If you aren’t having periods, you’ve probably been told “come back when you want children.” If you’re not thinking about having kids yet, tramadol and trazodone high amenorrhea can be easy to ignore. However, there are plenty of mental and physical health implications that you might not even know about. Writer Ally Sinyard finds out what having no periods for six years has meant about her health…
- Let’s get something straight first: you don’t need to be an elite runner to have RED-S (Relative Energy Deficiency in Sport), nor to take action when your period suddenly vanishes.
“A common myth about RED-S is that you have to be skinny to develop it,” Dr Cath Spencer-Smith, consultant physician in sport & exercise medicine, tells Stylist. “Most of my patients who have RED-S are not elite athletes; they work in the city and they decided to kickstart some programme during lockdown.” In fact, she says that you don’t have to be underweight to be calorie-deficient.
When friends learn that I haven’t had a period in over six years, they typically say, “Is that because of all the boxing?” It’s a fair guess and one which highlights just how normal we seem to think exercise-induced amenorrhea is. However, my periods actually stopped around 2014 when I was a healthy weight and running once a week or two between hangovers in a half-hearted attempt at balance.
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Why do periods stop?
I started training more intensively in 2016 after I stopped drinking, and only slowed down once the pandemic hit. If my periods had stopped then, when I was underweight and always cold, I’d have said, “Yeah, probably.”
I thought my period might return during lockdown; I’d decreased my training load, increased my caloric intake and put on some much-needed weight. And yet, still no period.
“I hear this from so many people,” Tina Muir, founder of Running For Real, tells me. Thousands of women have reached out to Muir ever since the marathon runner shared how she regained her period. “You’re probably right on the edge, 100 calories away. Pay attention to your discharge; if it’s changing, it’s a sign your body is trying and it’s coming.”
I smile and nod politely. If I’m being totally honest, after all these years and all the tests, I feel like this is just me now. My first two referrals to gynae ended with me being sent back to the GP, who told me that there was “nothing to worry about” and “to come back when I want kids.” I was told I had PCOS (Polycystic Ovary Syndrome)… then was told that the pill made it just look like I did.
On my second try for an answer around 2017, a friend sent me an article on RED-S. Formerly known as the Female Athlete Triad, it essentially means that your body isn’t getting enough calories. While the name-change came about to include other symptoms and the fact it also affects men, typical signs of RED-S in women include amenorrhea (absence of periods), disordered eating and low bone density.
Despite being underweight, I didn’t connect with what the article about RED-S was telling me, because of my long history of amenorrhea and denial. Nevertheless, I mentioned it to the doctor, who told me I “hadn’t lost enough weight for it to be caused by that.” The fact I still remember the exact words proves what a triggering statement that was.
Instead, he asked if I wanted children. I said no, so he asked why I’d come.
“Because it just seems odd that I haven’t had a period in years. Is it really bad for you?”
He sighed, shrugged, “We don’t really know much about that.”
It was only when I went for a smear test in 2019 when the nurse told me to lie to a GP and say I was trying to get pregnant, that I knew I had to keep pushing for an answer. Fortunately, I didn’t have to lie; I recently found a GP who reassured me that I was doing the right thing by persisting. And he’s not the only one…
“Come back when you want to have children? I completely disagree with that,” says Dr Spencer-Smith. “What if it isn’t RED-S? Maybe someone is sitting on a hormone problem that’s been there for a long time or they’ve gone into early menopause, or they might even have a pituitary tumour that is blocking the production of normal hormones.
“Whatever it is, it’s never OK to not have a normal, regular menstrual cycle. It’s a sign your system is sick. That’s why it’s really important to get it checked out.” And I would add, from my experience, be persistent.
What are the effects of amenorrhea on health and fitness?
I recently had a call with gynaecologist after my third round of tests. Everything looks normal, which I’m grateful for. But again, I’m told the only thing to do, unless I want to have children, is go back on the pill or have a coil fitted. They say it probably won’t bring back my period but it’ll look after my endometrium, and going on the pill will help look after my bone density (more on this in a minute).
With the prospect of having amenorrhea forever, I wanted to find out what it actually means when you don’t have periods. What are the effects on your body, your fitness, your mental health and wellbeing?
“When we talk about secondary amenorrhea,” Dr Spencer-Smith begins, “which is when you have had periods previously but they’ve now stopped, it’s a net effect result along with a load of other net effect results. It’s not that amenorrhea is the root of all evil; it’s affected in the way all the other things are affected.”
In a nutshell: the amenorrhea itself isn’t hurting you, it’s a sign that something else is.
Dr Spencer-Smith explains you need a certain amount of calories left “in the kitty” to take care of “housekeeping” in the body — and that’s about 1,400 calories.
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If you then consistently fall below those 1,400 calories a day for more than five days in a row, after you’ve added up your caloric intake and taken away your activity, you start to switch off your hypothalamic pituitary axis (HPA). “This is the housekeeping axis for happy hormones,” Dr Spencer-Smith tells me, “which also affects your bones, immunological system and, actually, having a happy mindset as well. It’s not just about periods.”
The reason your HPA switches off is because the calorie deficit makes your body believe that there is a threat, so it shuts off your cycle. This makes sense; reproduction is hardly a necessary bodily function if you’re about to fight a bear.
If your HPA switches off, your oestrogen levels drop. “When your oestrogen levels drop, that’s a big driver for your bone density to shut down,” says Dr Spencer-Smith. Osteoporosis can then come about as a collective fallout (which is why I’ve been recommended to go back on the pill). Fortunately, you can recover some of that bone loss, but not all of it. If you’re getting recurring injuries or even stress fractures while training, there’s your sign.
As well as affecting your periods and bone density, RED-S can also affect your immune system, your muscle and strength systems and your cognitive abilities. What surprised me most was hearing Dr Spencer-Smith link RED-S to PCOS and depression – two previous diagnoses I’ve had.
“Sometimes people have a scan and they’re told they have PCOS, when in fact, it’s RED-S. If you have RED-S, your ovaries will have the appearance of being polycystic.
“Also, one of the first signs that you’ve over-trained, which is a sign that you’re slipping into RED-S, is that you don’t sleep well and you can have feelings of depression. Often people are diagnosed with depression when, in fact, they’ve got RED-S.”
Amongst many other health implications, one study also suggests that irregular or absent periods can affect sports performance, and “have significant emotional impact, creating anxiety and an altered perception of self-normalcy.”
Impact on performance was what made running coach Elkie Mace sit up and pay attention. After all, there are proven benefits to training to your cycle, and the above study also indicates “reduced responsiveness to training and subsequent performance” as another consequence of RED-S.
“An athlete with periods who does a heavy weights session in the middle of her cycle will generally get more from that workout than an athlete who doesn’t have a period,” Mace tells me.
“For me, the forced rest from breaking my hip brought my periods back in three months. Now I have my cycle back, I want to keep it and I want to regain my fitness, but not to the detriment of my bone health. It’s a fine balance, but worth finding for both the long term health effects and benefits to your training.”
How to get your period back
So, what happens next? If the doctors have ruled out everything else and you think it might be RED-S, how do you get your cycle back? How could I?
“Taking the pill is not the answer for RED-S,” says Dr Spencer-Smith. “We do give people the pill sometimes but we haven’t really shown that it supports the system, because there’s too much else going on that’s not right. Restoring normal hormonal calorie balance is the only answer to RED-S.” In short, increase your calories and rest.
Muir tells me that one day she just “snapped” and stopped all exercise, channelling her competitive nature into being “the best period get-backer ever.”
“I stopped running and ate everything I could to put weight on. I just laid on the coach. It was probably not the best for my health, but after 14 years of constant exercise, I think my body relished it.”
Ten weeks later, she was pregnant. Muir tells me the quality of her life improved the moment she got her periods back, as she no longer suffered from the symptoms that came with it: insomnia, anxiety, being cold, bad body image issues and stomach upsets, to name just a few.
“I wrote a lot of the symptoms off,” she admits. “I would tell people the insomnia was because ‘I was just one of those people who needed less sleep,’ and the cold was ‘because my grandma had Reynaud’s.’ It was only once I got my cycle healthy, I realised those things weren’t there anymore.”
“From my experience, it had to be quite drastic for my cycle reset,” says Mace. “Previously I’d tried not doing as many intense sessions and being careful with my nutrition. It seems to me you need to have a total break, which is very difficult if you enjoy your exercise and that’s part of your mental health and wellbeing on a wider level.”
“You don’t have to stop what you’re doing to get your period back,” Muir adds, “but if you aren’t prepared to stop or severely back off, you’d better be drastically increasing your calories way above what you’re expending, to give your body that extra reassurance that it is safe.”
Both Muir and Mace concede that, when fitness is such a huge part of your identity, this is easier said than done – and the biggest battle with RED-S is a mental one.
“Most of what you have to go through is not the physical side of things,” Muir says, “but the mental and emotional side of figuring out who you are and detaching that huge part of your identity – your sport or exercise – from who you are. It’s really hard, when everyone knows you as this person.
“It’s not about eating more, but removing that critical lens we tend to look at ourselves through. A lot of people who lose their periods are highly strung perfectionists who want things to be done right, who will really commit to things. We tend to have a critical view of our bodies and, rather than seeing them as this amazing thing that is resilient and strong, we see it as never good enough, never being what we want it to be, never looking how we want it to look.”
It made me wonder just how many other women out there are ignoring their missing periods. “With more people getting into running during lockdown,” Mace ponders, “maybe there are more people out there with this problem than there were 18 months ago. Some women might find their periods are shorter or their periods between them are longer. If you think you’re on the edge of it, I’d say use an app like Fitr to help you to monitor it.”
If, like me, you doubt it’s RED-S even though it probably is, here’s a question: How do you feel about eating significantly more calories a day to get your cycle back? If the thought scares you, that probably means you need to take a long, hard look at your relationship with your body, exercise and food.
RED-S is challenging to diagnose, which makes me wonder if that’s why doctors have never mentioned it to me. When I raised it on my call with the doctor yesterday, they conceded it was a possibility but still pressed the decision to go on the pill or coil.
Given that I have little other option, I’ll go back on the pill as a last resort – but first I’ll take advice from Dr Spencer-Smith, Muir and Mace. I’ll seek out professional help for upping my calories and cutting my exercise load, which will mean confronting every niggling fear and thought and idea I’ve cultivated over the years about weight gain.
After all, my body image issues could very well be what got me here in the first place. It doesn’t matter that I don’t want children; this is about reclaiming my body and my health. What could be more important than that?
If you or someone you know is living with disordered eating, check out the eating disorder charity Beat website where you’ll find plenty of help and confidential advice.
For more first person experiences, recovery ideas and nourishing recipes, hop over to the Strong Women Training Club.
Images: Ally Sinyard/Getty
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