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Hypothalamic Amenorrhea, Underfueling, and the Endurance Athlete

This is a repost of a guest post I wrote for The HA Society. If you struggle with Hypothalamic Amenorrhea, I recommend checking out Dani's work for an additional resource and source of support!

In 2019, former Nike-sponsored athlete Mary Cain set the running community aflame when she came forward with her story of abusive coaching and disordered eating, suffered at the hands of former Nike Oregon Project coach Alberto Salazar. (1) According to Cain, Salazar, who is currently serving a 4-year ban for doping allegations, routinely humiliated her by weighing her in front of her teammates and criticizing her body and weight. She was just 18 years old.

As a dietitian who works primarily with endurance athletes, I was heartbroken and angry on Mary’s behalf, but not shocked by her revelations. Distance sports, like other weight-centric events such as gymnastics, are rife with athletes and coaches who pursue lightness and leanness to the detriment of their health and, ultimately, their performance. I work with clients to unpack their mistaken belief that maintaining (or achieving) a thin frame is a sure way to reach their goals, even though they know they’re increasing their risk of injury and health complications. It upsets me that this culture of chasing leanness failed Mary (and many other elite athletes), and it upsets me that it continues to fail my clients and others like them.

Mary Cain lost her period for three years. She’s not alone – some estimates indicate as many as 65% of female distance runners have experienced secondary amenorrhea. (2) And unfortunately, a culture exists within the endurance community that treats weight loss, low body fat and thinness as not only expected but mandatory for success. Given that the risk factors for developing hypothalamic amenorrhea include disordered eating (underfueling), excessive exercise (heavy training), and psychological stress (the burden of excellence in your sport) (3) – it’s not surprising that amongst endurance athletes, this diagnosis is common, and difficult to overcome.

I talk to a lot of competitive, fast women who want to perform at their very best. It can be hard to go against the traditional perception that staying lean is the most important aspect of that goal – even when you’ve been told it’s likely not the best thing for your training or your health. And even more so, when your training seems to be on a roll, it’s hard to hear that you might need to take a step back. But the reality is that it’s never normal to lose a period – no matter what your coach or even your doctor tells you. And before you decide you’ll get it back “when you’re done” and that this is the sacrifice necessary for performance – you should consider the consequences of choosing to ignore that red flag. Long term health complications of an estrogen deficiency can include fractures and osteopenia/osteoporosis, cardiovascular disease, and infertility. (4) Furthermore, the underlying issues that result in losing your period will more than likely set you back in training. You may experience short term results, but the drawbacks of training undernourished and overly stressed will outweigh any benefit you receive from weight loss. The most likely result will be frequent stress fractures or other bone injuries, burnout, and poor performance.

If you are an athlete struggling with deciding what to do after the loss of your period, you don’t have to go through it alone. It’s understandable that you may feel conflicted hearing advice to reduce or stop high intensity exercise completely. That’s why it’s so critical to get a team around you, from a therapist, to a dietitian, to a supportive coach – who all understand your drive and the importance of maintaining your long term health. They can keep you motivated, focused on reducing your stress, and taking the necessary steps to restore your period.

Everyone’s recovery process is different, and it’s hard to make any sweeping statements about a healthy return to sport. However, many athletes find that by taking time now to correct the energy imbalance that is causing the amenorrhea, they are able to return to training down the road. And since consistency is a major factor in developing as an athlete, training well-fueled (and without needing constant stops for injury recovery or fatigue) can actually make you stronger and faster than you were before.

No short term result is worth the mental anxiety and health setbacks that underfueling can cause. You are enough, just as you are – and sacrificing your period for an athletic result is a decision you’ll likely regret. You deserve your physical and mental health, so reach out for help when you need it. You are worth it.

Ready to fuel yourself to run your best? Join the interest list for my upcoming online course, Fast + Fueled: The Nutrition Roadmap for Female Athletes.


1. Cain, Mary. “I Was the Fastest Girl in America, Until I Joined Nike.” The New York Times, Nov. 2019,

2. Mountjoy, Margo et al. “The IOC consensus statement: beyond the Female Athlete Triad--Relative Energy Deficiency in Sport (RED-S).” British journal of sports medicine vol. 48,7 (2014): 491-7. doi:10.1136/bjsports-2014-093502

3. De Souza, Mary Jane et al. “2014 Female Athlete Triad Coalition Consensus Statement on Treatment and Return to Play of the Female Athlete Triad: 1st International Conference held in San Francisco, California, May 2012 and 2nd International Conference held in Indianapolis, Indiana, May 2013.” British journal of sports medicine vol. 48,4 (2014): 289. doi:10.1136/bjsports-2013-093218

4. Shufelt, Chrisandra L et al. “Hypothalamic Amenorrhea and the Long-Term Health Consequences.” Seminars in reproductive medicine vol. 35,3 (2017): 256-262. doi:10.1055/s-0037-1603581

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