Growing up, Allison Kreiger Walsh, 34, barely had time to do normal teenage things, let alone think about her ability to have children in the future. A competitive gymnast and baton twirler since age five, by the time the Orlando, Florida native got to high school, her days were whittled down to the strictest of schedules: she left for school early to train, hit the gym for several hours after class, completed homework, and then ran off to dance practice from seven to 10 p.m. “I started struggling in silence,” Kreiger Walsh tells Bustle. “I just wanted to be a teen, but I didn’t want to let anyone down.”
Overwhelmed by the pressure and stress, one day when she was 15, she got home from practice and made herself throw up. “I was so worked up that I got sick,” she says. “And something inside me said, ‘I feel better,’ because in that moment, nothing mattered. Not the stress or the pressure, or the chaos going on in my life. I thought I had control, but I was out of control. Then, the next time, I forced it.” Over the next year, she began restricting her food intake as well, which she says gave her a feeling of “numbness.”
When Kreiger Walsh went into treatment for anorexia and bulimia in 2000, she had dental issues, broken blood vessels in her eyes, GI problems, and she had lost her period. She has foggy memories of a physician explaining that her future fertility might be at risk.
“My doctor said, ‘You could potentially not be able to get pregnant later in life,’” Kreiger Walsh explains. “But, you know, you kind of just put that information in the back of your mind.” She was only 17, after all.
Kreiger Walsh stopped individual gymnastics training as she entered college, wanting to stay the course in her recovery; she just competed with a team, which meant far less pressure. “I was still integrating foods back into my diet, and I was very sensitive to the fact that I was vulnerable,” Kreiger Walsh says. “I stayed away from crazy things. I wasn’t much of drinker, for instance, because I didn’t want to drink too much, or throw up.” She remembers being tuned into her triggers, including lack of control and high-stress situations. In short, her primary focus was “total health,” and her period ultimately came back soon after she started classes.
But in 2010, when Kreiger Walsh was in her mid-20s and began trying to start a family with her husband, her pregnancy tests came back negative month after month. “At that point, I’d been in healthy recovery for about a decade and was like, ‘Okay, I thought we were past this,’" she says. After a year of trying to get pregnant and failing, the words of her childhood doctor came rushing back.
"Unfortunately, many women associate physical fitness with health."
Kreiger Walsh was experiencing the long term impact of what is known as hypothalamic amenorrhea (HA), a condition in which menstruation stops for at least several months due to issues with the hypothalamus — a small, but crucial part of the brain that regulates everything from hormones to emotions. As Melissa Esposito, MD, a fertility specialist at Shady Grove Fertility Clinic in Harrisburg, Pennsylvania, tells Bustle, having too little body fat is often the cause of this diagnosis. “The problem with extremes is that, in order to cycle, you need a critical amount of body fat,” Esposito says. “If you don’t have it, the hormones in the brain that tell the ovaries what to do will kind of shut down. Women will stop getting their period, because they’re not producing enough estrogen; there’s no lining to shed.”
Esposito says that with hypothalamic amenorrhea, periods may become irregular or just stop altogether over time. “They may never come back,” she says. “I have a few patients who are hypothalamic. You can gain a little weight, but the periods may never come back to normal.”
Research has indicated that women who were underweight at age 20 may have trouble conceiving later on, but it is also possible to trigger amenorrhea later in life. As our culture becomes increasingly obsessed with working out, clean eating, and calorie tracking, fertility issues are an invisible risk for many women. “Hypothalamic amenhorhea affects about one to two percent of women of reproductive age,” Nicola Rinaldi, Ph.D., author No Period. Now What?, a book for women with HA who are trying to get pregnant, tells Bustle. “But I always wonder if those statistics are higher now, with these mantras like, ‘strong is the new skinny,’ where women are exercising harder and cutting more calories.”
Rinaldi knows the hardships of HA firsthand. When she was trying to get pregnant, she was hypothalamic, but also considered herself very “healthy,” participating in sports like ice hockey, squash and volleyball, as well as working out everyday. She loved exercise, and didn’t think she was doing anything excessive. But it’s hard to diagnose a problem you can’t see, like missed periods, especially if you are getting a withdrawal bleed on the pill (if you’re on certain forms of birth control, you don’t ovulate and your period is regulated artificially through the hormones you receive, so you may still bleed, even with HA). Rinaldi says “there were few resources available” for women trying to get pregnant after developing HA, but the first step is resuming the body’s regular menstrual cycle. When Rinaldi went off birth control, that’s when she realized there was a problem.
“I felt like I was eating plenty, but I still never ate things like bread and was probably not getting enough carbs.”
Brittney Motzkus, a 27-year-old trainer from San Diego, CA, had the same issue as Rinaldi. She’d always been an active woman, from the time she got her period at age 13 onward. And she loved exercising, pushing herself to new limits. She felt “lethargic” without it. “I didn’t go more than two days in a row without exercise for two years,” she explains. As she studied exercise science in college, she got “more intense” about weight lifting and changing her body fat percentage. “I have no idea when I lost [my period] on the pill, but I haven’t had it for three years,” she says.
Looking back, she does see just how intense things had gotten. “I lost 10 to 15 pounds teaching multiple classes, doing workouts, and staying active with clients,” Motzkus says. “I felt like I was eating plenty, but I still never ate things like bread and was probably not getting enough carbs. My body fat percentage was eight or ten percent. Although my BMI was normal, I was just super-lean.”
In order to try and get pregnant naturally, she found Rinaldi’s book and has been following the regimen: eating more and freely, reducing exercise by about 50 percent, having two complete rest days, and above all else — not stressing about what her body looks like — which can often be the hardest part. Lots has been written about the thriving “fitspo” community on Instagram, which is dominated by an illusive “skinny-strong” aesthetic. It’s been linked to the rise of orthorexia, a restrictive eating disorder (ED) centered around consuming only healthy or “clean” foods — but its effects on women’s fertility go largely undiscussed. “I’ve had to stay far away from comparison,” Motzkus says. “I unfollowed a lot of my fitness inspirations on social media. I’ve had to be kind to myself, and be mindful; this is a time of healing and repair; this is part of my health. I’ve had to challenge my idea of what’s truly healthy, whether that’s being skinny, lean, or working out. There’s so much more to life.”
“My dream is for a patient with a normal BMI to go on Instagram and say they sleep eight hours a night, have three balanced meals with two balanced snacks, and they feel good.”
According to fertility specialist Brian Levine, MD, founding partner and practice director of Colorado Center for Reproductive Medicine’s New York location, the pressures to be fit have increased in recent years, often at a dangerous cost. “Unfortunately, many women associate physical fitness with health,” he tells Bustle. “Some of the most famous fitness social media stars have incredible lean and toned bodies, but at the cost of their reproductive health. Many patients tell me that they are on a ‘fad’ diet to lose weight to help kick-start their summer ‘makeover.’”
Balance is far healthier for reproductive health, says Levine. Especially as women delay pregnancy into their thirties and forties, Levine says they might be unintentionally harming their chances of pregnancy even more in this culture that encourages extremes of “wellness.” “Many people take up endurance athletics as a way to ‘get in shape before they get old.’ This does not work,” he says (at least with fertility). “Instead, patients should focus on sleep hygiene, healthy eating, and routine physical activity... My dream is for a patient with a normal body mass index (BMI) to go on Instagram and say they sleep eight hours a night, have three balanced meals with two balanced snacks, and they feel good.”
Since she started trying to live a more balanced life, Motzkus has gained 25 pounds back, and her cycle is now slowly restarting. Right now, her periods have been about 45 to 60 days apart. Mentally and emotionally, though, she’s been struggling. “As a trainer, sometimes I feel like I’m held to a higher standard and the comparison is heightened,” Motzkus says.
It’s difficult to track the true prevalence of eating and fitness disorders, but according to the most recent statistics from the National Eating Disorders Association (NEDA), 35 percent of female college athletes are at risk of anorexia and 58 percent are at risk of bulimia. Roughly 3 percent of the general population struggles with exercise addiction, according to a 2011 study. In specific populations, the eating and exercise disorders may be higher; some research has suggested that up to 42 percent of gym-goers over age 18 have “a destructive relationship” with their workout regimen, and a 2012 study found that 69 percent of women who “participate in sports that emphasize aesthetics or leanness” experience some form of amenorrhea.
“The treatment is often so simple, but it’s the hardest to hear. You have to gain weight.”
Meg Reburn, 35, from Boulder, CO, tells Bustle that she was working out too much, eating too little, and under too much stress when she lost her period in 2007. “I was in residency to be a midwife, and I didn’t have a lot of time,” she says. “I had lost my fiancé suddenly, and my life was out of control.” Exercise, once a stress-reliever, began to have the opposite effect. “I liked to be active,” she says. “But I’d work 24 or 36 hours in a row, and then I’d come home and run 10 miles.” Reburn says she was also only consuming about 1200 or 1300 calories a day.
After going to multiple doctors without a firm diagnosis for her lack of menstruation, an endocrinologist eventually told her she was hypothalamic. She tried hormone replacement therapy to resolve HA, but stopped due to uncomfortable side effects, like bloating and breast pain. But whether or not kids are in the cards, Reburn knew she'd have to make some changes. She had osteopenia as a result of the HA — the precursor to osteoporosis — which is more common among women with the condition due to deficient estrogen — women's bodies require estrogen to maintain bone health. “The treatment is often so simple, but it’s the hardest to hear,” Reburn says. “You have to gain weight — probably more weight than you lost when you lost your period.”
According to Levine, the body knows when it is in “fight or flight” mode and will shut down non-essential functions if there aren’t enough nutrients to support them; ovulation and procreating are not important “if you’re fighting off sabertooth tigers,” he tells Bustle. Unfortunately, your body doesn’t know the difference between doing that, and say, running to keep up with other women on Instagram.
By slowing her exercise regimen and eating more, Reburn did recover her period. She gained 20 pounds, and increased her body fat percentage from 16 to 24. “I’d love to say it was a graceful journey gaining weight, but it was not,” Reburn confesses. She found things that helped her, though. Most importantly, she says she focused on body positive mantras. “It sounds silly, but I changed the way I talked to myself,” she explains. “It wasn’t, ‘Oh, you’re so fat,’ but rather, ‘Your body needs this extra layer right now.’”
Fahimeh Sasan, MD, an assistant professor of obstetrics and gynecology at Mount Sinai Hospital in New York City, encourages women to “stay on a good, healthy trend for pregnancy.” You can keep your same workout regimen up, as long as you’re within those healthy weights and body fat percentages, and you’re thinking about your routines as a means to create and sustain a new life. “Go get a checkup with your doctor before you start trying,” she tells Bustle. “Be at your best before you get pregnant.”
“I’ve always been ‘the fit girl,’ so I’ve had to find value outside of that.”
Regular workouts relieve stress and help maintain overall health — which, if and when you do conceive, are key to a healthy pregnancy. But the culture operates in extremes. We’re inundated with confusing messaging, especially on social media, where images of glowing expecting mothers who used to be (and still kind of are) glowing fitness influencers, are a common occurrence. It’s no wonder more women are likely to develop disordered eating or exercise habits than we can accurately count.
For women who are considering getting pregnant and are concerned they may have issues with food or exercise, doctors can provide some answers. Esposito says with her underweight patients or heavy exercisers, marathoners, or cross-trainers, she’ll look at whether they have that “critical” amount of body fat necessary to conceive. Athletes typically already have lower percentages, at 14 to 20 percent for women. “And if I find out she’s exercising an hour and a half a day, I might suggest she back off a bit,” she says.
To combat stress and deal with any underlying issues, Esposito also sometimes recommends counseling or visits with a dietitian just to make sure everything is OK psychologically. “If a [woman’s] partner [is] in there telling me a woman is still counting calories or training too much, for instance, then I worry about their ability to maintain a pregnancy,” she explains. As it stands, women with eating disorders do have a higher risk of miscarriage.
Rinaldi says replacing some workouts with other hobbies helped her to feel less antsy as she recovered from HA. “Find activities to fill the time,” she suggests. “Knitting, cake decorating, spending time with friends, making connections. Some of those things get pushed out of your life [when you become obsessed with fitness] and you don’t realize it.” (You’re not giving up your workouts then, but rather adding new, enjoyable routines to your life.) Motzkus has similarly found that “surrounding yourself with uplifting people” makes these big mental shifts a bit easier. “I’ve always been ‘the fit girl,’ so I’ve had to find value outside of that,” she explains.” What you value in others is probably not your physical fitness; the people you love probably value similar things in you.”
After trying for more than a year to get pregnant, Krieger Walsh was referred to a reproductive endocrinologist. She walked in the door disheartened, feeling like the past was back to haunt her. However, just liked with her ED treatment, she had a team working with her, with a step-by-step plan for increasing her odds of getting pregnant. “They were very positive,” she says. “They told me, ‘This does happen, and here’s what we’re going to do.’ It would have been so easy to beat myself up again for my past, since we had been trying for so long.”
“Fitness and diet culture has set these ideals of health that we are supposed to live up to...but they have no idea what’s going on in each of our individual bodies.”
Doctors started her on Clomid, an oral medication that stimulates reproductive hormones and prompts ovulation. “I had been on that for several months, and were about to go on the shots, when we were standing in the doorway to Lowe’s and got the call,” she explains of hearing the news she was pregnant. And all has ended well in Kreiger Walsh’s fertility journey; she now has two young girls, ages six and ten.
It’s hard to change routines and gain weight in order to regain a cycle or work toward pregnancy, Motzkus admits. She’s now cut her exercise regimen in half, but the changes mentally have been more difficult to conquer. She focuses on how the ideals she gravitates toward are unrealistic at best. “Fitness and diet culture has set these ideals of health that we are supposed to live up to, and they tell us the ways we’re supposed to eat, and how we’re supposed to work out, but they have no idea what’s going on in each of our individual bodies,” she explains.
Even after HA, the necessary changes don’t stop. With pregnancy and motherhood, bodies and routines will change faster than ever — which can take an additional toll on the psyche. That’s why it’s important to try to find balance before even starting the process.
Reburn has also learned how to eliminate “triggering” thoughts, items and routines, as well as find appropriate support. She says a Facebook group for women dealing with HA was “wonderful” as she worked to regain her cycle. She also threw out her old, smaller clothes as she gained weight. “It wasn’t like, ‘Oh, I’ll wear these when I lose the weight again,’” she says. “No. I didn’t want to punish myself.” Instead, after 10 years without her period, Reburn celebrated when it returned.
“You never know how you’re going to feel, but those changes were on my radar,” Kreiger Walsh says of being pregnant, finally. “I wasn’t necessarily comfortable at my new size, but I was so focused on eating and staying well for my child. When there’s another life involved, that changes everything.”