Female Athletes: What your period is telling you

As someone who grew up in a house that NEVER talked about periods / menstrual cycles, I sometimes laugh at the irony of HOW MUCH I talk about periods every day. I really mean it.  It comes up weekly with the female athletes that I see. It comes up so much so that I don’t hesitate or even give the topic a second thought. I hope that continues so that my daughter feels totally comfortable talking about it as she gets older. Although, I’ll probably be the “embarrassing mom” that talks about it too openly. I can already see the eye rolls and hear the “ughh, moommmmm”s now.  But, oh well. It’s a fate I’m willing to embrace if it means she’s aware of its importance and how it can be a sign and indicator of her overall health.

TOday I’m talking all about female athletes and their periods from the sports nutrition angle

I want to discuss why a female’s period becomes a focus in the work that I do and why I put such importance on it. Having a menstrual cycle is a normal function of the female body as they reach and navigate through puberty. A young female athlete should get her period by 15 years old.

Typically if a young female has reached 15 years old without ever having had a period it is termed “primary amenorrhea” and she is typically referred to a specialist to determine if something is going on in the body that has prevented her cycles from starting. 

It is fairly normal for a young female athlete to reach menarche (her first period) and for her periods to be a little irregular at first. However if she gets further into her sport and you notice it stops completely and she goes months and months and months without having one, OR, it normalizes and then her training increases and she starts skipping her periods, that is not normal. Losing her period or going three months or more without it is not a badge of honor displaying what a hard core athlete she is. This is a medical condition known as “secondary amenorrhea”. 

Whether the athlete is experiencing primary or secondary amenorrhea, there is reason to take a look at what might be going on. I’ve seen and research supports that it can be a cause for concern in the sports world.

Annoying BUt important

I know that having a period as a young female athlete can be VERY annoying. The cramps, the fatigue, nausea, bathroom breaks. It’s very annoying and very inconvenient. So, when we skip one or more periods or delay ever starting, we may think, “sweet, one thing I don’t have to deal with”.  However, what we may not realize is that this period and regular menstrual cycle is very important for injury prevention and performance, specifically things including (but not limited to) hormone regulation like estrogen which impacts bone health. 

While there can absolutely be an anatomic or endocrine issue going on, amenorrhea can also be a result of underfueling, the theme we have been covering the last couple of months. And that is what lands so many athletes in my office and why I’m so concerned with the female athlete’s cycle. What is happening here is that the athlete is demanding a very high amount of energy due to training for sport. However, she is not consuming enough energy each day for the body to cover all of the demands being placed on it between energy needs for sport, school, growth and development and daily physiological functioning (breathing, heartbeat, digestion, menstrual cycle, etc.). So, I like to explain this as:

In this state of limited energy availability (or, Low Energy Availability) the body takes an inventory of the functions not absolutely needed in the immediate present to function and it starts powering down or even shutting off those identified systems. That’s when the athlete loses her period. The body says, “I don’t absolutely need you right now to live and function and so I will power you down or turn you off for a bit until I have more energy. Right now I need to use all of this energy for this other function over here”.

my thinking when a female athlete tells me her cylces have been absent or irregular.

When a young female athlete walks into my office and tells me she has not had a period in the last 3 to 6 months or more, I get very concerned about her health, performance and risk of injury, particularly the state of her bone health. If she isn’t already seeing me with a stress fracture, I’m  on heightened alert of her susceptibility to acquiring one in the near future. And, even if she is lucky and avoids a fracture, it can still put her at risk for low bone mineral density and osteoporosis later in life. Not having her cycle is also a sign that she could very likely have RED-S, which we know from my previous posts means she could be setting herself up for further complications like decreased performance, stomach issues, heightened anxiety, cardiovascular concerns, altered iron levels and more.

So, what can you take away from today’s post? Today I want to leave you with a few questions you or your athlete can ask regarding her period to determine if she is fueling well to prevent injury and perform her best…

Period check to determine if your female athlete is fueling well:

• Has your athlete started her period by 15 years old?

• Is your female athlete having monthly periods?

• Does your athlete have regular periods EXCEPT during her sports season? For example: “I have a monthly period all year with the exception of cross country season. I lose it for 4 or 5 months and then it comes back after my season is over”.

  • This indicates likely underfueling in-season

• Does your athlete only have her periods when injured?

  • This could indicate that she may be underfueling when she is fully training. When she is taken out of her sport and her activity decreases her intake is finally able to meet physiological demands and her periods resume.

• Is your young female athlete struggling with or has she in the past struggled with stress fractures?

  • NOTE: An athlete can still experience stress fractures with regular periods and an optimal energy intake. They could be more a result of specific nutrition deficiencies. However….

  • Make sure to at least ask, “is she having regular periods?”

    • If she is not, it should be a red flag to start taking an even closer look at her fueling and working on optimizing and increasing her energy intake as soon as possible.

    • In my practice, stress fractures are often a result of underfueling AND certain nutrient deficiencies (not getting enough food each day = not getting enough nutrients each day)

Now, or course, a young female’s athlete’s period, or lack there of, should always be checked on by the appropriate specialist (pediatrician, OB, endocrinologist, etc.). But, today, I encourage you to not gloss over the fact, that her FUELING could be the reason for her menstrual irregularities. Or, her STRESS INJURIES could be a result of her MENSTRUAL IRREGULARITIES, which could be a result of her UNDERFUELING.

For more info on underfueling you can check out my latest posts linked below….

• Is your athlete underfueled?

• RED-S: The reason for your athlete’s struggles?

• Underfueling: Intentional or Unintentional?

Much love & a well-fueled athlete,

Taylor

Oh! And, if you do feel like your young female athlete is struggling with her fueling and you need a place to start, feel free to grab a copy of my Getting Started Guide to a Well-Fueled Young Athlete! 

RED-S: The reason for your athlete’s struggles?

RED-S: Is it the reason for your athlete’s struggles?

I know I’m talking a lot about underfueling lately. But, with what I know and all I’ve seen in the last couple of years, I feel like I would be doing my followers, clients and athletes a true disservice if I glossed over the topic or, worse, didn’t address it at all.

So, today I’m going to spend time giving you a surface-level overview on a relatively new medical condition known as Relative Energy Deficiency in Sport, also known as RED-S. 

I talk about this condition ALL THE TIME whether I’m in clinic or speaking in schools or speaking at a conference. I can speak in depth on this topic for 30 to 45 minutes if given the time but this post is just to give you an introduction to this important-to-know-about condition so it will be much more brief. So, today I hope to hit the high points on this important condition called RED-S.

BEFORE THERE WAS RED-S

Researchers have been studying underfueling, or as I explained in my last post, Low Energy Availability (LEA), for a long time. 

Lea in Females

Initially this occurrence of LEA was associated with females in what was termed the Female Athlete Triad. The Female Athlete Triad  is a medical condition in which a female athlete experiences one of the following: 

1. Compromised bone health

2. Irregular menstrual cycle

3. Underfueling (intentional or unintentional)

lea in Males

As researchers and clinicians continued to look into underfueling and its effects on athletes, their health and their performance they found that a similar condition to the Female Athlete Triad with similar consequences could present itself in males as well. And so a condition in male athletes was established called the Male Athlete Triad. 

In males the condition could manifest in several ways, very similar to females:

1. Compromised bone health

2. Altered hormone levels and cycles (testosterone levels, etc.)

3. Underfueling (intentional or unintentional)

In both Female Athlete & Male Athlete Triad…

Not all components have to be present to be diagnosed by a physician. It might be that the athlete only exhibits one. However, if one component is present, it is very likely that others are present as well and so further examination into the others is recommended. From my practice, I see that the root cause is the underfueling. And from there, if not noticed and managed leads to what we see and the athlete experiences - the bone injuries and / or the hormone changes. lost periods, etc.

In practice…

I typically come in when a female athlete has:

• lost her period for 3 months or more or 

• has experienced one or more stress fractures or

• when an athlete has exhibited some significant weight loss or a weight plateau in the last few months to years, causing her to start falling off her growth chart.

I’ve found that for some female athletes it takes a small amount of underfueling and for others it takes extreme underfueling for their menstrual cycle to be disrupted. But, just because a female athlete still has her period, it does not mean she is for sure fueling enough and appropriately. Just something to keep in mind.

I typically come in when male athletes have:

• had one or more stress injuries in the last year

• had altered labs at their last pediatrician visit  or 

• H=had recent weight loss or a weight plateau, causing them to start falling off their growth chart.

DISCOVERING RED-S

Researchers and clinicians were aware of the Female and Male Athlete Triad but continued to study the effects of underfueling and LEA (and we’re still studying LEA today).

the effects of underfueling and LEA can reach beyond decreased bone health, hormone regulation, and menstrual dysfunction

As they studied athletes and underfueling they started to see that the effects of underfueling and LEA can reach beyond decreased bone health, hormone regulation, and menstrual dysfunction. It can actually have a much wider scope of impact on the athlete’s health and performance. Underfueling can impact an athlete’s:

• mental health (seen or felt as increased anxiety for example), 

• cardiovascular health (ex: slowed heart rate as the body tries to preserve energy)

• metabolism

• gastrointestinal health

• immune system

• endocrine system

• haematological (iron deficiency anyone?)

• growth & development

DETECTING RED-S

Putting this into practice, some examples of when I would look further into RED-S and check an athlete’s fueling would be:

• A typical non-anxious athlete begins to struggle with anxiety.

• An athlete already diagnosed with anxiety has been feeling heightened anxiety lately.

• The pediatrician or other medical professional has observed a very low heart rate.

• The athlete has started complaining of GI issues like constipation or feeling like it takes a long time to digest food.  Maybe they just don’t get hungry anymore.

• The athlete is constantly getting sick or it’s taking a long time to recover.

• The athlete has experienced an injury and it’s taking a longer than expected amount of time to heal and recover.

• There are delays in growth and development. This could look like the athlete’s weight and height plateauing or falling off their growth curve. It could look like a 16 year old female athlete still not every having had a period.

• The athlete is complaining of extreme fatigue with exercise, weak muscles, hitting a wall. Labs come back from the pediatrician and patient has low iron levels.

• The athlete gets hormone labs at their well-check visit or another visit and they find low and altered levels of specific hormones.

what next?

Now, it’s important to take into account that there could be something very clinical going on and these complications have nothing to do with nutrition, so of course get it checked out by the appropriate specialist.  

BUT, at the same time, if there has been any change in the athlete’s training or the athlete’s intake, it may benefit the athlete to look at their fueling. Are they getting ENOUGH fuel each day? And then, are they getting enough of the best foods for them within those fuel choices? 

In practice…

Similar to what I included above, athletes with suspected RED-S typically show up in my office when:

• A female athlete has lost her period for 3 months or more

• A 15 or 16 year old competitive female athlete has not yet started her period

• An athlete has experienced one or more stress fractures

• An athlete has exhibited some significant weight loss or a weight plateau in the last few months to years, causing them to start falling off their growth chart.

• The athlete is experiencing repeated injuries or illness

• The athlete has had a sudden change in intake and food preferences

• The athlete has received altered nutrition labs like iron levels from the pediatrician or other markers that may indicate dehydration or altered nutrition intake

Sometimes taking a look at the athlete’s fueling plan and giving it a boost AND BEING CONSISTENT with these changes, can improve digestion, can help the athlete with their anxiety, can decrease illness and can allow appropriate, necessary and needed weight gain so the athlete can continue to reach their height potential and get through puberty.   

What I’m talking about today is something I see in my practice all the time. It’s also all found in the scientific literature. I’m linking a resource below in case any of you like to get really into the details and the science (like I do 🙂).

Resource for more reading:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9724109/pdf/nihms-1853616.pdf

And here’s a great graphic that explains RED-S by Keay & Rankin…

And, if you think your athlete could benefit from improved fueling, you can download my free Getting Started Guide HERE!

Until next time!

Much love and a well-fueled athlete,

Taylor

Is Your Athlete Underfueling? A Common Oversight

Is Your Athlete Underfueling?

Many of my posts have an underlying theme of underfueling but I realized I have not created a post specifically devoted to this topic. So, that’s what I’m going to take a few minutes to talk about today.

If you have been following along with me on Instagram lately, or in my Newsletters, then you have seen me talk about this topic. It has been the most asked for topic that coaches and athletic trainers have asked me to come speak on in this last year. And it is one of the top two reasons athletes have come to see me in clinic since the beginning of 2023 (with probably the other one being helping them navigate nutrition in their recovery, like from an ACL tear and repair).

Going into the field of sports nutrition and then, more specifically, pediatrics I didn’t think this is what I would spend the majority of time talking about. Although, it should not surprise me because for a time in my childhood I was absolutely another underfueled young athlete - even when I improved my fueling significantly, I was still underfueling. And I didn’t realize that part until I got into this field as an adult, started working with young athletes, and studying the field. So, I know how easy it is to say, “no, my fueling is good. It’s so much better than a year ago. There must be another reason for (xyz). Or, I’m doing well so my fueling must be optimal now”. 

If the young athlete is experiencing any of the signs or symptoms I’m about to mention, then they and their support team really need to take a closer look into their fueling. Improved food and energy intake can have a huge impact on performance, helping the athlete achieve the muscle gains they have been working on, it can improve endurance and speed, it can improve mental focus and, a big point, it can keep your athlete in the game and away from nutrition-related injuries that can have them out of their sport for months. From a health perspective, being well-fueled can improve the athlete’s mood, help keep anxiety down, promote heart health, metabolic health, and bone health. 

Maybe you are the athlete or have the athlete who has experienced some of the signs and symptoms below but they are still performing and practicing well. My thoughts to that are... 

“Ok, great. So you’re performing well off of minimal fuel. But, for how long? And, if you can perform well off not enough, JUST IMAGINE what you could do, how you could perform, the levels you could get to if you were fueling WELL. If you were fuleing your BEST. If you are talented and driven and scrappy enough to perform well off of too little fuel or the bare minimum, just think about what your body could do if it had all that it needed!! Imagine what it could do if it didn’t have to power down or compromise different systems so you could practice and perform?

I’m so passionate about this, clearly. And I get SO EXCITED when I see athlete’s performance improve with improved fueling. It could be small changes it could be big changes, but it makes a difference and I love to see this “click” in the young athletes I work with.

This is not just me talking about fueling and how important it is. This concept of underfueling has actually been studied and continues to be studied in great detail. From it has developed a term call Low Energy Availability, meaning the athlete does not have enough energy available at the end of the day each day to perform all of the functions demanded of it (think - exercise, studying, growth, development, breathing, eating, heartbeat, hormone cycles, etc.). Another way I like to explain this is that “if you have been underfuling consistently for a long period of time, you are likely in a state of Low Energy Availability (LEA)”. It can be intentional or it can be unintentional, but either way it means that some function of the body is very likely getting powered down or compromised (think loss of menstrual cycle in females, sluggish performance, fatigue, lowered heart rate, etc.) and can lead to decreased performance and injury.

Further research shows us that Low Energy Availability is often the root cause of a few other medical conditions now recognized in athletes.

These medical conditions stemming from LEA are:

• Relative Energy Deficiency in Sport (RED-S)

• Female Athlete Triad

• Male Athlete Triad

I’m not going to go into detail about these today, but will instead devote a separate blog post to each topic. They all can lead to decreased performance, health problems or injury, none of which we want in our young athletes! In future posts I also want to talk more about potential reasons for underfueling - intentional vs unintentional. The reason the athlete is underfueling can have a big impact on how we help them get fueled and the projected timeline of return to optimal fueling (or return to sport).

So, I’ll leave you today with a handful of the signs and symptoms of underfueling. Is your athlete experiencing any of these? If so, it’s likely time to start looking into their fueling habits and create a plan. And, definitely stick around for future posts where I go a little deeper and provide insight into these medical conditions caused by underfuleing.

Signs and Symptoms of Underfueling:

• Dizziness

• Fatigue

• Weight Loss

• Hair Loss

• Growth Disturbances (athlete stops gaining in height)

• Unable to build muscle

• Lost period or not starting period by age of 16

• Heightened anxiety and/or moodiness

• Low iron levels / iron deficiency

• Low heart rate (but must distinguish between underfuling and lower heart rate that elite athletes tend to have)

Much love and a well-fueled young athlete,

Taylor

Oh, and if you’re looking for a little more direction and a place to start taking action, you are welcome to download my free Getting Started to a Well-Fueled Young Athlete!