I'm so glad he brought this up!
There's no doubt that athletes come in all shapes and sizes, even endurance athletes. And sadly, we're seeing an epidemic of a population that is over-fat, which certainly spills into the athletic community. Over-fat athletes are a real issue, and participating in sport alone isn't the "cure" for a healthier body composition (this is an issue we often discuss with Dr. Phil Maffetone on EP and have covered extensively in past episodes). So I'm totally on board with the need to help this population as well.
At the same time, though, there's another population of athletes who are silently suffering from hormonal dysfunction and hypothalamic amenorrhea, but you have NO IDEA because outwardly there are no obvious physical signs necessarily -- even body composition isn't enough to tell whether a female is menstruating are not (a woman can be a "normal" bodyweight but still have amenorrhea for other reasons, like too much stress). At the end of the day, hypothalamic amenorrhea (HA), the female athlete triad and/or RED-S syndrome are incredibly common issues in female athletes, in particular endurance athletes and any sport that values leanness, but we often let it go under the radar because it's a touchy subject that's often still "taboo" to talk about it.
"In women who participate in sports that emphasize aesthetics or leanness, such as ballet or running, the prevalence of secondary amenorrhea can be as high as 69%, compared with 2% to 5% in the general population" (1).
Compared with the over-fat epidemic, having amenorrhea can be kept a secret and often women are ashamed, embarrassed and/or are scared to talk about it--as a result, many of us may have no idea that she is suffering inside. I was that woman for years. I was terrified to talk about my missed periods for fear I'd lose all respect and credibility; for fear that I'd be seen as an alien; for fear that I'd be labeled as tarnished and inadequate; for fear that is was unacceptable to even say the word "period" in public. Actually, there was a point where I built enough confidence to try and talk about it on this VERY blog! I wanted to be real. I wanted to talk about it--talking it out always makes me feel better. So I hit publish and the backlash started. I got NASTY hate comments on the post and people telling me things like, "What kind of role model are you is you don't even get a period?!"
I was too weak and scared at the time to stand up and fight it. So I deleted the post. This was likely 2008-09 ish.
Back then, I knew enough to know this wasn't healthy or normal (although, fairly unaware of long-term consequences*), so out of concern I talked to my doctor (a conventional PCP). Other than that only a few close family members and friends knew. As far as getting help from my doctor at the time? Honestly, she was a nice woman but she did nothing to truly help me; conventional medicine did absolutely nothing to truly me regain a healthy period--other doing a provera challenge, then telling me to go on birth control, eat more, exercise less and gain weight. Really? We know that eating more and exercising less (i.e. energy balance) and appropriate bodyweight are indeed ways to heal and regain menstruation, but this information was told to me in a very matter-of-fact way that didn't register with me whatsoever. It basically felt like they were saying, "Go eat some fatty burgers and ice cream, stop working out, retire to the couch and get fat." To which I wanted to say, "Fuck you." They had no idea who I was, they had no idea how my brain ticked, they had no idea I was a dedicated athlete who "had" to maintain fitness and my physique to perform in my sport. The Western doctors made me angry, so I gave up on seeking help from them. What I needed was an education and someone who could relate to me and be sympathetic. I didn't have that person. I felt alone.
Female hormonal imbalance and amenorrhea are about more than just "eat more - exercise less - gain weight." It's a sensitive psychological issue and must be handled with love, care, and sympathy for the female suffering. This is why I like the, "Relative Energy Deficit in Sport" (RED-S) Syndrome, which ties in the psychology of it, and also makes note that males can suffer form this as well!
"Psychological consequences can either precede RED-S or be the result of RED-S. The clinical phenomenon is not a 'triad' of three entities of energy availability, menstrual function, health and athletic performance" (2).
In other words, it's complex. It doesn't have to fit the tight definition of the female athlete triad to apply--it can be more, it can be less, it can manifest in different ways, but at the end of the day it's a problem when hormonal dysfunction occurs in athletes. Thankfully, there is a way to get the body back in balance and restore function, and to do so you have to address the mental and physical.
That's the beauty of HA, the recovery rate is undeniably high. After feeling like Western medicine failed me, I made a huge effort to self-educate to learn more for myself about amenorrhea; if I had to go it alone so be it. But then the catalyst for me was finding the right mentors in 2013-14 who talked to ME, listened to ME, and who weren't just reading out of a textbook on what "should" be done. I took the proper steps to heal and recover. Yea, I had to change a lot but the payoff was worth it. Low and behold I got my period back and it STUCK (took some time to normalize), and I was happy and comfortable with the process. I was still happy with food choices, exercise habits, and my body. Mentally I got cozy with everything and accepted my new ways. It required a mindshift and some soul searching, but it wasn't that scary after all!
I WANT TO HELP
I'm still angry that conventional medicine doesn't offer an education and proper tools to heal, so now that I know better I want to help! I've gained the confidence to speak up over the years, and I want to be a voice for many women who are silently suffering, confused, or perhaps don't even realize the depths of what amenorrhea really implies. I want to be someone they can turn to for help, with zero judgement just love. I want to inspire women how to regain normal functioning or simply treat their bodies better, with more compassion and love.
I am not medical doctor so there are certainly things I can and can't do to help women with their health, but as Nico and I discussed in this podcast, oftentimes you just need to find someone who can relate to you and the situation, and that'll be the ticket to success in regaining menstruation. As such, I love spending my days working directly with women on how to regain their menstrual cycle. And guess what, we don't talk too much about eating more and exercising less. They usually know those things so we touch base on them to make sure it's being executed smartly and without a lot of stress involved. From there, honestly the conversations are about so much deeper than food and exercise talk. These are living, breathing, feeling women who just need someone to bet here for them, listen and be the voice of reason so that they can get out of their own head. Sometimes there are harsh truths, like telling a girl, "Yea, maybe you have to give up training and racing for a while just to fully relax, but it doesn't have to be forever!!! You can of course get back to it, I did and kept a period (BQ 2015)!" It's better when that comes from me, a woman who's been there and gets it.
Anyway, a few closing thoughts:
1. Don't judge a book by its cover--there's a good chance you have NO IDEA what's going on inside.
2. Amenorrhea is as much psychological as it is a physical issue.
3. We need to be sympathetic to all sensitive health issues, not judge and offer support--whether it's helping someone who's over-fat or someone with amenorrhea.
*I talk about some potential long-term consequences and much more on HA in athletes in particular over at lifepostcollective.com, where I recently launched a new women's health video series. Check it out for free with code "lpc4me" at sign up.