Psychological Stress, Menstrual Irregularities, and Performance Outcomes Among Elite Female Athletes

Elite female athletes are simultaneously exposed to two demanding physiological systems: a hypothalamic-pituitary-gonadal axis that governs reproductive and menstrual function, and a hypothalamic-pituitary-adrenal axis that mediates the response to psychological and physical stress. A growing body of evidence indicates that these systems are not independent; chronic psychological stress, whether generated by competitive pressure, financial insecurity, selection anxiety, injury, or the cumulative load of training, can suppress gonadotropin-releasing hormone pulsatility and precipitate menstrual dysfunction, including oligomenorrhea, secondary amenorrhea, and functional hypothalamic amenorrhea. This review synthesizes epidemiological, endocrinological, and sport-science literature published between 1982 and 2026 to examine the prevalence of menstrual irregularities among elite female athletes, the neuroendocrine mechanisms linking psychological stress to reproductive suppression, the overlapping constructs of the Female Athlete Triad, Relative Energy Deficiency in Sport, and overtraining syndrome, and the consequences of these conditions for athletic performance, injury risk, and bone health. Reported prevalence of menstrual dysfunction among athletes ranges from 6% to 79%, substantially exceeding the 2% to 5% observed in the general population, with marked variation by sport type, culture, and energy availability. Concurrently, 4% to 68% of elite athletes report depressive symptoms and up to 33.6% report combined anxiety and depressive symptoms, with female athletes consistently reporting higher rates than male counterparts. The review further evaluates evidence on menstrual cycle phase and performance, concluding that while injury risk and subjective well-being show more consistent luteal-phase decrements, objective performance findings remain heterogeneous and are frequently confounded by inadequate hormonal verification. The review closes with a discussion of methodological limitations, sociocultural moderators, and implications for athlete monitoring, screening, and interdisciplinary management.