This piece is part 2 to last week’s blog post on how periods affect training. If you haven’t already, give it a read!

When it goes wrong

A topic I have spent some time (though probably not enough) discussing on my Instagram page, as well as on here, is overtraining and RED-s, or Relative Energy Deficiency in Sport. The condition has spent more time in the limelight recently, with high profile cases coming to the fore, and more people on social media opening up about their experiences too. However, unfortunately the topic is still shrouded in mystery and shame, meaning that every year more people are affected. Even worse, it’s often assumed that losing your period is a normal, even healthy side effect of training, and isn’t anything to be concerned about. This is a myth that needs to change. 

Exercise is a stressor to the body. For the most-part, it is a good stressor, leading to adaptive changes to make us faster, stronger, fitter. There comes a point, however, where the demands of a particular sport go beyond the recovery that is given, and beyond what the body can handle. There are many ways that this can happen, and the outcome is a cascade of physiological responses with serious, even life-changing, consequences. RED-s refers to a state where there is insufficient energy intake for the amount of training being undertaken, leading to reduced bone density, low energy availability and, among other things, hypothalamic amenorrhoea, or stopped periods. In the general population, around 2% – 5% of women are affected. Within athletes, the prevalence is much higher, at 3.4% to 44%. 

Somewhat problematically for diagnosis and recovery, there are many stories of athletes having their best seasons right before their body starts to shut down. This is because the effects of RED-s take time to come into play, and can be caused by the most innocuous-seeming deficiency in calories over a long period of time. However, this is an important issue as it is increasingly common even among for-fun athletes, even those of a ‘healthy’ BMI, and RED-s is quietly sidelining more and more people.

Periods are important. They show that your hormones are functioning as they should – it is impossible to function optimally as a human and athlete without the hormones your body needs.

Why do people lose their periods?

Secondary amenorrhea is when you have experienced regular periods before, but then stop menstruating for 3 months or longer after that point. Functional hypothalamic amenorrhea (FHA) is a type of secondary amenorrhea, caused by low energy intake, weight loss, stress or a combination of these factors. Note: you do NOT have to be underweight and be training loads and have a really low calorie intake for this to happen. All of these make it more likely, but FHA can happen to anyone. It is also important to rule out other causes of amenorrhea, in case it is caused by some other factor. 

Losing your period as a side-effect of training should never be seen as acceptable. The idea that it’s a sign that you’re working hard is both harmful and wrong – you can train much better if you have a healthy cycle. 

Evolutionarily speaking, FHA in times of stress may have been adaptive. If you can’t support your own body and health, there’s no way you could support another life (i.e. a baby), so it doesn’t make sense to ovulate, as this is energy consuming. The downregulation of the body’s natural functions protects the brain and vital organs. However, there’s no questioning that it is a red flag that something is up, and in this day and age we are lucky to have the knowledge to protect ourselves against such outcomes. 

What happens when you lose your period?

FHA results from changes in the hormone GnRH, which in turn reduces luteinising hormone (LH) and eventually oestrogen availability. This has a number of negative consequences affecting the whole body, including bone density, cardiovascular health and mental health. The longer it continues, the greater the effects. Conditions such as osteoporosis, previously associated with post-menopausal women, also become more likely, due to the reduction in oestrogen’s protective effects on bone density. This in turn increases risk of injury such as fractures. Research suggests that athletes with menstrual irregularities are also likely to experience more injuries and recover slower from those injuries.

There can also be short and long-term consequences for reproductive health. Of course, if you are not ovulating, you cannot get pregnant (though this should never be used as a form of birth control!!), but there may be long-term impacts on fertility in response to chronic amenorrhea. However, when treated properly, the prognosis for future fertility is good. 

How can I get my period back?

This is a question I get asked a lot, and I am reluctant to give prescriptive answers, as I am not a medical professional. Generally speaking, reducing stress on the body and increasing energy availability are good places to start. Often the causes of FHA are not entirely physical, and seeking professional mental health help can assist too. 

These are some of the factors most important to optimising physical health:

• Ensure you are allowing for adequate rest between training sessions. 
• Reduce the number of very intense sessions per week, and space them out.
• Make sure you are eating enough carbohydrates, fats and proteins. 
• Avoid fasted training sessions. 
• Get enough sleep – it is vital to recovery! 
• Eat within 30 minutes of a training session. 
• Reduce stress in other areas of your life where possible.

If you are unable to get your period back by yourself, after reducing exercise intensity and improving recovery, it is recommended to seek professional help as soon as possible. A specialist sports dietician should be able to help if you’re concerned or not sure if you need pointing in the right direction. 

Conclusions

With the increase in uptake of sports, and higher stakes especially in competitive sports, it is unlikely that conditions such as FHA and RED-s are going away any time soon, especially among young women. While we place pressure on men and women both to perform and look a certain way, regardless of actual health, it is vital to continue to educate athletes and coaches on the consequences of not treating our bodies well and with respect. 

Unless you’re actively trying to get pregnant, it can be easy to push issues such as FHA to the back of your mind, especially if the perceived immediate benefits are greater the perceived long-term risks. Ironically, if your primary concern is performance rather than long-term health, it will be difficult to become healthy and thus perform optimally. I’m hoping that by talking about it more and improving public awareness, we can start to encourage people to seek help when they need it, and hopefully reduce stigma while we’re at it! 

If you’d like to learn more about this topic, these podcasts were particularly helpful for me:

• Trained: Georgie Bruinvels – Using the Menstrual Cycle as a Personal Trainer
• The Food Medic: Women Are Not Small Men
• The Food Medic: Inferior: How Science Got Women Wrong
• The Bad Boy Running Podcast: Race Nutrition with Renee Mcgregor

If you found this blog post helpful, please do share with anyone who might find it useful or share and tag me on Instagram! Many thanks to specialist Renee Mcgregor for talking me thorough these complex issues too. If you enjoy my posts regularly, please consider contributing so I can keep this page up and running (no pun intended).