A 23-year-old woman in Zhejiang province, China, who was exercising about six times a week for roughly 70 minutes each session, experienced a progressive reduction and eventual cessation of her menstrual periods. Her hospital evaluation found that her female hormone levels were unusually low, comparable to those of a 50-year-old, prompting medical professionals to diagnose exercise-associated amenorrhoea. Doctors advised the woman to stop her intense workouts and focus on restoring her energy balance.
Exercise-related amenorrhoea (a form of functional hypothalamic amenorrhoea) is a medical condition where menstruation stops for extended periods in women who undertake intense or excessive physical activity combined with insufficient energy intake. In this condition, the body reprioritizes energy use, reducing reproductive function as a survival response.
The hypothalamus, part of the brain that regulates hormones, reduces the pulsatile release of gonadotropin-releasing hormone (GnRH) when the body is in a state of energy deficit.
This leads to decreased secretion of luteinizing hormone (LH) and follicle-stimulating hormone (FSH), hormones necessary for ovarian cycles and menstruation.
Without adequate hormonal stimulation, ovulation stops, which in turn causes menstrual periods to cease.
Medical literature identifies several factors that contribute to exercise-linked menstrual disruption:
High exercise volume and intensity, especially without adjusting energy intake.
Low energy availability - burning more calories than consumed.
Rapid weight loss or body composition changes.
Low body fat percentage, which affects hormone production.
Stress and metabolic strain related to heavy training.
For example, athletes in endurance or aesthetically focused sports (such as long-distance running or ballet) show higher frequencies of amenorrhoea, often linked to net energy deficits and hormonal changes.
Stopping menstruation is not merely a cosmetic issue, it reflects underlying hormonal imbalance. Scientific studies show that chronic amenorrhoea is associated with low estrogen levels, which play a role in bone metabolism and reproductive health. Persistently low estrogen has been linked to decreased bone mineral density, higher risk of stress fractures, and longer-term reproductive implications if not addressed.
Medical experts recommend several measures to help prevent exercise-related menstrual disruption:
Ensure that calories consumed through diet adequately cover the energy burned during exercise and daily activities.
Reducing the frequency or intensity of workouts, for example, limiting intense training to three to four sessions per week can help restore hormonal balance. Traditional practices like yoga or moderate exercise may be beneficial in the recovery phase.
A healthy body fat percentage helps maintain normal hormone production. Very low body fat is a documented risk factor for menstrual disturbances.
Women experiencing missed periods should obtain a medical assessment to rule out other causes and evaluate hormone levels, nutritional status, and bone health. Rest and nutritional rehabilitation are often central elements of management.
What is exercise-related amenorrhoea?
Exercise-related amenorrhoea is the cessation of menstrual cycles due to a combination of intensive physical activity and insufficient energy availability, leading to suppression of reproductive hormone signals.
Is exercise-related amenorrhoea reversible?
Yes. In many cases, menstruation can return after reducing exercise intensity, restoring energy balance, and addressing nutritional deficits, though recovery may take several months. Medical supervision helps guide this process.
What are the long-term risks if amenorrhoea continues?
Prolonged amenorrhoea is associated with low estrogen levels, which can increase risk for bone density loss, stress fractures, and potential fertility issues if not properly treated.
Exercise-related amenorrhoea is a neuroendocrine response to energy imbalance caused by intense training and inadequate nutritional support. The case of the 23-year-old woman in China highlights how excessive workouts, without appropriate energy intake, can lead to cessation of menstruation and significant hormonal disruption. Awareness of energy balance, training moderation, and medical evaluation can help prevent and manage this condition.
References
Baranauskas, Marissa N., Jessica A. Freemas, Stephen J. Carter, Joanna M. Blodgett, Charles R. Pedlar, and Georgie Bruinvels. Amenorrhea and Oligomenorrhea Risk Related to Exercise Training Volume and Intensity: Findings from 3705 Participants Recruited via the STRAVA™ Exercise Application. Journal of Science and Medicine in Sport 26, no. 8 (August 2023): 405–409. https://doi.org/10.1016/j.jsams.2023.07.001
Otis, Carol L. “Exercise-Associated Amenorrhea.” Clinics in Sports Medicine 11, no. 2 (1992): 351–362. https://doi.org/10.1016/S0278-5919(20)30536-6
(Rh)