Dr Richard Burden and Dr Emma Ross
This month’s Telegraph Women in Sport Supplement has done another outstanding job of bringing attention to some fundamental challenges sport faces in supporting health and wellbeing in female athletes. Last month Bobby Clay, and this month Issy Morris, have shared their stories of having osteopenia in their 20’s because they had suffered RED-S – Relative Energy Deficiency in Sport. This is a broad-spectrum syndrome which arises when athletes don’t get enough energy from their diet to fuel their training. In women, one of the signs that an athlete is suffering, is that her menstrual cycle starts to become irregular, and left untreated, her periods stop altogether. The important hormones of the menstrual cycle, like oestrogen, flat-line and the long term health consequences are multiple, including a decline in bone density, leading to osteopenia and osteoporosis in young, fit women.
This is a good example of why we refer to the menstrual cycle as a vital sign of health (the others being blood pressure, heart rate, breathing rate and temperature – all the things the doc checks when you take a visit with an ailment). The presence of a regular menstrual cycle in a woman of reproductive age is a really good indicator of health and vitality. That’s because your body is pretty clever about knowing what functions to preserve (the ones which are keeping you alive right now) and which ones to switch off (like the reproductive system which is important for our long-term health, and the survival of our species, but not for making sure you make it through your training programme). In athletes, having a healthy cycle, meaning ovulation, a period, fluctuating hormones, and symptoms which are mild and manageable, is a great big tick on their health scorecard each month.
Yet why don’t we prioritise menstrual health in sport? In fact, why in sport are there long-held myths like “I don’t have a healthy cycle but that is a predictable consequence of my training”, or “I can’t be light enough and fuel at the same time”, or “getting to the top of your sport will mean losing your period”? These myths need busting, fast. Otherwise, we will continue to see generations of female athletes who normalise or silence menstrual cycle dysfunction as ‘just a part of sport’. This is counterintuitive. A healthy, resilient athlete is not an athlete who has lost her natural cycle.
It’s essential to have healthy menstrual function if you want to have a long, successful athletic career and to also protect long-term health beyond competitive sport. But for those who don’t think you can have both (be successful in sport, and maintain healthy menstrual function) we need to start providing evidence that you can. Whilst high profile examples of the devastating effects of RED-S and chronic amenorrhea continue to be highlighted, and rightly so, it is equally important for us to shout loudly the message that it is entirely possible to have a healthy, functioning menstrual cycle AND be an elite athlete. It is possible to complete high volumes of intensive training, fuel optimally AND perform at the highest level.
We’d like to share an example of an athlete who we have worked with recently. She is a 25 year old female athlete, attempting to be selected for her first Olympic games. She competes in a multi-discipline sport requiring high volumes and intensities of physical and technical training. There is a very high prevalence of RED-S in her sport where leanness is considered essential for peak performance. This athlete experienced a variety of symptoms and training outcomes she felt could be menstrual cycle related and perceived them to have a negative impact on aspects of training and performance. So we conducted high frequency hormonal and symptom monitoring for 3 consecutive menstrual cycles using Hormonix from Mint Diagnostics (testing salivary hormones every other day across the cycle), alongside sport specific training load and subjective wellness metrics. The hormonal monitoring provided a picture of healthy fluctuations and cycle lengths which were, importantly, maintained as training volume increased. The hormonal profile and menstruation confirmed that this athlete’s cycle had ovulation, a period, and healthy hormone balance. With monitoring, we found that her symptoms were related to the phase of her cycle, but that symptoms were varying from cycle to cycle. This gave us the insight we needed to develop strategies to reduce symptomatic cycles and, importantly gave the athlete confidence that there were no significant menstrual cycle irregularities impacting her health and ability to compete.
In sport we have the knowledge that menstrual cycle dysfunction isn’t healthy, and it will ultimately impact performance and long-term health. With technology like Hormonix we have the capability to objectively measure menstrual cycle health. We have the knowledge; we have the tools. It seems we are waiting for sport to develop the vision and policies which mean female athlete health is prioritised, and menstrual health becomes an important part of overall athlete health metrics. We are waiting for sport systems to accept there are no excuses for female athletes to be in a situation whereby their long-term health is in jeopardy because of training and competition.
We have the knowledge. We now have the technology, the means and the know-how. There really shouldn’t be any more excuses.