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No Periods - Should You Be Alarmed?


Menstrual bleeding is a normal monthly event for most women, so should you be concerned if you or your daughter stops bleeding or has not started having regular periods?

Athletic Amenorrhea

Kate E. Temme, MD
Dr. Kate Temme

Kate Temme, MD, specializes in sports medicine and women’s health, including treatment of the female athlete triad. According to her, the female athlete triad is composed of three interrelated conditions that include:

  • Energy availability (nutritional intake)
  • Menstrual function
  • Bone mineral density

The triad occurs along a spectrum from optimal health to disease. At the extreme, the triad is defined by low energy availability (with or without an eating disorder), amenorrhea and osteoporosis. Girls and women can have one, two or all three components. Low energy availability is the core component of the triad, and affects bone health by decreasing new bone formation, and increasing bone resorption due to a lack of estrogen. Without adequate nutrition, adolescent girls miss out on critical bone health – a price they may pay throughout their whole life.

“The vast majority of bone density is built in the years surrounding the onset of menstruation,” says Dr. Temme. “Without estrogen, a girl cannot build the critical bone mass she needs throughout her lifetime. This can result in low bone density, fractures and osteoporosis.”Mother and daughter exercising

Dr. Temme sees girls who have multiple stress fractures due to repetitive movements. While training errors may be at fault, frequent stress fractures are often associated with poor bone health.

“Gymnasts, ballet dancers and runners – any athlete who participates in a ‘lean physique’ sport - can be at greater risk, but the triad can affect girls and women across a wide range of sports and activity levels” she says.

According to the American Society for Reproductive Medicine and the American College of Sports Medicine, girls who have not yet menstruated by the time they are 15 have a condition called primary amenorrhea. Women who have previously had a period and stop menstruating for three or more consecutive months have secondary amenorrhea.

Primary Amenorrhea

“Primary amenorrhea can result from genetic, anatomic or endocrine causes. In young athletes, primary amenorrhea may occur when a girl does not eat enough to support the amount of energy she is expending in her sport,” says Dr. Temme. “In extreme cases, this may be a result of an eating disorder, but often times, it is inadvertent – she is simply not getting enough nutrition to sustain the exercise her body is performing as well as her body’s other physiologic functions.”

This imbalance of energy intake versus energy expenditure affects the body’s endocrine system, including reproductive function and estrogen production.

“It’s the body’s way of saving energy for all the exercise a girl is doing,” she says. “Certain biologic systems shut down, affecting metabolism, skeletal and reproductive health.”

Secondary Amenorrhea

In some cases, secondary amenorrhea can be associated with low estrogen levels and can lead to osteopenia, which is the precursor for osteoporosis, osteoporosis and bone fractures. It also decreases a woman’s chance of becoming pregnant.

Monica A. Mainigi, MD
Dr. Monica Mainigi

“When a woman’s body doesn’t have enough estrogen, she does not ovulate.” says Monica Mainigi, MD, assistant professor of obstetrics and gynecology at the Hospital of the University of Pennsylvania, “This is the body’s way of saying there is not enough energy to support a pregnancy.”

Dr. Mainigi specializes in infertility and reproductive endocrinology. She explains that some women who exercise excessively or restrict their caloric intake can experience secondary amenorrhea and infertility. One of the first steps is a comprehensive evaluation by a gynecologist to identify the cause of amenorrhea so that a personalized treatment strategy can be developed.

Treating the Female Athlete Triad

“Treating girls and women who have the Female Athlete Triad is complex and requires women to be plugged in to the right resources,” says Dr. Mainigi. At Penn, nutritionists, counselors, orthopaedic specialists and endocrinologists work together to provide coordinated care for these athletes.

“Simply telling a woman to eat more or train less is not the answer,” says Dr. Mainigi. “Her personal identity may be wrapped up in appearance, athletics and performance, and she can lose sight of what is healthy and what is not.”

Dr. Temme adds that there are positives when it comes to treatment.

"The good news is that when discovered early, and treated comprehensively, a lot of the damage can be prevented.”

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