the female athlete

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This article explains the impact of menstruation and menopause on the female athlete and in particular those running long distances.  Hopefully it will demystify some of the science and help you adapt your training and events to the rhythms of your body.  It was written by Shirin Shabestari based on a into ultra webinar by Rene MacGregor. Renee is a leading sports dietician specialising in REDs, female health and eating disorders.  Let us know if you have any thoughts or comments.

Understanding the rhythms of the body

Hormones at their best

When we think of our hormones we typically only think of testosterone and oestrogen. We don’t often realise we have a big range of hormones (thyroid hormone, leptin, growth hormones etc) that help various parts and aspects of our body to function well. Hormones play a role in our digestive system, body composition, cognitive function, mood, bone health, immune function, physical performance and digestive system. This is why when they don’t work for us at times during our lives, they could have a significant impact on our lives. 

The same run that you may have done a week ago and it felt amazing at the time, might feel absolutely terrible on another day. It leaves us wondering what is going on! It can be hard to believe or accept that could be down a chemical imbalance in our body. Although there has not been a huge amount of scientific research done on women, the research that has been done has highlighted some key information about menstrual health and its impact on our lives as athletes.

A Beautiful and Healthy Pattern

Let’s have a look at the basic menstrual cycle (28 days). It is important to note that every female will have a different cycle. A normal cycle could range between 23 and 35 days. It is not unusual to have a shorter or longer cycle. The only thing to look out for is if there is a sudden change in the usual cycle and the change from short to long or vice versa  happens more frequently. Our menstrual cycle is a barometer of health so our body is trying to tell us something if the cycle starts to change or look different. 

Day 1 to day 10 of a normal cycle is known as the follicular phase and that is divided into early and mid follicular phase. The start of this phase is when we are bleeding and that again could vary from female to female and could last from 2 to 7 days. As you can see, our hormones during this phase is fairly stable (oestrogen and pogestrone). Most women will find that they feel the most stable during this phase. Soon after having your period, you may feel that life doesn’t get on top of you as much. You would be up for training and you will be okay to push yourself a little harder and you are less likely to be affected by small changes in your diet (in case you don’t quite get your nutrition right). Next is the ovulation phase which is day 10 to 15 for most women. We can see a sudden spike in the Luteinizing Hormone (LH), an important hormone responsible for ovulation. This hormone is directly affected by exercise intensity and it is the hormone affected by peri/menopause. The rise is LH coincides with a rise in Ostrogen (Estrogen). Women often find that they feel either amazing or terrible at this point. Most women feel more attractive and confident during this phase for obvious biological reasons as this is when you are most fertile which goes to show that it’s not just our physical function that’s gets affected but also our emotional output. 

In Luteal phase, LH and follicle stimulating hormone (FSH) which have now done their job (ovulation) drop and our body produces Corpus Luteum which provides us with progesterone. High levels of progesterone and oestrogen are now going to prepare the uterine lining ready for a possible pregnancy. They decline in the next phase when we don’t get pregnant and that’s when we get our menses again. When these two hormones are at their highest and progesterone is dominant, this is when we notice those fluctuations in our mood, our blood sugar levels. We may notice that we get quite hot, and have a higher sweat rate. You are more likely to get dehydrated. That’s why if you are racing or during training, you would want to pay more attention to your carb intake to keep those sugar levels topped up. Although we know this happens usually around day 23 and 24, we are not sure when exactly it happens for individual women. The only way you can determine when this happens for you as an individual, is tracking your cycle and understanding your own symptoms. To make matters more complicated, even in individual women, our cycle differs from month to month. Lack of sleep, stress or an increase in training, will influence how we experience our menstrual cycle. The science behind this is not perfect but what we do know as a fact is that these hormones are powerful and will impact our body and emotions. 

In our 40s, we may enter perimenopause and that is when these hormones will stop behaving in their regular patters. Regular blood tests on athletes have shown that the hormone levels can change from week to week sending us very different signals. This is why most GPs don’t do blood tests beyond the age of 45 as the hormones constantly change. 

Optimising our Hormonal Health – Eat your Carbs!

We know from all the science out there that sufficient carbohydrate is key to a optimal hormonal health. This is even more important if you are active. In dealing with athletes that suffer from secondary amenorrhea (not getting a period for more than 3 months) , It is the carbohydrate availability that is investigated and ensuring that they get enough around their training which is why fasted training or intermittent fasting is not encouraged for women. In women, when you consume enough carbohydrates, you produce a thyroid hormone called T3. When T3 is low, it means you are not taking enough carbs. When low, T3 sends a message to our hypothalamus which then down regulates our menstrual and reproductive health. 

Estrogen is very important to our bone health . Good sources of Calcium and Vitamin D is crucial to optimise bone health. Protein and B vitamins are important in the luteal phase of our cycle. Scientific evidence shows that it is when our B vitamins are low, that we experience pre-menstrual syndrome (PMS) symptoms such as heightened anxiety and fluctuating moods. Athletes that struggle with PMS symptoms are encouraged to take B6 and B complex to level things out (B vitamins can be found in wholegrains). Essential fatty acids health us with our inflammatory response. Oily fish, nuts and seeds all are great sources for those. Iron is crucial for hormonal health. It’s been shown that one in four women have iron deficiency. A lot of women don’t eat red meat anymore. Staying on top of your iron intake is very important if you experience heavy blood loss during your menses. Red meat, eggs, beans and pulses and fortified cereals are all good sources for iron. Bear in mind that plant based sources are more difficult to absorb. It is best to combine plant based iron intake with some Vitamin C to help absorption. Remember that taking food rich in iron too close to consuming tea and coffee reduces its absorption. Finally gut biome has been shown to play a significant role in our mental health and better immune system. Studies have shown that extreme sports like ultra running seem to disrupt our gut biome so it is important to aim for a healthy intake of antioxidants, fibre and gut biome in our diet.

Potential threats to menstruation

Our cycle can be threatened by either medical or lifestyle conditions. Medical conditions such as PCOS (Polycystic ovary syndrome) or thyroid disruption, prolactinoma (high levels of prolactin due to a benign tumor in your pituitary gland) so if an individual is not having a regular cycle, it is not always a given that this is due a lifestyle choice. Practitioners diagnose by exclusion. 

Peri-menopause

A medical condition that happens to all women and is also known as menopause transition. It usually starts in women in their 40s but it can be earlier specially if there is history of early menopause in your family. Women often tend to experience menopause similar to their mums. The difficulty is that most of our mums didn’t know much about their condition and didn’t talk about it. It has only been in the last 2 to 3 years that we have started talking about peri-menopause, menopause and hormone replacement therapy (HRT). This is due to the fact that we now live longer, we are staying active for a lot longer and therefore we are beginning to see the direct impact on our lives and performance. It can actually last as little as few months or up to a decade, and there is no way of knowing how long it might be for you as an individual. Peri-menopause stops at menopause when ovaries stop producing eggs and our oestrogen levels are very low. The average age of menopause tends to be 51 so in today’s society we are probably spending a third of our lives in menopausal state which then has implications for our health and performance. 

These are some of the signs of peri-meonpause but it is worth mentioning that they are well over 100 possible symptoms and these are just the most common ones. 

An interesting picture that is emerging out of the latest research shows that women that are most active tend to experience the least physical symptoms, but may have quite a lot of emotional symptoms (low mood, heightened anxiety etc). On the other hand, women who are more sedentary and less active tend to have more physical symptoms (hot flushes, joint pain etc).  An individual may have all of these or none and there is really no way of knowing. We do however know that if you eat well – the Mediterranean diet is being suggested – it does help with the peri-menopausal symptoms as it’s high in antioxidants, and fatty acids, wholegrains and etc. So eating well and being active is our best chance in tackling and hopefully preventing most of these symptoms.

Athletes and peri-menopause

The research on athletes going through peri-menopause is almost non-existent but some of the most common concerns are fatigue and poor recovery due to lack of quality sleep. Scientific evidence recommends an active lifestyle to help with mood, body composition and lowering the risk of heart disease that also rises from the low levels of oestrogen. 

It is important to bear in mind that hormonal fluctuations and irregularities puts a lot of stress on the nervous system. If you track your heart rate variability (HRV) on your watch or other tracking devices you may notice real fluctuations in your HRV before your period and around ovulation. That is a clear influence of our hormonal fluctuations on our nervous system. Women going through peri-menopause who are experiencing these big fluctuations have to take extra care with their nervous system. Things like yoga and mindfulness do help. If your nervous system is already heightened, running is not always going to help. It will only add to the stress on your body. It is particularly hard to hit the right balance if you are a runner because we tend to love running and believe it makes us feel better but sometimes it’s not the best for our body. HRV tracking is something that is encouraged as a crude value of seeing where your body is. After races it is normal for you to have a low HRV as your body is trying to recover. 

Nutrition is a key consideration for women going through peri-menopause. It has been shown that increasing protein intake can really support recovery. It could be useful for plant-based women to take supplements particularly if you are doing a lot of training so adding a bit of protein powder (pea or soya) can really be helpful. With oestrogen and progesterone declining, our gut biome can be affected so you might experience more digestive issues so it is important to stay on top of gut biome and take plenty of wholegrains, colourful and fermented food, and probiotics. As oestrogen drops we love our bone protection. Having dairy products as well as vitamin D sources can mitigate some of that affect. Once again carbs is key! A lot of women who go through peri-menopause struggle with the change in their body composition and body shape. Our body tends to carry more weight around our abdomen rather than our hips as oestrogen drops. If you are a runner or you are physically active, it is vital that you don’t avoid or cut back on carbs. As those hormones drop, we also lose the ability to burn fat as fuel so we become much more reliant on carbs for fuel. 

To HRT or not to HRT?   That is the question!

The choice is every individual’s personal choice. The latest advice is that you can start HRT as young as the age of 45 if you suffer from severe symptoms. While in the past there were only one or two options, there are now many kinds of HRT. There was also a study or two that raised safety concerns but that is now disproven. Given the variety of options, it is really worth doing your research. The website Balance is a great source of information. The benefit of taking HRT as a female runner is 1) you will not get the peaks and troughs of the hormones so it might stabilize the performance 2) it helps keep your bones healthier. At the moment, there are no other alternatives apart from lifestyle choices. 

From a lifestyle point of view, our menstruation can be threated if we don’t consume enough energy and as a female athlete, one may go into low energy deficiency as training is expensive. Human body requires a lot of energy. A lot more than what we normally think. So we need to ensure enough energy intake particularly carbohydrates. The difficulty is that we live in a society that constantly tells us that we need to “move more and eat less”. According to 2022 stats from WHO, 43% of adults are considered obese. This often leads to us being bombarded with unhelpful messages forgetting thay around 53% of us are not obese. Public health messages are not really nuanced or specific enough. There has been a significant number of interventions trying to prevent obesity over the last 25 years yet rates of obesity and overweight keep increasing. This may show that those interventions and public health messaging may not be the way forward. Biologically we are biased towards energy balance so we actually need to “move more, eat more”. The more you do, the more your body will demand energy. Only when we eat enough, our bodies allows us that hormonal cascade that makes us get faster and stronger. People have the false assumption that if they create deficit, they will get lighter and faster. When that happens, your body goes into compensatory behaviour as it can’t maintain biological functions. Your energy will always divert towards training and movement (including walking your dog, going up and down the steps at work etc.) so other biological functions such as recovery may suffer. If you keep depriving your body from enough energy day after day, week after week, your body will then have no chance to repair and rebuild. We need energy for our brain, our recovery and rest and even digesting our food before we can have enough for movement (see slide below).

Low energy availability basically affects every aspect of our body’s biological processes such as causing erratic menstrual cycle. For some women, it is their recovery that gets affected and they may start having niggles (ligament, tendon problems or bone injuries) or symptoms associated with auto-immune conditions. They may experience digestive issues. You just don’t get that progression from your training. You are doing all this work but not seeing the benefit. You are not getting leaner, or faster or stronger. Low energy deficiency underpins REDS (Relative Energy Deficiency in Sport) and it doesn’t only affect the elite.

A study has shown that probably around 73% of recreational athletes suffer from low energy deficiency. REDS can also happen if there is ‘under-recovery’ and acute stress on the system. There is two type of REDS: Intentional and Unintentional. Unintentional REDS happens when an individual just doesn’t appreciate how much fuel they need. Intentional REDS is often associated with an eating disorder and an individual is consciously making a choice to either eat less, or move more or do both. This latter type is much more psychological and more complicated to work with. This is a coping mechanism and a mental illness. The individual is expressing how they are feeling through their undereating or over-consuming. 

The concern is that individuals that take part in our sport usually have a particular type of mentality. Races like the Spine etc is not an activity that general public would like to do. It takes a certain type of person to put themselves through these. These personality traits are often high achievers, determined, self critical, obsessive, profectionist and compulsive. If you put such an individual in the right psycho-social space, you will create the perfect storm for potential dysfunctional behaviours. Modern society is a difficult place to live. There are lots of social ideals about how we eat, how we look, and how we train. While ultra running is a very inclusive friendly environment, it can get competitive and nurture such behaviours specially if you don’t have an awareness of your personality type or know how to manage your expectations. 

Some of the most common mistakes are:

• Insufficient fuelling (intentional or unintentional)
• Insufficient recovery (specially in ultra-running).  Elites often tend to do one or two big races in a year because they are aware how important that periodisation is. Many recreational athletes do an ultra every month if not every week. 
• Fixating on weight over performance.
• Over competing/training
• Cherry picking “evidence” (on social media we tend to follow people we admire or agree with rather than choosing people we wouldn’t agree with.) We are creating confirmation bias about our beliefs. It is important to be open to other opinions and voices so you get a different perspective. 
• Developing limiting beliefs (once again based on what we choose to read or hear i.e. I must do 10,000 steps a day. A lot of public health messaging fits into this category and is often not backed by evidence)  Walking everyday is going to make you healthier but the number 10,000 steps is not a number to get hung up on. 

One of such limiting beliefs is that if you eat less you will lose weight. Again if you starve your body of the energy it requires, your body will go into compensation mode and down regulates your metabolism. You don’t necessarily lose weight. A lot of these are just assumptions and may not be very obvious or visible so it’s good to reflect on the questions above. If you find yourself saying yes to a couple of these, then it may be worth exploring that and not ignoring it. 

REDS, peri-menopause or both?

These two conditions have very similar symptoms in the way they affect our biological functions and our menstruation. Bone stress injuries, low mood, changes to cognition, menstrual cycle are all result of low oestrogen. When you go to your GP as a woman in your 40s and present with these symptoms, the likelihood is that you will be told that it is peri-menopause whereas a lot of us may be suffering from REDS. The only way to identify that is through HRT treatment and if their symptoms don’t go away, then it is likely that it is REDS. This is something we need to be mindful of this. 

Empowering women

Being equipped with all this information allows us to make better decisions. This is not just for having an excuse for why you can’t train well or  perform well but hopefully this will help you understand that there will be days and there will be times that our hormones do influence how you feel. It is not a weakness to accept that a training session may not happening today. Renee herself is 48 and is entering the peri-menopausal phase. She finds it to be a strange experience as there is no predictability. One day you feel great. The next day you feel terrible. This can be very challenging if preparing for a big race. Renee says she expected to have a clear indicator that this is happening (period stopping suddenly being one) but she still has a normal cycle. But what she has noticed is changes to her mood and fatigue levels that she couldn’t explain. Every individual’s experience is very personal and different. Renee started HRT beginning of this year but recently came off it. As her hormones are still fluctuating, she found it hard to adjust the dose and she has been advised by her GP to take a break from it. Nothing is absolute. Don’t be fobbed off. Don’t be put off. Keep going back and try and get the support you need. There is help out there and we can feel better. It’s all down to working out what is right for you at this given time. What works for your best friend may not work for you. Some women may need higher doses and some women require lower doses. Some women won’t get one with a type rather than the other. It is very individual. There is more science coming out.

Carbohydrate availability

We have spoken about this a lot but this doesn’t just mean eating lots of carbs before a big race. It means topping up the carbs you need for your body throughout the day everyday. If you are training most days, your carbohydrate requirement will be relatively high all the time. An example is aiming for carbs at every meal and every snack. Let’s look at a training week and say you have full glycogen stores on Monday and you go for an easy run and your levels drop a bit but you don’t recover very well so you drop to 80%. On Tuesday you have a hard session (something awful if your coach is Damian Hall) which will completely deplete your energy levels. You are now down to 0%. You go into Wednesday and only an easy run but you have only managed to get back to 20% and you are going to feel it. That’s why you might feel tired or get that injury. That niggle that is kinda there but we just ignore it. You haven’t fuelled properly. You haven’t rested properly. You push yourself and that is the switch. So it’s good to be aware that carbohydrate availability is not just what we eat before a run but it’s the bigger picture and includes what happens after sessions. 

If someone is diagnosed with REDS, they will need to think about modifying their training. This is something to think about for peri-menopausal women. Renee says she talked to her coach Damian Hall at the beginning of this year about reducing her running days and doing more strength . She was finding research that showed reducing run days but increasing strength sessions helps adapt better. By maintaining your strength, you are also maintaining your lean muscle mass and obviously your speed. So if you suspect low energy availability, reduce your running. Running can have a very negative affect on our nervous system. If someone is in low energy availability or REDS, they are often encouraged to do more strength to help reduce the overall stress on their nervous system. 

Being mindful of social media

Posts like this might pop on our social media. We might immediately recognise it as propaganda but for people who may be vulnerable or do not particularly feel good about themselves and are looking for answers to feel better, a post like this can probably give you the wrong end of the stick when it comes to nutrition. Social media after all is virtual reality. It is not factual. 

Managing stress

Stress has the biggest impact from everything from our sleep, to our recovery to our hormonal health.  Stress is not just emotional stress. Stress is physical stress of training. Not eating enough creates stress. Not recovering well is stress on your body. Home stress, work stress, are all layer upon layer of stress. The more layers of stress we have, the more likely we are to not feel well or perform well so managing stress is a big part of our lives. Sometimes going for a run is not always the right thing to do. Mindfulness, yoga and meditation might be good alternatives to help manage the stress better. You need to work out what is the right balance for you. Running does not always relieve stress. 

Managing thoughts 

This is a big one. We often get caught up in our thoughts. When we are in that phase, we can’t access what is really going on for us. For examples, if you decide that you are tired and that you don’t go for a run, you may start to think that if you don’t run, you may lose your fitness or I won’t be ready for that race, I shouldn’t really eat that if I haven’t run etc. You are losing sight of what is really going on which is nothing more than “I am really tired and I need a rest.” Understanding that thoughts are not factual, and we shouldn’t be really believing our thoughts. They are happening, they are real, they are often unpredictable but we don’t have to respond to them. 

Managing comparison

We all have a tendency to compare ourselves to others. It is easy to get caught up in that. Remember that you only ever really know what is going on for ‘you’. There is no point comparing yourself to anyone else but you because no one else is going through the same things you are. Comparison is a pointless exercise and doesn’t ever achieve anything. It only ever makes you more miserable and stops you from enjoying your life. 

Renee’s top tips:

• Limit social media exposure (it does inform us and has a direct affect on our mental health)
• Comparison is the thief of joy
• Nurture your body – show it some respect (and it will work for you)
• Your sport/body/achievements are not your identity or worth

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