No Period, No Problem for the Gymnast? Not Quite

What does body weight, periods, and bone health have to do with the gymnast?

Today’s society is filled with misinformation on weight gain, body change, and normal growth and development for the gymnasts. A lot of the focus is on “weighing too much, “being heavy”, etc. Maybe you’ve even heard it’s normal for a gymnast not to have her period because of intense training.

But, there’s an often ignored side to this coin. It has to deal with weighing too little and the gymnast experiencing what’s called Relative Energy Deficiency in Sport Syndrome (RED-S).

Now, to be really technical, RED-S is often more of an issue with too low of body fat versus just body weight. Read this and this post for a good primer on the differences and what’s pertinent for the gymnast.

Not every athlete that has issues with what I’m describing below is necessarily “too lean”.  In an aesthetic sport like gymnastics though, it’s often the case in relation to delayed growth and development.

Relative Energy Deficiency in Sport Syndrome (RED-S)

Relative Energy Deficiency in Sport Syndrome (RED-S) was formerly called the Female Athlete Triad. The Female Athlete Triad was characterized by 3 things: weight-loss, amenorrhea (loss of menstrual cycle for at least 3 months), and stress fracture diagnosis. Even though this is often seen in thin athletes, it was not limited to them. In fact, research by Boston Children’s found that athletes who had low energy availability often had higher BMI (body mass index, a measure of weight and height) than those with adequate energy availability.

In 2009, the International Olympic Committee changed the name of “Female Athlete Triad” to “RED-S” as this collection of symptoms (syndrome) also effects males.

The root cause of RED-S is inadequate energy availability (calories). This is linked to many different symptoms such as delayed puberty, amenorrhea, poor recovery/healing, stress fractures, and mental health issues.

A number of high-level gymnasts experience what’s considered “delayed puberty” which is often a sign of inadequate energy availability.

How do you know if this is going on with yourself or your athlete?

• No menstrual cycle by 15 ½ (primary amenorrhea) or skipping periods
• Frequent injuries, poorly healing injuries (overuse)
• Decreased training response (not performing as expected in the gym, conditioning much harder for them than normal)
• Decreased immunity (frequent colds, viruses, etc.)

Is your gymnast “too lean” for normal periods?

Often times we blame the thin athlete on having a “high metabolism”. Or we accept that “training is just intense”. However, we now know that if an athlete is adequately fueled (and they’re recovering from the workouts both physically and mentally) the reproductive system should still work. This is great news.  Meaning you don’t necessarily need to pull your athlete out of the sport if they start having symptoms of RED-S. They “just” need to eat more (which often requires working with a registered dietitian).

Sometimes this issue of being “too lean” is driven by disordered eating. Other times it’s a totally innocent mismatch in energy availability versus needs due to increasing practice volume, etc. As a parent or coach, you need to be cautious and curious in these situations.

The whole goal of sports nutrition is to “fuel the work required”. This means we have a solid meal/snack foundation to support basic energy needs, daily activity, PLUS the additional fuel to support intentional exercise. We can adjust the fuel to cover the “intentional exercise” based on training intensity/duration, injury status, etc.

When it a concern for a gymnast to not have started their period?

Some gymnasts may experience what’s considered primary amenorrhea, meaning they have not started their period by 15 ½ years of age. This is usually due to inadequate energy availability for high level athletes. But it could also be related to other medical issues like polycystic ovarian syndrome or a more serious hormonal condition that needs attention from an endocrinologist.

Your athlete’s pediatrician can get a fairly accurate estimate on where they are in terms of “development” based on Tanner staging. If your athlete is older than 15 ½ and hasn’t started their period, it’s definitely worth an evaluation with a registered dietitian sports nutritionist and a visit to the doctor. I used to work in a pediatric endocrinology clinic and worked hand-in-hand with the physicians on cases like these. I’d evaluate the patient’s nutrition which provided valuable information to the physician to help them make a proper diagnosis.

Does your gymnast need to gain weight?

Gymnasts are often resistant to eating more out of fear of “getting fat”. This is largely due to what society presents as an acceptable body. Even worse, gymnastics is an aesthetic sport with too much pressure on the “look” of a gymnast instead of on the performance. Being thin doesn’t equal optimal performance. Often an athlete trying to get their body to a level of leanness is where we see a decline in performance. That is not a “win” in my book.

But, the good news is that it doesn’t take “a million” pounds of weight gain to restore the menstrual cycle. Most athletes will see return of menses with 5-10 lbs of weight gain and TIME if they were previously menstruating. For growing child/teen gymnasts, they may need to gain more weight than that to catch up to their normal growth curve. How much weight an athlete needs to gain is highly individual. More weight could be needed in the situation of an eating disorder with malnutrition (severe weight loss). In the case of an eating disorder with weight loss, we’ll typically see menses resume once weight returns to the previous point before menses stopped. Just because menses return doesn’t mean they are experiencing monthly ovulation. It’s important to follow up with a physician and ensure consistent menses once they resume.

Weight gain for an athlete struggling with inadequate energy availability can take thousands of calories. I’ll set a “weight gain goal range” since weight is not static. A good weight gain goal is anywhere from 0.25 to 1.5 kg per week or about 0.5-1% bodyweight per week. Again this all depends on the athlete.

For instance, I worked with a high-level gymnast that was 15 years old, 5’2, 120 lbs (BMI 73%tile which is normal) and had started her period around 13 years of age. She started restricting her food intake for a variety of reasons (feeling she had to be “thinner” to perform better, lots of family stress/had just moved across the country and changed gyms, etc.) and dropped to 104 lbs. With this weight loss, she lost her period (secondary amenorrhea). After months of working together on weight restoration and normalization of eating, she got her period back when she was back to ~120 lbs.

Secondary Amenorrhea: Also A Problem + My Story

I don’t mind sharing my personal story. I hope it helps some of the parents and athletes reading this blog know they aren’t alone when it comes to period and weight issues.

As a gymnast, I got my period around 12 years old but then it took 6 months to get another period. This is normal. The first year is expected to be irregular, but after that the cycle should start to regulate to every 21 to 35 days. I lost my period again around 14 years old as training intensified (4 hours a day, 5 days a week PLUS my own conditioning at home on the weekends). I’d lose my period in the summers when training was intense, and then I’d have a cycle maybe 2-3 times in months of January to May. We were told this was normal and didn’t think much more. Looking back, this was certainly due to under fueling and what would be considered secondary amenorrhea due to inadequate energy availability. I barley ate breakfast, ate like a bird at lunch, had no pre-workout or intraworkout nutrition, and picked at dinner (which only got worse when the eating issues intensified around 16).

But then, the situation got complicated. My body weight stabilized, and I retired from gymnastics during Senior year of high school. I still didn’t get a period my entire Freshman year of college, and was diagnosed with Polycystic Ovarian Syndrome (PCOS). The diagnostic criteria for PCOS includes having two of the three following symptoms: Oligomenorrhea, Hyperandrogenism, and Polycystic ovaries.

At the time of my PCOS diagnosis, I had oligomenorrhea (infrequent periods) and mildly elevated testosterone. Yes, women have both estrogen and testosterone in their bodies. In my situation, the elevated testosterone was likely related to muscle mass as I’d been weight training and “eating clean” my entire Freshman year of college, as I tried to figure out my identity post-gymnastics.

The doctor (a reproductive endocrinologist) put me on a hormonal birth control to “regulate my periods” and help with the “weight gain”. Even though I was somewhere between 120-125 lbs at 5’5 and wore a size 2. I was still really struggling with eating disorder thoughts and behaviors which caused a lot of stress. The menstrual cycle is not only closely related to nutrition status but also psychological stress.

I had a bad reaction to the birth control and stopped taking it. From there I made it my “mission” to “heal my hormones”. I read online how to “cure PCOS”. There is no “cure” for PCOS, more so symptom management. Anyways, I embarked on a year and a half of crazy dieting (paleo, autoimmune paleo, grain-free, lectin free, dairy free, sugar-free) and ended up gaining 20-25 lbs due to a super distorted relationship with food/exercise. I did end up getting my period once I started eating normally again and started therapy for the first time since being diagnosed with an eating disorder at 16.

To get SUPER personal, I continued to have normal periods for the next few years and my weight eventually stabilized back down where it was “normal”, and my diet consisted of all food with regular balanced meals and snack. This is a huge part of why I am so passionate about #allfoodsfit, because crazy dieting did nothing but make my life miserable. More on that in another post.

At this point, I’m married and on hormonal birth control so in terms of the potential fertility issues associated with PCOS, we’ll have to wait and see. Given my form of “lean type” PCOS which seemed to be more related to disordered eating patterns and stress, I’m hoping that trying to get pregnant in the future will be with minimal difficulty since the eating/stress management issues have been resolved for years.

Is going on birth control a solution?

Fertility is a really important aspect of an athlete’s health that is often over-looked because they’re still young. But, what happens to the body during adolescence can have an impact on future fertility and other aspects of health like bone mineralization.

Often physicians will say that an athlete “losing their period” is normal; they think it’s just due to the stress of the sport. This is untrue and can be remedied with adequate food, not birth control.

If you take your athlete to the doctor and are prescribed birth control for “no period”, be aware. It’s not going to solve the actual issue. Gymnasts are often told the birth control will “regulate their periods” and “protect their bones”. Not true. Birth control does nothing to regulate the menstrual cycle, period. It doesn’t matter if we’re dealing with amenorrhea due to inadequate nutrition or another hormonal imbalance like polycystic ovarian syndrome. Birth control is simply a band-aid. It causes a “fake period” via a drop in progesterone that signals shedding of the uterus lining. This “period” is known as a withdrawl bleed.

So what do periods have to do with bone health?

A lot of gymnasts are like “yay, no period”, but there are long-lasting effects from amenorrhea. Especially when due to inadequate energy availability. The first and foremost is poor bone mineralization; the body will likely not have adequate estrogen to keep the process of bone formation and breakdown in balance. This imbalance due to lack of estrogen weakens and increases susceptibility to fracture. Hard-to-heal stress fractures in the back, hips, pelvis, and feet are often results of inadequate energy availability leading to poor bone mineralization. This can even be classified as osteopenia or worse, osteoporosis. Taking all the calcium and vitamin D in the world will not strength the bones in this situation; the body needs adequate calories, protein, carbs, and fats to heal.

More importantly, females develop the majority of their peak bone mass by age 18. The bones will have reached their maximum strength and density into their early to mid-twenties. How you treat your body during your teen years can majorly impact the rest of your life. It is the parents’ job to ensure their child/teen is meeting their nutritional needs. Parents may face some resistance in this especially if disordered eating issues are at play. If you have any questions, I’d highly recommend meeting with a registered dietitian nutritionist who can guide you and your athlete.

In Summary

In summary, normal periods and balanced hormones are an essential aspect to a gymnast’s overall health and well-being. If your gymnast has not started their period by 15-16 years old, I’d recommend a physician and dietitian nutritionist evaluation. You want to ensure they are fueling their bodies adequately to support reproductive health. If they started their period but are now missing cycles, they would also benefit from a full nutrition assessment.

They may need to potentially gain weight (bodyfat) and that’s OK. This is something we can slowly work through as to not cause excess distress. Like I said earlier, most athletes don’t gain a ton of weight when we get them fueling properly as their metabolism picks up and the nutrition is used for muscular growth and development. It’s amazing how good an athlete will feel once they’re nourishing their body properly, and thus how much better their performance will be.

Contact me to work together and ensure you or your gymnast is not missing out on this crucial aspect of gymnast health that could haunt them long after sport.

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