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What every female athlete should know about exercise and reproductive health

What every female athlete should know about exercise and reproductive health

9 min read

Before I was a fertility doctor, I was a disciplined athlete. As a Division I NCAA Track & Field athlete and All-American, I knew how to use my body as a tool for competition. But it wasn’t until I became a medical professional that I developed an understanding of what all this could mean for my reproductive health.

Sure, you could say, “What college student-athlete truly knows about fertility, or has any desire to think about family planning?”

But the point is, I didn’t even understand my menstrual cycles. As an athlete, frankly, it was more convenient to skip my period because I didn’t have to worry about cramping or bloating when it came time to focus on intense training and competition. At the time, I had no idea that *not* getting a period could also be a problem for my overall health.

At Modern Fertility, our mission is to get info about fertility and reproductive health into people’s hands earlier in life. In this article, I’m answering some of the most common questions I get from patients about exercise and reproductive health.

Here are the key things to know:

  • Aiming for a minimum of 150 minutes of moderate intensity exercise, or 75 minutes of vigorous exercise per week is recommended for general health.
  • The “female athlete triad” is a combination of factors that can occur in high-intensity athletes, starting in adolescence. It includes three factors: disordered eating, not getting a regular period, and low bone mineral density. If untreated, the female athlete triad can increase risk for injury, as well as cause difficulty conceiving.
  • If you’re getting a regular period (and are not on a method of birth control that suppresses ovulation) that’s a sign that you’re likely ovulating.
  • However, getting a regular period does *not* mean that you’re definitely “fertile” or will have no problems getting pregnant — there are other factors to consider, like sperm quality and checking in on your fallopian tubes and uterus.
  • Whether or not kids are on the horizon for you, it’s a good idea to check in with your healthcare provider if you’re not getting a regular period (unless you’re not getting a period because of birth control). Your period is an indicator of your overall health, and not getting one can lead to issues later on in life.
  • Some of the best ways to get proactive about your reproductive health are to track your period, check on your reproductive hormones, and (if you’re not looking to have kids now, but want to keep your options open in the future) learn about egg freezing.

How much exercise should I get?

We know elite athletes work out and compete at the highest levels of their sports. But what’s the right amount of exercise for general health? The American Heart Association recommends a minimum of 150 minutes of moderate intensity or 75 minutes of vigorous exercise per week to maintain optimal general health.

The intensity of exercise can be measured based on your target heart rate or by methods of rating perceived exertion (RPE) such as the Borg scale which uses scores of 6 to 20 to assess your perceived exertion. For example, on the Borg scale, a score of 6 is no exertion at all (think watching TV on the couch) and a score of 17 is a very hard workout that leaves you breathless (vigorous activity).

If you’re an athlete or avid exerciser, you might regularly exceed this recommended minimum — and that’s great! In the sections below, we’ll dig into what to watch out for and how to take care of yourself if you’re very active.  

What are some of the reproductive health challenges female athletes face?

There are three factors that can impact reproductive health in high-intensity female athletes starting as early as adolescence. This combination is often referred to as the female athlete triad. It includes:

  1. Disordered eating, or not eating enough calories to sustain high activity
  2. Not getting a regular period (or having your period disappear)
  3. Low bone mineral density

Short-term consequences may include an increased risk of injuries such as stress fractures, strains, and tendonitis. Long-term consequences may include difficulty conceiving in the future and early onset osteopenia (bone loss) or osteoporosis (bones that are weak or brittle) which can increase the risk of major fractures later in life.

Can very high intensity and volume of exercise impact my hormones? What does that mean for fertility?

When your body faces periods of intense stress from things like severe nutritional deficits, prolonged periods of psychological stress, or sustained vigorous physical activity — all of which we can see in athletes — it can actually alter the hormonal balance of your body. (We’re not talking about an occasional strenuous workout here — it’s prolonged, vigorous exertion over time that can have this effect. Think of a competitive runner training for a marathon or an elite gymnast.)

This can lead to a disorder called functional hypothalamic amenorrhea (FHA). If your body is facing one (or more) of the stressors listed above, it can set off a hormonal cascade that can turn off reproductive function.

In other words, in times of energy deficits, your body shuts down reproductive function to preserve energy for vital organs (like the brain, and heart). This can mean that you stop ovulating, periods become irregular or absent, and it may become difficult to conceive. (Check out this post for more info on exercise, conception, and pregnancy.)

If you’re a competitive athlete and you aren’t getting a period, you should definitely talk with your doctor — more on this below.

I’m not on birth control and my periods are regular. Does that mean I’m ovulating?

Most likely, yes. Regular and predictable menstrual cycles are one of the best signs of ovulation. Most people will come to recognize what is normal for them in terms of cycle length, menstrual flow, and symptoms prior to starting their period. Studies have shown that women with regular menstrual cycles (between 21-35 days) are 99.5% likely to be ovulating each month.

Women with regular menstrual cycles but who have hirsutism (aka abnormal hair growth in a male pattern — which can be a sign of hormone imbalance and could point to PCOS) have a 60% chance of ovulating in a given cycle.

Here’s an interesting fact: a study that evaluated menstrual cycles in over 1 million women not on birth control noted that approximately 69% of women had a 1-6 day cycle variation over the course of the study. We’re taught that the “textbook” 28 day cycle is what we should expect, but it’s actually completely normal for cycle length to be longer or shorter, and to vary from cycle to cycle.

Ok, so if I’m not on birth control and my periods are regular — does that mean I’m fertile?

No, and it’s a very common misconception that regular periods = fertility. Just because someone has regular menstrual cycles and has evidence of ovulation (like positive ovulation predictor kits, a change in cervical mucus etc.) does not mean they are definitely fertile.

Why? Fertility is complex, and your menstrual cycle is just one piece of the puzzle. Other factors that can tie into fertility include sperm quality and well as physical structures like the uterus and fallopian tubes.

I am a competitive athlete (or I exercise vigorously) and I haven’t gotten a period in months or years. I’m ready for kids now. How can *not* having a period interfere with the process of getting pregnant?

First, let’s back up and break down the key things that must happen to conceive (without medical assistance):

  1. You need to be ovulating. (If your body doesn’t release an egg, there’s nothing for the sperm to fertilize.)
  2. You need at least one open fallopian tube (for egg and sperm to meet and fertilization to take place) and a normal uterine cavity (for the embryo to be able to implant).
  3. And, sperm needs to be present at the right time (aka, the “fertile window”), to fertilize the egg.

So, if you’re ready to get pregnant but your period is irregular, you’re unlikely to be ovulating regularly. This means it’ll be harder to time intercourse to have sperm present at the right time to fertilize an egg.

If you’re not ovulating at all, that means there won’t be any chances for fertilization to occur. No ovulation = no egg = no pregnancy.

Ok, got it. If I’m not on birth control and not getting a period and I’m ready for kids now, what should I do next?

Meet with your OB-GYN or a fertility specialist so they can do a deeper dive into your hormones to get to the bottom of why you’re not getting your period. For some people, the cause may be reversible by scaling back exercise, increasing your caloric intake, or an adjustment of certain hormone levels with medication (like abnormal thyroid or prolactin).

For elite athletes who have functional hypothalamic amenorrhea (FHA) regaining your menstrual cycle may require assistance from your gynecologist, a fertility specialist, a nutritionist, and your trainers to find the best treatment to allow you to fulfill your goals as an athlete as well as your goals of starting a family.

However, for some, reversing FHA can take months or even years. Instead of waiting that long, your fertility specialist may suggest treatment options to assist with ovulation. These may include injectable medications to induce ovulation in conjunction with timed intercourse (TIC), intrauterine insemination (IUI), or options for IVF, depending on your age and desired family size.

Regardless, it is important to seek out medical care immediately if you are not having regular cycles so you can get a plan in place for your goals.

I’m a competitive athlete (or I exercise vigorously) and I haven’t gotten a period in months or years and I’m NOT ready for kids. What should I do? Does it matter?

Even if kids aren’t on the horizon now, I’d still definitely recommend consulting with either your OB-GYN or a fertility specialist to determine the underlying reason you’re not getting a period.

Here’s why: understanding why you’re not getting a regular period can provide insight into your overall health. Some doctors even refer to your period as “the fifth vital sign.” Not getting a regular period, or experiencing cycle abnormalities, can be a sign of an underlying medical condition — like hypo- or hyperthyroidism, hypothalamic amenorrhea and polycystic ovary syndrome (PCOS.)

The earlier you seek out answers, the sooner you can initiate treatment or lifestyle changes to improve menstrual regularity.

What about if I’m on birth control?

Some forms of hormonal birth control alter your menstrual cycle. For example, if you’re taking birth control pills, using the birth control patch, or using a vaginal ring, you’ll experience bleeding during your “placebo week” when you’re taking inactive pills or remove the patch or ring. If you have a hormonal IUD, you may notice irregular spotting or maybe even no periods at all.

The bleeding you get while on forms of hormonal birth control like the pill, patch, and ring is not a ~true~ period, even though it might look visually similar to the bleed you’d get if you weren't on birth control. Instead, these bleeds are called “withdrawal bleeding” and are triggered by your body adjusting to suddenly being without the hormones in birth control. (As opposed to a “natural” period, which happens as a result of hormonal changes triggered by ovulation.)

So if you’re on the pill, patch, or ring, these methods can mask period regularity — and the withdrawal bleed you get on these methods doesn’t count as “getting your period” the same as if you were not on birth control.

What’s your best advice for athletes who want to be proactive about reproductive health?

1) Track your periods.

Pay attention to cycle length, signs of ovulation, and get a baseline on what’s normal for you. If you find you are having irregular periods ( < 21 days or > 35 days from the start of one period to the start of the next period) see your OB-GYN or a fertility specialist to initiate a work-up.

Note: if you’re on the pill, patch, or ring, your menstrual cycle will be altered by the hormones in the birth control, so tracking your cycle won’t provide insight into your body’s underlying processes. Talk to your healthcare provider if you have any concerns.

2) Check your hormone levels.

Have an understanding of your ovarian reserve and your thyroid and prolactin levels to assess whether anything needs to be addressed today. (The Modern Fertility Hormone Test is an easy and affordable way to check your levels at home. Every test is customized to you, and you can take it whether or not you’re on birth control.)

3) Consider consulting with a fertility specialist to discuss egg or embryo freezing.

If you know you want to delay having kids but want to keep your options open, I would strongly recommend you consult with a reproductive endocrinologist and infertility specialist to learn more about egg/embryo freezing and discuss your specific success rates.  

The bottom line

Historically, we haven't had proactive conversations with female athletes about how to take care of their reproductive health. It's taken decades to shake off the rhetoric that women's bodies are weak, and the notion that female athletes are "less than" their male counterparts. But we do women a disservice by not talking openly about reproductive health. When we show up to our sports as our full selves, armed with knowledge about our bodies, that's true power.

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Dr. Temeka Zore

Dr. Temeka Zore, MD, FACOG is a fellowship-trained reproductive endocrinologist and infertility specialist and board-certified OB-GYN at Spring Fertility in San Francisco.

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