Periods are a pain… literally. But is it normal for dancers to have an irregular (or even nonexistent) cycle?
No. It might be common, but irregular and/or nonexistent periods can be a sign of a more significant medical issue. There are two types of “missing periods.” The first is a delayed onset of menstruation, also known as primary amenorrhea. The second and, for the purpose of this article, more concerning type is secondary amenorrhea. Secondary amenorrhea results in dancers who have previously menstruated, but then experience 3 or more consecutive months without a cycle (6 or more consecutive months in those with previously irregular periods). Let’s review why this might happen and what a dancer can do to prevent or solve it.
Reasons for A Missing Period
- The use of oral contraceptives (AKA birth control)
- Recent and rapid weight loss
- Having too low of a percentage of body fat
- High levels of physical and/or emotional stress
- Natural causes like pregnancy and breastfeeding
- Hormonal imbalances such as PCOS and various thyroid conditions
Looking at this list, more than half can be considered lifestyle factors that are related to weight, stress, and exercise. These are often the culprit of one of the most common classifications of secondary amenorrhea: functional hypothalamic amenorrhea (FHA). FHA occurs when the hypothalamus (a small gland located at the base of the brain) dysregulates (AKA slows or stops) the production of certain hormones required for human reproduction; namely: estrogen and progesterone.
I’m not looking to become pregnant anytime soon! …So why should I be concerned?
Okay, back up… the ability to menstruate isn’t just for the benefit of reproduction (though for obvious reasons, that is a big benefit down the road!). Now if you haven’t yet menstruated for the first time, and you’re younger than 15, then there may not be cause for concern… just yet. The time at which a woman gets her first period can vary from as young as nine-years-old to as late as sixteen years old. But since many dancers undergo rigorous training during these pubescent years, it can be tough to decipher whether or not this delayed onset is related to age or to RED-S, a syndrome resulting from energy imbalances.
But if you have menstruated in the past and now your cycle is practically nonexistent, then we’ll need to chat. Disordered eating behaviors, especially when coupled with intense exercise or dancing, can be a major red flag of impaired production of estrogen. Estrogen doesn’t only play a role in your period. In fact, this hormone is also a key player in bone development and when hypothalamic production runs low, such as in FHA, the risk of bone-related injuries and stress fractures skyrockets. In the long run? You’ll also risk severe bone loss, which is seen in conditions like osteopenia and osteoporosis. Furthermore, it can contribute to infertility down the road.
Steps to Period Recovery
Identifying and resolving disordered eating behaviors is one of the first steps you can take to promote a regular period. Disordered eating behaviors often include:
- Dieting or restrictive rules around food.
- Intense levels of exercise as a way to punish or “make up” for “bad” eating habits.
- Compulsive eating habits, such as binge eating in response to under-eating.
- Frequent weight fluctuations.
- Obsessive behaviors around food such as calorie-counting and food measuring/weighing.
Working with a Registered Dietitian Nutritionist is encouraged if you feel stuck in a pattern of disordered eating. You can also grab this free starter guide from my online program, The Healthy Dancer© to begin the work of detangling those habits.
Though easier said than done, simply increasing the amount of food you eat throughout the day is a great next step. But how should you monitor “how much” to eat if calorie counting is discouraged? For dancers with a history of extreme food restriction, calorie awareness is an important step toward weight restoration. Knowing a roundabout daily calorie goal might be necessary in order to provide your body with a sufficient amount of food to support both its metabolic and physical needs. Though calorie needs vary greatly among individuals, this article will help you calculate a starting point. Just a hint… most dancers need at least 2500 calories per day (and oftentimes, even more!).
Eating balanced meals and snacks consistently throughout the day, such as every two-to-four hours, is another way that dancers can make sure they’re getting enough in. Fueling the body intuitively should be considered only when a dancer’s weight has been restored and a regular menstrual cycle ensues. Here are a few articles to read once you’re at that point:
- Intuitive Eating for Dancers
- Breaking Food Rules
- Lost Your Hunger Cues?
- Understanding Hunger and Fullness
Nutrients for Period Recovery
Aside from eating enough calories to support a period-friendly body weight, certain foods, and nutrients can be beneficial for menstrual health. Here are a few to consider:
- Omega 3s and monounsaturated fats, which are abundant in plant oils like olive and canola, walnuts, ground flax, and fatty fish like salmon and tuna. Fat is also required for vitamin and mineral absorption. This will help your body gain the bone-building benefits of vitamin D and calcium.
- Full-fat dairy has some research supporting not only benefits for bone health but also benefits for period health. One study found that 1-2 servings of full-fat dairy per day, including whole milk, 4% (or full-fat) yogurt, and cottage cheese seemed to support ovulation.
- Whole grains and other sources of complex carbohydrates like quinoa, farro, wild rice, and whole-grain bread promote steady levels of blood sugar and insulin. However, be mindful not to overdo the amount of fiber in your diet as excessive intake can impair ovulation.
- Plant foods high in iron, like beans, lentils, pumpkin seeds, dark leafy greens, fortified cereals, tofu, and other legumes might promote fertility (AKA your period).
Dance, exercise, and amenorrhea
Aside from food, physical activity is another major factor in the presence of FHA. For dancers, high-intensity and above-average training are common, especially around summer intensive and nutcracker season. This often coincides with an increased risk of the development of amenorrhea. First, most dancers underestimate their nutritional needs so it’s incredibly important that you work with a registered dietitian who can help you evaluate whether or not your intake is supporting your expenditure. The likelihood that a dancer is eating “enough” alongside an intense dance schedule is low. But aside from this, even for a dancer who is eating plenty— it’s possible that a surge in stress hormones (which is part of the body’s normal response to exercise) contributes to amenorrhea
And there’s another problem… most dancers, especially those who rely on their dance career as a source of income, aren’t willing nor able to put their physical activity on hold. If that’s the case, you’ll want to first consider lightening up on your cross-training routine. Hitting the gym after class might be putting too much stress on your body. Working with a dietitian and mental health therapist is your best bet for learning how to turn your exercise routine into a more sustainable plan that encompasses joyful movement.
Should dancers take birth control to induce their period?
In the past, oral contraceptives were suggested in the treatment of bone loss related to amenorrhea. However, this practice is no longer recommended because of its potential to mask the underlying reason for menstrual dysfunction (energy imbalance) and delay the required treatment (increasing caloric intake and weight gain). Furthermore, research suggests that even with hormone therapy, impaired bone mineral density persists among ballet dancers, suggesting other factors at play beyond just estrogen insufficiencies.
Preliminary research suggests a potential association between transdermal estrogen (an estrogen patch) and improvements in bone mineral density. However, this too remains debatable and inconclusive. If concerned, dancers should consult with a trusted medical doctor prior to starting supplemental estrogen and work with a Registered Dietitian Nutritionist to ensure energy balance is being promoted.
Managing Day-to-Day Stress
Emotional stress can suppress the hypothalamic production of reproductive hormones. Therefore, I encourage you to reassess the stressors in your life. Whether it be a relationship-, family-, dance- and/or academic-related, consider ways to lighten the mental and emotional load.
Physical stress also plays a role.