Tips from Nancy Clark
Women and Nutrition: Tips for Athletes with Amenorrhea
Athletic women are generally looked upon as being fit and healthy.
look from the inside out shows a different story. Approximately
active women are unhealthy to the point they stop having regular
menstrual periods. This condition is called amenorrhea and is
characterized by estrogen deficiency, similar to menopause. Although
some women deem amenorrhea as a desirable side effect of exercise
because they no longer have to deal with the hassles and possible
discomfort of monthly menstrual periods, others recognize absence
periods is linked with health problems:
Loss of calcium from the bones
Almost a three times higher incidence of stress fractures (24% of
athletes with no or irregular periods experience stress fractures
as compared to only 9% of regularly menstruating athletes)
Long-term problems with osteoporosis starting at an early age. Amenorrhea
can also interfere with the ability to conceive easily should the
athlete want to start a family.
Causes of amenorrhea
Many women believe they have stopped menstruating because they are
exercising too much. Not the case. Many very thin athletes who exercise
very heavily have regular menses. Other women believe they have
stopped menstruating because they are too thin. Also false. Studies
suggest no differences in body fatness between athletic women who
do and do not menstruate regularly.
The question remains unanswered: Why, given a group of women who
have similar exercise programs and a low percent body fat, do some
experience menstrual problems and others don't? The answer commonly
relates to nutrition. The woman with amenorrhea may be striving
maintain a weight lower than what is appropriate for her genetics.
the cost of achieving this desired leanness is inadequate nutrition,
she'll stop menstruating.
Prevalence of amenorrhea
Although amenorrhea is not sport-specific, sports with the highest
prevalence include ballet (19 to 44% of dancers) and competitive
running (24 to 26% of runners). An estimated 3 to 5% of sedentary
women also experience menstrual irregularity; this is strikingly
less than what prevails among athletic women. You are more likely
to become amenorrheic if you have lost weight quickly, have a low
body weight, low percent body fat, exercise very hard, had irregular
menstrual periods even before you started to train hard, are feeling
emotionally stressed, and have a restrictive diet.
Amenorrhea and anorexia
Although amenorrhea exists among women with no eating disorders,
loss of menses is certainly a red flag symptomatic of restrictive,
anorectic type eating behaviors. The American Psychiatric Association's
definition of anorexia lists "absence of at least three consecutive
menstrual cycles" among the criteria. Other criteria include:
weight loss 15% below that expected, intense fear of gaining weight
or becoming fat, and distorted body image (i.e., claiming to feel
fat even when emaciated), all of which are concerns common to female
Resolving the problem
If you feel as though you are struggling to balance food and exercise,
you might want to seek counseling from a trusted physician, dietitian
and/or counselor. To find a local sports nutritionist, call 800-366-1655
or visit www.eatright.org and use the American Dietetic Association's
The possible changes required to resume menses include exercising
to 15% less and eating a little more. If you totally stop training,
as may happen if you are injured, you may get your period within
months. Some amenorrheic athletes have resumed menses by simply
exercising less and gaining no weight or less than 5 pounds. This
amount of weight gain is enough to achieve better health yet does
result in your "getting fat."
The following tips may also help you resume menses - or at least
rule out nutrition-related factors.
1. Throw away the bathroom scale. Rather than striving to achieve
a certain number on the scale, let your body weigh what it weighs.
2. If you have weight to lose, don't crash diet but rather moderately
cut back on calories by about 20%. You are eating too few calories
if you are always hungry and obsessing about food.
3. Eat adequate protein. Amenorrheic athletes tend to eat less protein
than their regularly menstruating counterparts. Even if you are
a vegetarian, remember that you still need adequate protein. Eat
additional yogurt, fish, beans, tofu and nuts.
4. Eat at least 20% of your calories from fat. If you believe you
will get fat if you eat fat, think again. Although excess calories
from fat are easily fattening, some fat (20-30% of total calories;
40-60+ grams fat/day) is an appropriate part of a healthy sports
diet. Nuts, peanut butter, salmon, olive oil are healthful choices.
5. Include small portions of red meat 2 to 3 times per week. Surveys
suggest runners with amenorrhea tend to eat less red meat and are
more likely to follow a vegetarian diet than their regularly menstruating
counterparts. Even in the general population, vegetarian women are
five times more likely to have menstrual problems than meat eaters.
It's unclear why meat seems to have a protective effect upon menses.
6. Maintain a calcium-rich diet to help maintain bone density. A
safe target is the equivalent of 3 to 4 servings per day of low
fat milk, yogurt and other calcium-rich foods. Being athletic, your
bones benefit from the protective effect of exercise, but this does
not compensate for lack of calcium nor lack of estrogen.
Is there long term damage?
Amenorrheic women who resume menses can restore some but not all
of the bone density lost during their months of amenorrhea. Hence,
their goal should be to minimize the damages of amenorrhea by eating
appropriately and taking the proper steps to resolve the problem.
Every woman always wins with good nutrition!
Nancy Clark, MS, RD is Director of Nutrition Services
at SportsMedicine Associates in Brookline MA. She is author of Nancy
Clark's Sports Nutrition Guidebook, Second Edition ($23) and her
new Food Guide for Marathoners: Tips for Everyday Champions ($20).
Both are available via www.nancyclarkrd.com
or by sending a check to Sports Nutrition Materials, 830 Boylston
St #205, Brookline MA 02467.
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