As an athlete, I’m sure you’re well-trained in following rules: “If you want to be faster, be lighter.” “If you really care about improving, don’t miss a training session.” These messages from coaches, friends and family, and social media echo what many people believe to be true about athletes and performance – by all accounts, athletes are most successful when they prioritize being lean and fully “committed” at all costs.

But what happens when, as a female athlete recovering from amenorrhea, you’re told that the exact opposite – that gaining weight and resting more – is key to truly optimizing your health and performance? How do you make sense of these contradictions, and what do you do if your lifestyle makes hitting pause and prioritizing recovery feel impossible?  Let’s dive in!

Understanding Hypothalamic Amenorrhea (HA)

Hypothalamic Amenorrhea (HA) is the loss of menstruation due to excessive stress, overtraining, and inadequate caloric intake. Many female athletes lose their periods without realizing that they’re under-fueling. Others intentionally restrict food in pursuit of a certain body composition, mistakenly believing it will enhance performance. However, prolonged energy deficiency leads to serious long-term consequences.

HA falls under the broader condition known as Relative Energy Deficiency in Sport (RED-S), which occurs when an athlete’s energy intake does not support their training demands. A subset of RED-S is the Female Athlete Triad, which consists of:

1. Disordered Eating — Often rooted in the pressure to “lean out,” athletes may develop restrictive eating habits that lead to calorie deficits.
2. Irregular or Missing Periods — When the body lacks sufficient energy, communication between the brain, pituitary gland, and ovaries is disrupted, resulting in menstrual irregularities or complete period loss.
3. Bone Loss — Estrogen, a key hormone for bone health, decreases significantly in women with HA. This puts them at 2-4 times higher risk for stress fractures.

Left untreated, HA not only impairs fertility but also increases the risk of osteoporosis, mood disturbances, chronic fatigue, poor recovery, immune dysfunction, and more—none of which support peak athletic performance.

How HA Impacts Athletic Performance

Despite the misconception that being leaner and training harder leads to better results, HA actually hinders performance by:

• Reducing energy levels and endurance
• Impairing recovery from training sessions
• Increasing injury risk due to weakened bones
• Causing mood disturbances such as anxiety and depression
• Weakening the immune system, making athletes more prone to illness

For female athletes recovering from amenorrhea, recognizing these risks is the first step toward making necessary changes for long-term health and peak performance.

Steps to Recover Your Period Without Giving Up Your Sport

Though we generally recommend that women in the Food Freedom Fertility (FFF) Society take a step back from high-intensity exercise so that the body has time to heal, the reality is that some people are unable to completely stop (more on this later…). If this rings true for you, there are a few guidelines to follow to give your body the best chance at recovery:

1. Prioritize Fueling Before and After Workouts

There’s a lot of hype about intermittent fasting or fasted workouts, but this research is done almost exclusively with men. It does not account for how women, and especially active women, can experience disruptions in their hypothalamic-pituitary-gonadal (HPG) axis in response to fasting, which in turn can trigger irregularities in ovulation, metabolism, and mood.  To quote international exercise physiologist and nutrition scientist Dr. Stacy Sims, “women are not small men” and nutritional recommendations should be tailored to reflect that.

Pre-Workout: Aim to eat a carb-rich snack 30-60 minutes before exercise. Options include:

• Graham crackers
• Energy bars
• Rice Krispies Treats
• Bananas

If eating before workouts feels challenging, start small and gradually increase portion sizes to train your gut.

Post-Workout: Refuel within 60 minutes of finishing exercise with a meal or snack containing carbohydrates, protein, and healthy fats to optimize recovery and hormone balance.

2. Limit “Unnecessary” Exercise

Many female athletes have a structured, predetermined training plan (think marathon runners who have mapped out their training until the race, or college athletes with required lifts and practices), yet still opt for extra movement to get that competitive edge.  Is your strength coach offering an optional early-morning lift? Are you choosing to bike (instead of drive) a few miles round-trip to a local park to meet up with friends? During HA recovery, it’s best to put a pause on any extra movement outside of what’s required by your sport to help reduce the stress on your body. Here’s a few tips:

• Opting for additional lifting sessions
• Biking instead of driving to places
• Participating in non-mandatory team conditioning sessions

During HA recovery, it’s crucial to eliminate excess movement and focus only on required training to reduce the overall stress on your body.

3. Seek Support from a Trusted Coach, Trainer, or Medical Professional

In my experience, many athletes are hesitant to make lifestyle changes because they are afraid of what their coach or teammates will think, or that these changes may affect their status on their team. To get ahead of these concerns, it can be incredibly helpful to welcome at least one person – a coach, team captain, athletic training, team psychologist, or anyone else you trust- into your recovery journey. You can decide how much you disclose, but having someone “in your corner” that can help advocate for any modifications you may need makes the process that much less isolating.

*It’s important to note that many coaches and medical professionals have limited knowledge about HA and might not understand the recovery process. When confiding in someone, make it clear that you’re not asking for recovery advice, but instead are looking for support in your recovery process.  And, if you feel that it is in your best interest to fully step away from your sport, trust your conviction.

When reaching out to a coach, athletic trainer, or team doctor:

• Explain that you’re making temporary adjustments to recover from HA.
• Emphasize that you’re not asking for advice on how to recover, but rather seeking support during the process.
• If needed, provide educational materials on HA and RED-S to increase awareness.

If stepping away from your sport feels like the best option for your health, trust your intuition and prioritize long-term well-being over short-term competition.

Final Thoughts

Recovering from HA as an athlete is challenging, but proper fueling, reducing exercise whenever possible, and having a strong support system are keys to setting your body up for success. Female athletes recovering from amenorrhea must recognize that they may not be able to control every factor of their training schedule, but they do have control over their nutrition, and this can make all the difference between another month of missing their period and a healthy menstrual cycle!

All this being said, there is an important difference between being unable to change your training schedule versus being uncomfortable or scared to do so.  If you are someone who feels like you need to exercise compulsively because you are afraid of what will happen to your body if you take a break, I encourage you to reach out to the FFF Society for more support. The FFF has helped 350+ women from all backgrounds recover their periods and restore their fertility, so if you’re in need of more structured help, book a Fertility Strategy Call today!

References:

Boston Children’s Hospital. (n.d.). Female Athlete Series: Female Athlete Triad. Boston, MA; Boston Children’s Hospital. Retrieved from https://www.childrenshospital.org/sites/default/files/2022-03/female-athlete-triad.pdf.

Cabre, H. E., Moore, S. R., Smith-Ryan, A. E., & Hackney, A. C. (2022). Relative Energy Deficiency in Sport (RED-S): Scientific, Clinical, and Practical Implications for the Female Athlete. Deutsche Zeitschrift fur Sportmedizin, 73(7), 225–234. https://doi.org/10.5960/dzsm.2022.546

Wang, M., Chee, J., Tanaka, M. J., & Lee, Y. H. (2024). Relative energy deficiency in sport (Reds) and knee injuries: Current concepts for female athletes. Journal of ISAKOS. https://doi.org/10.1016/j.jisako.2024.05.012 

Meczekalski, B., Katulski, K., Czyzyk, A., Podfigurna-Stopa, A., & Maciejewska-Jeske, M. (2014). Functional hypothalamic amenorrhea and its influence on women’s health. Journal of endocrinological investigation, 37(11), 1049–1056. https://doi.org/10.1007/s40618-014-0169-3