Athletic amenorrhea is a disorder of the ovarian-menstrual cycle caused by intense training. It is manifested by a delay in sexual development with the absence of menarche, the cessation of menstrual discharge for six months or more, anovulatory bleeding (opsomenorrhea, oligomenorrhea, polyproymenorrhea), masculinization. It is diagnosed by laboratory examination of the content of steroid hormones, folliculometry, densitometry. To restore the cycle, lifestyle correction is recommended (reduction of training, more caloric nutrition), according to indications, calcium preparations, estrogen-progestogenic agents, ovulation stimulants are prescribed.
N91 Absence of menstruation, poor and rare menstruation
Over the past 50 years, there has been a significant increase in the number of cases of athletic amenorrhea, which is also called exercise-induced amenorrhea. If in 1964 more than 90% of the participants of the Summer Olympics in Tokyo had a normal monthly cycle, then only 12 years later 57% of the athletes who came to the Olympic Games in Montreal suffered from some kind of menstrual dysfunction. In 1993, the concept of the so-called “women’s sports triad” was introduced, which includes amenorrhea, malnutrition and a decrease in bone density associated with intensive training and conscious restriction of the amount of food consumed. The disorder is more often diagnosed in professional athletes engaged in athletics, demonstration sports (artistic, gymnastics, synchronized swimming, figure skating) and ballet dancers.
Disorders of menstrual function in female athletes are mainly associated with the restructuring of the body in response to intense training. The prerequisites for the emergence of the disorder are also changes in lifestyle and eating habits, the use of hormonal pharmaceuticals. Experts in the field of sports medicine, obstetrics and gynecology consider the main causes of amenorrhea associated with physical exertion:
- Physical and psychological stress. Intense training, participation in sports camps and competitions contribute to the activation of the hypothalamic-pituitary-adrenal system. This leads to a decrease in the secretion of gonadotropins and, as a consequence, a violation of the endocrine function of the ovaries.
- Lack of adipose tissue. Extragonadal aromatization and the accumulation of steroids in adipocytes is one of the elements of regulating the level of estrogens in the female body. With a reduction in the amount of fat less than 17-22% (BMI)
- Restriction of the energy value of the diet. A conscious reduction in caloric intake at a high level of energy consumption is accompanied by an increase in the production of ghrelin, a stimulant of hunger. One of its effects is the inhibition of the production of luteinizing hormone necessary for ovulation.
- Taking anabolic steroids. Some women take androgenic anabolics to improve athletic performance, allowing them to gain muscle mass better and recover faster after heavy workouts. Drug virilization of the body is manifested, including amenorrhea.
The key link of hormonal disorders that cause athletic amenorrhea is a failure at the central hypothalamic—pituitary level of regulation of the monthly cycle. Hyperproduction of cortisol and corticotropin-releasing factor during stress activation of the hypothalamus, pituitary gland and adrenal glands inhibits hypothalamic secretion of gonadotropic releasing factors. As a result, an insufficient amount of follicle-stimulating and luteinizing hormones is released, the maturation of oocytes is inhibited, the synthesis of estrogen and progesterone by the ovaries is disrupted. A similar effect is caused by transient hyperprolactinemia, increased levels of serotonin and opioid peptides, which are also the results of stress and significant physical exertion.
An additional factor is the increased secretion of ghrelin by the gastric epithelium due to the discrepancy between the caloric content of food and the high energy consumption of the body during sports training. Against the background of hypergrelinemia, even with initially normal levels of follicle-stimulating hormone and estrogens, the synthesis of luteinizing hormone decreases, respectively, ovulation does not occur. Hyperandrogenism, provoked by the use of anabolic steroids and transient stress hyperprolactinemia, plays a certain role in the pathogenesis of menstrual and reproductive dysfunction.
The systematization of the forms of athletic amenorrhea is based on the same criteria as other forms of this menstrual dysfunction — the time of occurrence of the disorder, the degree of its severity and the features of the clinical picture. To choose therapeutic tactics and determine the prognosis of the disease, obstetricians and gynecologists most often use a classification in which they stand out:
- Primary amenorrhea. The athlete did not have menarche until she was 16. This type of disorder is more common in girls who have been professionally involved in sports since preschool and primary school age. The delay in sexual development is due to a busy training schedule and insufficient amount of adipose tissue.
- Secondary amenorrhea. Menstrual dysfunction occurred after one or more normal ovulatory cycles. The disorder is manifested not only by the absence of menstruation, but also by other types of dysmenorrhea. It is most often observed in athletes who are engaged in athletics, especially long-distance running.
In the most severe cases, the leading signs of the disease are the initial absence of menstrual discharge or the cessation of menstruation for 150 days or more. The period of complete amenorrhea may be preceded by anovulatory cycles with a shortening of the interval between menstruation to 21 days or less, an increase of more than 35 days, a decrease or increase in the intensity of discharge, short or prolonged periods. 66-85% of female athletes with amenorrhea have signs of masculinization: athletic physique (tall, narrow pelvis, broad shoulders), hypoplasia of the mammary glands, low rough voice, developed musculature.
In most patients, athletic amenorrhea is complicated by infertility due to the lack of ovulation. Even with less pronounced cycle disorders, when anovulatory periods are replaced by ovulatory ones and conception is possible, pregnancy is more often interrupted by spontaneous miscarriage, premature birth, and fetal development delay. Against the background of hypoestrogenism, characteristic of amenorrhea during sports loads, changes similar to postmenopausal osteoporosis occur in the bone tissue. Violation of microarchitectonics, a decrease in the density of tubular and spongy bones increases the risk of fractures, spinal deformity, and a significant decrease in growth. Chronic hypoestrogenism is accompanied by endothelial vascular dysfunction caused by a decrease in the cardioprotective effects of female sex hormones. In such patients, general atherosclerosis, coronary heart disease develops faster, sudden coronary death is possible.
A prolonged and persistent violation of the monthly cycle in a female athlete is a sufficient reason for a comprehensive assessment of the hormonal background and conducting studies aimed at identifying possible complications of hypoestrogenism. The most informative methods to verify the diagnosis of athletic amenorrhea are:
- Determination of the level of steroids. The tests reveal a low content of FSH, LH, estradiol, progesterone. Concentrations of prolactin, male sex hormones (androstenedione, dihydrotestosterone, total and free testosterone), cortisol, ACTH are usually elevated.
- Folliculometry. Dynamic monitoring of ovarian follicular tissue and endometrium using ultrasound allows you to detect the presence or absence of ovulation. The results of ultrasound examination are especially valuable in dysmenorrhea with anovulatory uterine bleeding.
- Densitometry. Confirms signs of osteoporosis caused by chronic hypoestrogenism. The patient can be assigned both a classical X-ray examination to assess bone mineral density, and ultrasound densitometry based on the reflection of ultrasound by the bone.
Ultrasound of pelvic organs, radiography of the Turkish saddle, ECG, determination of calcium, phosphorus, alkaline phosphatase, calcitonin, other markers of osteoporosis, total cholesterol, lipoproteins, calculation of the level of atherogenicity are recommended as auxiliary methods of examination. Differential diagnosis of amenorrhea caused by sports loads is carried out with anorexia nervosa, tumors of the hypothalamus, pituitary gland, adrenogenital syndrome, stromal ovarian tecomatosis, ovarian polycystic syndrome, persistent galactorrhea-amenorrhea syndrome, and other diseases in which the menstrual cycle is disrupted. According to the indications, the patient is advised by an endocrinologist, neurologist, neurosurgeon, oncologist, cardiologist, orthopedic traumatologist, nutritionist.
Treatment of athletic amenorrhea
In the absence of menstruation in an athlete over 16 years old or persistent secondary menstrual cycle disorder in women of reproductive age training, observation by a gynecologist-endocrinologist is indicated. Functional disorders caused by hormonal imbalance can usually be stopped with the help of non-drug methods. In more severe cases and in the detection of complications in the form of osteoporosis, medical correction of the condition is recommended. The management plan of a patient with amenorrhea usually includes:
- Restoration of normal energy balance. Mandatory first steps are to reduce the intensity of sports loads by 10-15% and increase the caloric intake by 8-16% (usually by 300-360 kcal). It is recommended to supplement the diet with dairy products, dietary meat, fish. As a rule, due to the correction of the training regime and the daily diet, menstrual function is restored within 3-4 months.
- Increased calcium intake. Sports menstrual dysfunction is often combined with osteoporosis. Therefore, the patient should take at least 1,500 mg of calcium every day in the form of a monopreparation or as part of mineral and vitamin complexes. The best assimilation of the macronutrient is facilitated by its combination with magnesium and vitamin D. In more complex cases, the appointment of an ossein-hydroxyapatite complex and flavones is justified.
Correction of the hormonal background. In the absence of the effect of reducing loads and a more caloric diet, it is possible to use drugs containing female sex hormones. Usually, combined estrogen-progestogenic oral contraceptives are used to regulate the ovarian cycle. If menstrual dysfunction is caused by a violation of only the luteal phase, it is permissible to use ovulation stimulants.
Prognosis and prevention
With the conscientious implementation by a patient with athletic amenorrhea of recommendations for reducing loads and increasing caloric intake, it is possible to quickly and completely restore the monthly cycle. To prevent the disorder, it is recommended to gradually increase the duration of classes, the number of approaches and the intensity of sports exercises, compliance with the training regime, sufficient rest and sleep, weight control and prevention of its significant reduction, at least 3-fold carbohydrate nutrition on training days. 1-2 days before menstruation and during menstruation, you should reduce the intensity of training, perform mainly complexes for muscle relaxation and flexibility, abandon strength exercises, jumps, tension of the muscles of the press and diaphragm.