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Article: Fitness and Menstrual Health

Fitness and Menstrual Health

Fitness and Menstrual Health


The Cost of Staying Fit: Missed Periods and Menstrual Health


Fit women often lose their menstrual period when training hard or dieting to lose fat. While some think it’s no problem, this could not be further from the truth.

In today’s article, we explore why a missed period should be of concern. Our nutrition coaches share tips on staying lean while balancing hormones for menstrual health. We also highlight how hormonal imbalance also affects men.


Case study

Maryann is young, active, and (apparently) healthy.

She eats a self-described “clean” diet. She weight trains twice a week and does about two hours of cardio four or five days a week.

A year ago, at age 43, she stopped getting her periods.

She didn’t mention it to her trainer. And it never occurred to her to consult a doctor. 

In fact, secretly, she felt relieved. After all, she did not want to get pregnant.

Besides, dealing with her monthly cycle had become a hassle. It interfered with her exercise program. And the weight fluctuations played with her mind.

So…no period, no problem. Right?


Understanding the menstrual cycle

The menstrual cycle is a series of changes women’s bodies go through when preparing for the possibility of getting pregnant.

Here’s how it works…

  • Every month, one of the ovaries releases an egg. (This process is called ovulation.)
  • At the same time, body-wide, hormonal changes prepare the uterus for pregnancy.
  • To begin with, a hormone called gonadotropin releasing hormone (GnRH) is sent from the hypothalamus to the pituitary gland (both located in the brain).
  • This neuro-cellular crosstalk then triggers the pituitary gland to release two other hormones: follicle stimulating hormone (FSH) and luteinizing hormone (LH).
  • In men, LH travels through the body's pathways and causes the Leydig cells of the testicles to produce testosterone. In women, they cause the ovaries to make estrogen and progesterone.
  • Additionally, LH helps to regulate the length and order of the menstrual cycle in females by playing roles in both ovulation and implantation of an egg in the uterus. 

Of course, the amount of estrogen and progesterone produced depends on which phase of the menstrual cycle one is in (i.e., follicular vs. luteal).

If ovulation takes place and the egg is not fertilized, the lining of the uterus sheds through the vagina. And this is what most people think of as a “period”. 

Here’s a visual of the process.


Energy balance and menstruation

Back to Maryann…what went wrong with this normal process?

(And why does this happen to so many female exercisers?)

In simple terms, a woman’s body is extremely sensitive to energy fluctuations.

When a woman is eating a restricted diet (especially if she’s intermittent fasting or skipping meals), or she’s exercising strenuously for hours every day, her body recognizes this negative energy balance as a threat to her survival.

So, the body shuts down “non-essential” body processes such as reproduction. In short, she becomes infertile. The scientific term for this is hypothalamic amenorrhea.

Hypothalamic amenorrhea is a condition in which menstruation stops for several months due to an abnormality involving the hypothalamus. The hypothalamus is a region of the forebrain below the thalamus which controls reproductive cycle (in all people),  and coordinates both the autonomic nervous system (fight or flight response). The activity of the pituitary gland, controls body temperature, thirst, hunger, and other homeostatic systems, and is involved in sleep and emotional activity. When one has hormonal imbalance of any kind, as in the case of menopause/thyroid/reproductive issues, the downregulation can be attributed to poor diet, chronic stress, or too much exercise.

The role of leptin

Girls now get their first period (aka menarche) earlier than in our grandparents’ generation.

This may be because, on average, kids are heavier than in the past. Since kids are becoming heavier sooner than they used to, their periods are also starting sooner. 

But to understand that, we need to understand the function and recognize the relationship between the hormone leptin, one's body fat, and the hypothalamus.

Leptin’s main function is to help regulate the long-term balance between our body’s food intake and energy use (expenditure). Leptin also helps inhibit (prevent) hunger and regulate energy balance so that our bodies don’t trigger a hunger response when it doesn’t need energy (calories). It does this by primarily acting on our brainstem and hypothalamus to regulate hunger and energy balance, though we have leptin receptors in other areas of our bodies.

Leptin doesn’t affect our hunger levels and food intake from meal to meal but rather acts to alter food intake and control energy expenditure over a longer period of time to help maintain the body's internally perceived "normal" weight. As far as the body is concerned, our idea of a normal weight, based on the scale, is irrelevant to how our bodies naturally "calculate" this magic number.

Leptin has a more profound effect when you lose weight. As our body fat (adipose tissue) decreases, leptin levels decrease, which signals our bodies to think that it is starving. This stimulates intense hunger and appetite and can lead to increased food consumption.

Your white adipose tissue (body fat) makes and releases leptin. White adipose tissue is the main type of fat in your body. It’s located beneath your skin, around internal organs, in the middle cavity of your bones. White adipose tissue serves as cushioning for various parts of your body.

The amount of leptin in your blood is directly proportional to the amount of adipose tissue your body has. In other words, the less body fat, the less leptin you have, and the more body fat, the more leptin you have.

So, when a child gains enough weight, there is a threshold amount of leptin produced to signal the hypothalamus to kick off the first menstrual cycle.

The opposite is true for women who get too lean or who restrict calories too much.

Getting too lean decreases the amount of leptin circulating in the body. This, in turn, decreases the activity of the hypothalamus which secretes GnRH - a precursor to testosterone, progesterone, and estrogen.

Since Maryann was restricting calories, exercising almost every day, and losing body fat, this combination of factors created a physiological balance which could have triggered the loss of her period.

The role of stress

As discussed, women’s physiological sensors are highly tuned in to sensing deficits. Whether in energy balance, essential nutrients, or body fat, women’s bodies quickly respond to deficiencies.

It is our DNA – it cannot be changed. However, this “deficit setpoint” will vary from woman to woman.

Some women can be naturally leaner, can work out with higher volume and intensity, or can eat fewer calories while staying hormonally healthy aka having a period.

Other women’s systems are more sensitive to any perceived restriction.

Of course, stress — of any kind — will make things worse.

For many female athletes (or even just active women such as ourselves), the demands of training and competing, pressure to succeed, and other normal life stressors such as jobs, school, finances, relationships, etc. can combine with nutritional and physiological stressors to shut our system down. 

The same thing can happen when the sympathetic nervous system (SNS), aka our “fight-flight” system, is overtaxed. For instance:

  • If we rely too much on stimulants such as caffeine
  • If we don’t learn how to calm down and recover often or deeply enough, giving our parasympathetic nervous system (PNS), aka our “rest and digest” system, time to activate
  • If we are constantly in self-critical, “gotta do it all myself”, control-freak or perfectionist or obsessive compulsive mental mode
  • If we don’t get enough quality sleep
  • If we skip meals or fast too restrictively or too often (which amps up our stress hormone production)
  • If we beat the heck out of ourselves with too many, too-demanding high-intensity workouts (such as Crossfit, MMA conditioning, or sprint intervals)…
  • …then our stress hormones are always on “high alert”, telling our bodies that threats lurk around every corner, and it is not safe to reproduce.

Since many female athletes or recreational exercisers can also be driven, high-achieving people who seek out stress and challenge and push themselves to be ever-better…well, all this sometimes creates the perfect storm. 

Why is hormonal health important?

Unless you’re planning on starting a family, infertility and losing your period might not seem like a deal. In fact, it might seem a nice break from the hassle of having periods. 

Not so fast.

Remember that your period isn’t just about pregnancy. Rather, it’s a side effect of normal hormonal health. In other words, losing your period (or having significant irregular periods) means that something is “off” hormonally.

Think of your period as a dashboard indicator light. When you lose it, the light starts blinking: Hormonal health alert! And you ought to pay attention. Not only does not having a period cause hypothalamic amenorrhea, as we age and transition through perimenopause and menopause, science has shown that delaying the menopause experience, by maintaining a healthy pain-free period, actually leads to longer lifespan and better quality of life, all factors being equal.

In the case of hypothalamic amenorrhea, those messages we talked about earlier — from the hypothalamus (brain + digestive + endocrine systems) to the pituitary (brain + endocrine system) to the ovaries (brain + endocrine system) — significantly diminish. And that means the production of hormones like estrogen and progesterone is dangerously reduced.

Why is that a problem if you miss a period and could really care less about starting a family? The bottom line is that what you don’t want and what your body is naturally designed to do are not mutually exclusive. 

Your body also needs these hormones for bone strength. Hormones are also required to keep you feeling healthy, energetic, and even-keeled psychologically.

In fact, because of the link between estrogen, progesterone, and bone health, many fit young women who lose their periods end up with weaker bones than their eighty-year-old grandmothers.

And yes, that includes the ones like Maryann, who regularly perform weight-bearing exercise, and whose diets are rich in calcium and vitamins D and K.

Neither strength exercise nor proper nutrition is enough to make up for hypothalamic amenorrhea. 

The brain’s connection to the… thigh bone

Unfortunately, a lot of young female athletes aren’t aware of their body’s needs for estrogen, so when they lose their periods as part of their training, they simply take it for granted.

In fact, the first issue that often drives women like Maryann to the doctor is not the loss of menstruation. It’s a mysterious pain in one of their thighs. 

The cause of that pain — as their doctors can easily discover with a little investigation — is a stress fracture.

This happens so often that there’s even a name for the syndrome (which by the way, affects both male and female): the Female and Male Athlete Triad.

Core symptoms of the Female Athlete Triad are:

  • Amenorrhea (being without a period for three months)
  • Decreased bone mineral density
  • Low energy availability (including disordered eating)

But the symptoms don’t stop there.

Estrogen and progesterone — along with other sex steroid hormones such as testosterone — have wide-ranging effects throughout our bodies.

So, if your hormones are disrupted, you might also experience:

  • Fatigue and low energy
  • Disrupted sleep (e.g., trouble falling or staying asleep, including the dreaded 3 am “blast out of bed”)
  • Hair loss (or for some women, facial hair growth)
  • Cold hands and feet
  • Skin problems like dry skin or acne flareups
  • Weight changes and changes to where you put on body fat (e.g., More accumulating around your middle)
  • Slow injury healing; more inflammation
  • Anxiety / OCD, low self-esteem and/or depression
  • Elevated carotene in the blood
  • Anemia
  • Orthostatic hypotension
  • Electrolyte irregularities
  • Vaginal dryness or thinning of tissues
  • Bradycardia (slower than normal heart rate)
  • Chronic pain (even if it’s just general aches or soreness)
  • Changes in digestion (such as constipation or bloating)
  • Changes to your breast size or shape (which you’d probably notice as bras not quite fitting right suddenly)

I can’t tell you how many times a young female athlete has come into my clinic complaining of thigh pain and, surprise, no periods. Further exploration usually reveals a pattern of restrictive eating or excessive exercise. Not to mention many of these other symptoms.

It’s a real shame. Because along with their periods, these young women are losing the very thing that matters to them most: Their health and their ability to have a better quality of life as they age.

But wait…men are at risk too

While the Triad is more prevalent in females than in males, both sexes have the potential to be affected by the Triad. Loss of menses is a prime signal of the Triad’s presence in females, and although it may be more difficult to recognize in males, their health can still be affected negatively by the Triad.

In our client’s case and one of the few men we coach, Jason, an ostensibly fit personal trainer, was tired. He’d been to many doctors, who put him on thyroid replacement without fixing the underlying cause — not enough food, and too much stress. A low-calorie diet, specifically intermittent fasting, combined with high stress spelled serious exhaustion for this otherwise healthy personal trainer.

Just like in women, when a man’s energy availability is chronically low, his hormonal health is at risk.

In Jason’s case, this showed up as a thyroid problem. We often see testosterone plummeting too. The same hypothalamus – pituitary – leptin - body fat -ovary/testis link is the culprit. It’s the same disruption pattern. 

So if you’re a guy, please don’t think this article is irrelevant for you.

In fact, you should be especially cautious. After all, you don’t have that obvious signal — a missed period — to warn you that you’re at risk. 

Which is why we all need to keep energy and hormones in balance or health will deteriorate. 


Energy deficit…or nutrient deficiency?

While energy deficits are probably the most common cause of amenorrhea in female athletes — and low thyroid hormone/testosterone production in men — they are not the only cause.

Vitamins and minerals

Dr. John Berardi, advisor to EQUINOX, Apple, and Nike, has worked with several fitness / figure competitors who lost their menstrual period while preparing for a contest.

After introducing a few vitamin and mineral supplements, their periods returned.

Of course, negative energy balance and nutrient deficiency are intimately connected. If you’re not getting enough food overall, you’re probably also missing out on specific micronutrients.

What surprised Dr. Berardi was the way these athletes responded to vitamin and mineral supplementation alone (without additional calories). 

“I was amazed when we experimented with this. We tested removing and reintroducing the multivitamin/ multimineral a few times. When the vitamins and minerals were in, periods returned. When they were out, menstruation stopped.”

This suggested to him that maybe, at least some of the time, energy deficit isn’t the problem so much as is nutritional deficiency. 


In the nutrition coaching program, we also noticed that adding a handful of slow-digesting carbohydrates to most meals also helps, as does making sure to get enough carbohydrates post workout.

Many health-conscious women restrict carbohydrates, particularly starchy or sweet carbs (such as potatoes or bananas), believing that carbohydrates are “bad” or that low-carbohydrate diets are “good” for everyone.

The result is the same: hormonal disruption, amenorrhea, and a physiological stress response to what the body thinks is deprivation.

There may be a good reason for carb cravings in the luteal (aka premenstrual) phase of the menstrual cycle: Carbohydrates may serve a physiological need in women that science doesn’t fully understand yet. 

With that said, the idea of specific micronutrient deficiencies — or even a link between carbohydrate intake and amenorrhea — is only a hypothesis. But it’s definitely food for thought.

Other causes of amenorrhea

Don’t ignore a series of missed periods. Along with nutritional deficiencies and energy imbalance, you could be dealing with quite a few serious underlying issues.

These include:

  • Polycystic ovary disease (PCOS)
  • Thyroid problems
  • Uterine scarring
  • Pituitary tumors
  • Premature menopause (peri-menopause)

Not to scare you or anything, but this is why it is so important to see your doctor if you stop getting your periods. Even if you don’t want to get pregnant.

Fixing what’s wrong

So, what happened with Maryann?

She cut down on a bit on her cardio training. (She didn’t eliminate it entirely, of course). She also started eating 500-1000 additional calories each day. 

Within a few months, she did gain a few pounds. However, because we replaced some of her cardio with weights, most of that gain was lean.

Either way, not only did we improve her strength and lean mass, without causing fat gain, we also improved her hormonal health, reducing her risk for other health problems including premature onset of osteoporosis.

So, what happened with Jason?

By addressing the real problems — metabolic down-regulation because of stress and inadequate food intake — we were able to wean Jason off his thyroid medication and on to a new, healthier path. 

What can we learn from both Maryann and Jason’s story?

  • If you are constantly fatigued, see your doctor.
  • Hypothyroidism (low thyroid) may be a symptom of something else, and it doesn’t always have to be treated with thyroid replacement.
  • Find the actual problem. In Jason’s case it wasn’t his thyroid, it was his low-calorie intake.
  • Look at your allostatic load — the sum total of all the mental, physical, and emotional stressors in your life.
  • You may be more stressed out than you realize — and if so, your body will be giving you clues.

What can’t be fixed?

Once energy and hormones return to a healthy level, our bodies can resume normal reproductive functioning again. Even though this may take a few weeks-months to occur, your reproductive health will return to normal functioning with proper nutrition as in both Maryann and Jason’s case. 

Once energy and reproduction are recovered, bone breakdown may decrease, but it is very difficult to recover your bone health back to normal.

We now know that when an energy deficient athlete eats more calories, it protects from further bone loss- but we don’t have good data yet to know if increasing food intake results in improving bone. More research is necessary- so it is important to simply avoid the bone loss in the first place and fuel your body properly to nourish your hormones and avoid negative health effects.

As for leptin, here’s not much you can do to raise your leptin levels to decrease hunger and appetite, since your leptin levels are directly related to how much adipose tissue your body has.

One study found that sleep-deprived people had high levels of ghrelin, a hormone that signals hunger, and lower levels of leptin. Getting appropriate amounts of quality sleep is important for several reasons, so, in any case, it’s beneficial to your overall health.

Lastly, since leptin is a hormone your body makes and not a nutrient (like vitamin C or protein), no foods contain leptin. 

What you can do

If you’re a health-conscious woman who works out and eats well take note: Losing your period isn’t something to take lightly.

Although we shared a case study using a 43 year-old female athlete, maintaining menstrual health is of vital interest to women of all ages. With stable menstrual health throughout one's life, the later menopause is pushed further out, and the less adverse affects in female aging, all else being equal.

If your menstrual cycle becomes irregular or stops altogether:

  • Make sure you’re meeting your body’s energy needs.
  • Increase calories or reduce exercise by a little bit.
  • Ensure you’re getting enough rest.
  • Consider taking a high-quality vitamin/mineral supplement.
  • Consider drinking KOKOBÉRNA's SACRAL WOMB Tisane to naturally contract the uterine system and gently stimulate the menstrual cycle using a synergistic blend of 100% organic adaptogen herbs.
  • Consider adjusting your carbohydrate intake to consume a handful of slow-digesting carbs at most meals. (And depending on your athletic needs, maybe even more.)
  • Check your head. Mindset matters because hormones are produced in the brain and funneled down through the endocrine system into our reproductive organs. Become aware of the response to thoughts and feelings along with nutrition and/or physical activity.
  • And see your doctor to rule out underlying problems. 

It’s never too late to start making healthier choices. Because, while you may not want to start a family today, you’ll want to be walking on those bones. For life. 

Work with us

Our nutrition coaches are diet-agnostic and work from a holistic perspective grounded in sound functional medicine principles. If you’re concerned with your body weight or want guidance on how to lose weight in a healthy way that supports the delicate balance of your hormones, talk to your healthcare provider or consider seeing an endocrinologist who specializes in hormones and can offer weight management programs. Apply for FREE to the KOKOBÉRNA Nutrition Coaching and Wellness Counseling Program here

Leave a comment, thoughts, or questions below.

In Good Health.



Excerpted and inspired from multiple sources to include:


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