone mineral density; it is relatively common among young women participating in sports. Diagnosis and treatment of this potentially serious condition is complicated and often requires an interdisciplinary team.”

“This complex disorder was first coined by the American College of Sports Medicine in 1992 after many experts in the field had noticed a pattern among adolescent and young adult female athlete patients. Even though this condition has been described for 2 decades, there is still much debate about how the components of the triad interrelate and how clinicians should manage patients with this complicated condition.”

“The main goal in treatment of young female athletes with the triad is a natural return of menses as well as enhancement of bone mineral density. While no specific drug intervention has been shown to consistently improve bone mineral density in this patient population, maximizing energy availability and optimizing vitamin D and calcium intake are recommended.”

“The female athlete triad is a potentially serious condition affecting many young women. Low bone density is a dangerous consequence of the triad, and the degree of low BMD in young patients is greatly dependent on age of onset and duration of amenorrhea. Low energy availability plays a crucial role in menstrual function and bone health. There are several different theories about the best approach to treating this complicated condition. However, it is universally accepted that triad prevention, early recognition, and a multidisciplinary treatment plan with a focus on proper nutrition and resumption of menses are extremely important and should be priorities among health care professionals, coaches, and other adults involved in the lives of female athletes.”

I went on my Instagram and Facebook platforms to ask women if they’ve ever experienced HA and if they would be willing to share their stories. There’s not much conversation around this in sports and especially not elite athletes. You’ll never hear anyone talking about it, so I wanted to ask and start the conversation.

I’m going to paste below (leaving names out obviously) the stories and comments that women gave me when I asked if they’d ever experienced this, how long, and if they got their period back, etc.

& if you’ve ever struggled with this, too, I’d love to hear your story!

“I’ve always been active (played softball/volleyball growing up) with normal periods as a teen... I got into the gym around 2013 and still had pretty normal periods."

I stopped getting normal period around 2014 with restricted intake and significant drop in BF. My period didn’t come back until about 2016 when I started reintroducing calories but my activity stood high. At this point, I transitioned from a more bb focused programming to powerlifting.. My doctor suggested taking birth control (🤦🏻‍♀️) after I had already been off for about 4 years (I got off right before beginning in the gym Bc I hated how bc made me feel) 

I Don’t really know if the BC specifically made me gain weight but I put on 20-25 lbs in the year I was on it. I decided to transition off and immediately lost my period again. So I’ve now been without a period since mid-2017. All my “markers” come back normal and the only suggestion doctors offer is to get back on BC (which I refuse)

— I’ve lowered cardio within the past few months and am eating about 300-400 cals above my projected maintenance (as of now) slowly bringing my calories up. I know ppl say to just jump to a specific number but I don’t feel as if that will be mentally healthy (for me)

I also want to seek out a trusted endocrinologist but I haven’t gotten that far yet.”

“I went through it honestly for years. I was competitive in cheerleading growing up and was always active. I got my period every two months. Fast forward to college it was still effed up. Tried the pill obv didn’t work lol. Came off of it and was still effed. I was doing CF and alwayssssss training super hard esp for the open and stuff. I would go moths without a period. The longest I think was 4 or 5 months. It also got way worse when I was dieting to 58. It wasn’t totally gone for years by any means but there was a point where I only got like 3 periods in the year”

“I lost my period for about two years after losing ten lbs to compete in the 63 kg weight class.  I’m 5’7”...so I got to be fairly lean. I was eating minimal fat so I could have more carbs to fit my macros (25-35 per day).  I got tested in January by a gyno for all types of things through blood drawing (thyroid, hormones, etc.). Everything was normal. They did an ultrasound to check for cysts on my ovaries.. .nope.  I asked her about nutrition and upping my fat and she gave very little feedback.

So through my research I decided that if I wanted to keep powerlifting I need to gain some weight and up my fat intake (at about 50-70 per day).  I have gained about 6-8 lbs which is so hard to accept. I got a period in April, then again in aug., sept., and now Oct.

I thought I’d share my story with you because I know you’ve mentioned HA.  I am so glad I decided to take control of getting my period back after learning all of the negative health implications that can stem from not having one.”

“Overexercising and underfueling. My cycle went away completely shortly after I competed in a figure competition. I hired an inexperienced coach and followed her guidelines to a T even though part of me knew it wasn’t right. I have no idea what I weighed but probably upper 80s when I’m 5’3”. Not good at all.

Anyways after that I did of course gain weight but was still quite small for my height (about 105-115) for the next couple years and continued to exercise intensely up until about 1.5 years ago. The day after I finished my ultramarathon I quit running completely for a year. Ate 2200-2500 calories a day. Only lifted weights 2-3x/week and went for walks and maybe some yoga here and there. I also started meditating daily and maybe like 6 months in I stopped tracking food all together.

I learned most from the book no period now what but then also joined a HA Facebook group and deleted fitspo’s on IG that didn’t serve my journey.  I ended up gaining more weight. I’m not sure what I Got up to. 140s? Idk. I’ve lost some weight since just from having freaking hormones that work - not intentionally dieting at all and still just eating as I please.

Went to doctors and reproductive endocrinologist. Was told I had premature ovarian failure by one and by the RE just basically he had no clue. No one ever mentioned HA. I stumbled upon it all on my own and went nuts on the research. My PCP was shocked when I came back a year later saying I had my first cycle again.”

“I did before I started working with you!! I think i didn't really have a period for about two years so probably my junior year of high school until we started working together my freshman year of college. I was taking birth control and had at some points been doing crossfit, weightlifting, and gymnastics/track/soccer at the same time.”

“I took a year off from bodybuilding because I had no energy. Would sleep for 14 hours a day and still be tired. Didn't see my period for 8 months. Turns out, I had insulin related PCOS and was pre diabetic.”

“Yes! Years ago I lost my period after a couple months where I had been on a super strict cut to lose fat, was drinking ridiculous amounts of caffeine, sleep was less than normal, and I was doing competitor training at crossfit. The combination of all of it led to my period disappearing. That was my wake up call and I cut back on caffeine, started eating more and taking care is my body (more sleep, better recovery, etc). I knew what was happening because I’d had irregular periods in High school when I ran track and cross country.

It missed 2-3 cycles, so not very long, BUT I knew exactly why it was gone when my first period didn’t happen. I instantly changed what I was doing because my husband and I wanted to start trying for a baby that year and I didn’t know how long it’d take to fix.

My periods were super irregular in high school and I was always super active. I had no idea why, but did internet searching in college. :) good luck on your research!

My basic thought was, my body is being stressed too much to support trying to grow a baby, so I need to stop doing the stressors. Instead what would my body and brain need to feel like it could support growing a human. I still worked out, but overall I made sure I wasn’t pushing everything so far.”

“I lost my period within the first year of crossfit. (Maybe the first 6-8 months to be exact)(I’ve also never been on birth control)

I got it back last year (2018) when I decided to stop training for regionals and stop weight lifting all together. 

Since then, it’s become more regular. I get it every 5-6 weeks now. 

I think a lot had to do with me slowing down. Stopping my high intensity training and focusing on my health. I did gain weight but I’m thinking that was because of the hypothyroidism.”

“This was like 6-7 years ago I was actually working out at a boxing/functional training gym and relatively  undereating. Lost my period for 8-10 months and went to my gyn where she diagnosed with PCOS “because I didn’t meet the criteria for female athlete triad.

But I’ve read quite a bit about relative energy availability. Because I was doing a lot of intense cardio 1-2 times a day and eating like 1600-1800 calories per day my relative energy was trash.”

“I got it doing too much CrossFit (6X a week) while simultaneously being on RP for my diet. I ran my body into the absolute ground. I probably was missing a period for 3 years. In January of 2019 I hired a macro coach recommended by Laurie Christine King. Shay finally for me to have a cycle around April. I definitely have gained weight, but I am totally cool with it because my hormones are now happy.  I am working out 5 days a week with paragon training methods and eating a whole lot more than I was last year. I feel much happier now for sure

I haven’t weighed myself in awhile, but I would guess I gained around 10-12 pounds. Definitely a pants size.”

“Hey! Not much weight gain involved oddly. I was just chronically under eating and absolutely hammering myself in the gym. When I got diagnosed with bulimia and addressed me underesting (and bingeing) - actually swapping time Crossfit helped, I got my period back.”

“Sure! So when I was 21, I started my weight loss journey at 230 lbs. I went on to lose a total of 90 pounds. Somewhere around 70-80, I noticed I went a long time without a period. Having long cycles wasn’t abnormal, however, they normally showed up. It eventually showed up, Then, I didn’t get one for 2 months. At this time, I was running about 3 miles+ a day plus doing spinning and other exercise. After I graduated from college, I started Crossfit and continuing to eat less/exercise more. I got down to the 90 pound mark and then started bodybuilding + running + orthorexic eating behaviors. I was exercising about 2+ hours a day, plus lived in Boston and would walk around 3-5 miles a day. Calories were somewhere around 900, unintentionally. After 7-8 months without a period, hair falling out, being cold all the time, depressed and other things, I realized how bad i was.  I started reverse dieting to get out of my eating disorder and get healthy.

It took another 4 months to get my period back-including eating more, working out less and starting vitex.

It came back for about 3-4 months and then I lost it again for another 6 or so as soon as I started doing CrossFit again.

I was never too small— just eating too little and exercising too much. It took reducing exercise to a normal amount and reverse dieting to get it back for good.

I reverse dieted up to about 2000 and gained about 8-10 or so pounds back to get it back for good.

Any time I dropped below 150 or exercised to intensely, it would mess up my cycle.”

“I lost my period for about a year and a half. I want to say it was my first two years of CrossFit. I actually got it back working with you. I lost it doing the RP templates. I didn’t realize how absolutely messed up my body was until afterward.”

“Yeah, I had always had a period on BC except for a phase of HA for 4 months in 2017.  It was when I had I lost ~10 pounds in less than a month due to exercise overload and low calorie intake (~1700/day)

Came back when I had to stop exercising.  I hurt my lower back/hip and couldn’t exercise and the weight quickly came back. I was eating more as well as a coping mechanism to my injury and gaining so much free time back.”

“Sooooooo where to begin.

Started CrossFit when I was 13, and play competitive softball my whole life. Got into high school and was still doing CrossFit, competitive softball, and high school softball. 

Started counting my macros Junior year of high school, and went into a ‘cut’ with a former nutritionist I was working with. She took my numbers down to 150P, 150C, and 50F. I was on those numbers for well over a year and lost my period my senior year of high school. I would always catch extra CrossFit workouts whenever I could and did even more during the summer because I didn’t have school to take me away from it. 

I went into college still doing CrossFit, playing college ball and lifting for college too. This is also the time I started to struggled with binge eating. It was a super dark time for me but I made it work while I was playing ball. Looking back, I’m not sure how I did it but I’m thankful that I got past it. Fast forward to beginning to work with you, I started eating more but not necessarily working out less. That was a huge struggle for me because I loved working out and still do. I did get my period back but it was veryy minimal. 

Post college, I’ve dialed down my exercise and actually fell in love with the workouts from Paragon Performance. They give me a little sense of CrossFit with body building and I can make them as intense as I want if I’m just itching for it. 

This and working with you is definitely on of the biggest reasons my period is back and on regular cycles. My body is still very sensitive for high intensity workouts and I have to keep my nutrition in check regularly to make sure I’m eating enough. I get distracted with work and grad school often so I’ve been making more caloric dense meals that are quick and easy to eat but also full of nutrients!

My period came back my sophomore year of college. And yes! I did have to gain weight. At my lowest I was 150, and was around 180 when I finally got my period back.”

“Hi Ashleigh, saw your post on Facebook about HA. I had it for about a year and a half, I’m roughly 15 months recovered now...got it towards the end of my crossfit years as I transitioned to powerlifting/strongman and became super competitive/competed at nationals, Arnold, etc. I was super lean despite eating close to 3,000 calories a day, I have a high metabolism but was basically burning everything off with my training.

Yes, I had to gain weight. It was an uncomfortable process and I had to buy new clothes and get over some mental demons. It took time and it was frustrating but I’m glad I went through it since I learned so much about my body and now know what to look for especially since I’ve picked up my workouts again and am slowly going back to competing. Your body needs to feel safe again to ovulate/cycle so some weight gain will likely be needed. Everyone is different with different timeframes. When I got serious and backed off competing and had to lower my weights plus eat more - for me basically at that 3,000 calorie level with lots of healthy fats and ice cream regularly which I always craved for some reason. It took me 3 months once I jumped in and got serious.”

“So I had it when I competed in the figure competition. I was basically starving to death and doing 45 mins of cardio twice a day. I lost a lot of weight but after I competed, I gained about 30 Pounds. I was miserable. It took me about 9 months of reverse dieting to be able to lose the weight again.

I didn’t have a period for about 2-3 months. Once I gained weight and started eating normal, I got my period back. I then reverse dieted for 9 months and lost weight again which I kept my period the entire time.”

“It happened freshman year of college. Moved down south, had weights 4times a week, 18 credit hours plus 5 practices a week that would last approximately 2-3 hours of straight general strength such as hills, stadiums, 32 minute workouts, mile repeats and etc.

I’ve lost my period for 4 months completely because of the stress and calorie deficit. I had to drink parsley tea and all to get it back because i can’t be on birth control due to my ovarian cysts. It was horrible. Once i got my period back i had it for 17 days straight heavy bleeding.

I had to increase my calorie intake because I’ve lost 42 lbs during the first two months of college. And because of lack of time I would only eat once a day and have maybe 1400 calories but i would burn around 3000 a day. Losing it actually increased my cysts growth, too.”

“I had it for about 5-6 years. When my twins were two I started my first serious diet (WW) and started running. It kind of spiraled from there. About a year into dieting and running I lost my period. I saw a couple of physicians and they would put me on the pill to trigger it into coming back but it never worked. At my peak I was running 15 miles a day and eating maybe 800 cals??? I got hurt a lot and had to stop running long distance. I pretty much had a really bad ED for three to 4 years—overexercise, restriction, purging with a ton of laxatives every day. I was in and out of recovery a few times. 

When I decided that it was the final time I would be in recovery, I switched to CF. It was prob about 2 years into CF that I got my period back—it just happened one day. I was still really overtraining but eating more and better quality food and not doing as much cardio. Honestly I think my body just had enough and was like I am going to make you gain weight and get you back in line. I put on about 20 lbs but needed it. My period came back but was super inconsistent. Apparently I was pretty fertile though because about 5 months after I got my period back I got pregnant. Surprise!😂”

“Mine started when I was a sophomore in college. I was in a super damaging relationship with a lot of pressure to be a certain size. I was way under-eating, over training and running soooo much. Eventually I got to the point where I was 103 pounds. At first, as I started “refeeding” I put on so much weight - around 40 lbs within a couple months still eating way too few calories. So I eventually worked alongside a nutritionist and personal trainer to establish a healthier respect for training and eating. I did a reverse diet and took my calories from ~1000/day to +1800/day and I am so much stronger and healthier. I have finally been able to maintain my weight between 125-130 even with the increased calories. It still took about 6 months after I started working with them for my period to come back at all. I still am not incredibly regular even now 2 years later but much better than I was.”

“I went about 6mths without my period about 2 years ago. I have Hashis and after digging a bit I was in a thyroid crisis and temporarily needed an adjustment in meds and had to get on testosterone because mine had plummeted. Once everything got leveled out I started getting one about every 60 days. Then 30. Now I’m at about every 24-28 days. No weight gain at all. I also increased my macros and lived in a maintenance mode for that time.”

“So I got my period when I was 11. With my period came terrible acne, so I was put on birth control at age 13. I took this on and off till age 22. I also began developing disordered eating at age 14. I struggled with eating disorders and sat well below my ideal healthy body weight pretty much my whole life till now. There were times where I stopped taking birth control and never got my period, but I just brushed it off. When I finally got off birth control for good 2 years ago, I never recovered a period. I was exercising intensely (weight lifting and climbing) and even fell in to BMI of 16 range. I felt terrible. I heard about hypothalamic amenorrhea and read a bunch of peer reviewed articles on the subject. I was introduced to NPNW and decided to change my life. My current life style was not sustainable and cost me friendships, relationships, health, and more. I gained a LOT of weight (35 + pounds) and decreased exercise. I never had to fully stop until waiting for period number 3. And that’s where I am! Getting used to this new, happier, healthier body 🙂”

“Of course - I was cutting weight to be a 48kg lifter working with WAG who told me on top of my five days of lifting I needed more cardio so I was doing some CrossFit, lifting 5x a week and working full time. My macros were 140/140/40 and my period completely vanished - I thought nothing of it since my periods were always super irregular - until I didn’t have one for months.”

“Always active kid! Went on the pill at 14/15for acne and because I was a dancer. 

Stopped taking the pill when I was travelling overseas at 20 and it never came back. The months following were stressful I decided to move to a new country and had a new love haha so I associated it with that.

I got really into training and was working as a trainer, same thing. 

My eating disorder developed around 22 I figured that was the main reason it continued to be absent. 22-24 I was severely under weight 25-26 I was eating properly but still too lean. This passed year I have allowed the extra 8-10lbs I have tried to adjust training... but being stronger I was training harder and competing.

I decided after my last crossfit Comp in July I’d take it seriously reduced my training by probably 45 minutes a day.  I am on HRT therapy. The works. And still haven’t gotten my cycle back.

I noticed ED habits sneak back up as I started gaining weight and my

Body is holding onto it and won’t lean out no matter what:(

So I have decided this is the season I am in, I need to enjoy food, life, relax and rest more and let my body try and adjust. 

We are also wanting a baby so that’s a motivator... but yep. 

8 years. 

Normal to heavier cycle as a young girl, got it at 12. Was super super regular and even on the pill if I missed a Day it would start. It was when I started watching my intake or less carbs it became less consistent even on the pill.”

“Missed my period for over a year and a half. i was a vegetarian for the first 17 years of my life, never had an irregular period. started crossfit at 17 and cut my calories drastically bc “i wanted to be skinny”. was doing 1-2 hrs of crossfit 6-7days a week plus 2 hr vb practices 5x a week and 2 hr marching band practices 2x week. also was a super stressed hs student. after a yr of no period, i went to a dr and got blood drawn, my progesterone levels were similar to someone in menopause. after 6-8 months of working with a nutritionist, my period came back, but it took a year or so for it to be regular again. i’m eating much more and exercising much less, but still sometimes have irregular periods when i’m stressed. I gained 35-40# in 1.5 years.”

“So may story is a little different than most.  2016-2017 after doing CF for little over a year my periods became super heavy and would last upwards to 14-20 days, during that time my BF was approx 28% and weight was around 180.  My diet consisted of low fat numbers of around 55-65 depending on the day. Went to doctors they wanted to do an ablasion, I refused. So I changed my eating habits and ate more fat like up to 90g a day. periods became normal BF dropped and weight dropped (I think BF went down to 23% and weight around 165)  Periods stayed normal for a few months. No cramping, duration was around 3-4 days. I got back heavily into working out just not CF. Periods was hit or miss but when they came it was hell. Ended up going back to doctor, long story short I had to have IUD placed to try and control the bleeding. This helped but took 4-5months of pain hell really.  Periods just recently came to an end. But I believe this is from the IUD and hormone levels being so low. I'm 47 and doctors just told me last month that I am now full blown menopause. 

So long story short - I highly believe that the intake of fat is what helped me with getting my period back and regular.  I went from 55-60g fat to 90g workout days and 120g non-workout days.”

“So I’ve struggled a ton with rapid weight loss and gain so it has affected my period a ton. When I first lost a bunch of weight back in 2015 I missed my period for months and then it actually came back to the point that I lost waaayy too much blood, and then it went away again for a long time when I lost a bunch of weight after my brain surgery. I saw multiple doctors, multiple times but always said it was my birth control just doing it’s job. So I’ve never been technically diagnosed with anything and it came back after I gained some weight back. I’m currently my smallest and everything has been extremely light or I miss it altogether.”

“I got it around 4 years ago when I was doing crossfit pretty intensely

I was going about 6 times a week and doing classes back to back

I had an eating disorder at the time too and was mostly going to crossfit for aesthetic purposes

I didn’t get my period for over 6 months

There was no weight gain

In fact, I lost almost 15 pounds and was seriously underweight from eating so little and overworking myself

It was until I got an injury back in 2016 that I was forced to take a step back

After I gained some weight again, I got my period back the month directly after.”

These are answers from an IG question sticker

“Yes! I did a lot of running and HIIT intervals.”

“Yes! I believe I was misdiagnosed with PCOS.”

“I have!”

“Yes. For 2+ years.”

“Oh yeah!”

“Early 2017 at the bottom of a weight cut and height of my CF training, I had HA for 4 months.”

“Went 8 months without my period!”

“Yes! Not competing in CrossFit, but from under-eating and over exercising.”

“I have!”

“Yess I went through it!”

“Not CrossFit, but yes intense training. I’m recovered for 11 cycles now after over 5 years of HA.”

“Yes!”

“Yes I did last year and most of it for 4 months after doing my cut for 6 weeks bc of low fat intake.”

“Yes. Competing in powerlifting.”

“Yes!”

“Powerlifting and bodybuilding training, even after introducing more cals and weight gain.. It’s been 2 years.”

So.. clearly a lot of women are dealing with this or have dealt with this. I hate how pushed under the rug it is.. mostly because people are probably not comfortable talking about it. I understand that I guess, but if it goes on too long it can really create a lot of damage especially to our bones. & for the ladies that want to have children in the future, this is something that you need to have. You can’t conceive when your period is missing!

I hope this blog was enlightening and you realized how many people are struggling with this. You’re not alone!