PMS and the Gymnast

We’ve all been there as female gymnasts.

While getting your period is the “entry into womanhood”, most young gymnasts think this monthly visitor is a total nuisance.

Premenstrual syndrome can be very distracting from performance and overall fueling, and many of the related symptoms can be quite disconcerting to the gymnast (bloating, abdominal cramps, excessive fatigue, etc).

Gymnasts and Delayed Puberty

Gymnasts notoriously have what is termed “delayed puberty” which encompasses delayed growth and maturation. When a gymnast doesn’t get their period by 15 years old, most in the medical community still think this “normal” since “they’re an athlete”. This is actually a medical condition termed “primary amenorrhea” and is part of the relative energy deficiency in sport syndrome (RED-S) which is a further expansion of the female athlete triad.

Delayed puberty and primary amenorrhea is not normal, and has consequences to long-term health and longevity in the sport.  See here for more information.

For those gymnasts who are getting regular periods (which is like the fifth vital sign),  the monthly premenstrual syndrome (PMS) can be very distracting to performance and overall fueling (which is no wonder why gymnasts think they are totally fine without getting a period).

There are some nutrition strategies that can be implemented to lessen PMS, but first we must ensure the “big rocks” are in place.

The Big Rocks of Gymnast Health and Performance

• Adequate Energy Availability
• Adequate Sleep
• Adequate Stress Management (therapy and sports psych is HUGE for the high level gymnast, don’t be afraid of adding these professionals to your team)
• Adequate Recovery (which hinges on the first three in this list)

If a gymnast is missing any of these important facets to overall health, it won’t matter what kind of fancy strategies you employ to lessen PMS, enhance recovery, etc.

Before we jump into what does or doesn’t work to lessen PMS symptoms, let’s review puberty and hormones for the female gymnast.

Gymnasts and Puberty

Menarche (first menstruation) should begin before 15 years of age. On average, females start their periods in the US is 12.8 years old with puberty-related body changes occurring between 9 to 16 years of age.

During puberty, a gymnast will gain at least 5-7 pounds a year and up to 10 pounds during the ages of 9-12 years; they’ll gain another 15-30+ pounds during adolescence from 13-17. For most gymnasts, due to “unintentional under fueling” or years of not matching their energy intake with high levels of expenditure (20+ hours training a week), they’ll continue to grow and develop in their late teens to early twenties depending how delayed growth has been and when they start menarche.

During this time the hips will widen, body fat will shift into the abdomen as the body prepares for menarches and then will redistribute this abdominal fat to the breasts and hips.

These body changes can be very disconcerting to the gymnast, especially when they are accompanied by stretch marks or cellulite (which is normal). It’s so important to help your gymnast realize these body changes are normal and necessary for them to reach their genetic potential in terms of performance.

With these body changes may come temporary setbacks to some aspects of their gymnastics, but this matured body can relearn the biomechanics of skills “misplaced” and will have a newfound power and muscular potential compared to the pre-pubertal “little girl” body.

What is the Menstrual Cycle?

A female’s period occurs during the first 5-7 days of the menstrual cycle, specifically the start of the follicular phase. The menstrual cycle is about 21-35 days with the average being about 28 days though this varies amongst individuals. The first part of the cycle marked by menstruation is termed the “follicular phase” and continues until about days 12-14 when ovulation happens or the release of an egg. This signals the start of the second half of the menstrual cycle termed the luteal phase.

PMS occurs during the 1-2 weeks before a female’s period and most symptoms dissipate at the start of menstruation.

The period portion of a woman’s monthly cycle is the shedding of the uterus lining that has built up over the month, but when a fertilized egg was not implanted (would only happen if pregnant), the lining is shed. Specifically, the drastic drop in progesterone before the first day of menses is what signals this. Females tend to bleed for 5–7 days, but this varies.

The Cause of Pre-Menstrual Syndrome

PMS symptoms include physical, psychological, and behavioral changes that can majorly influence quality of life, productivity, and performance for the athlete.

These symptoms must occur in the luteal phase and can last through menstruation, but there needs to be at least one symptom free week between menstruation and ovulation to be considered PMS and not another underlying disorder.

It was thought that these symptoms were just caused by the fluctuations in reproductive hormones (estrogen, progesterone, etc), but we now know that PMS also involves neurotransmitters (brain hormones that help control mood, etc).

One study found that 42% of females between 16–22 years old experience PMS symptoms, and these symptoms were found to be significantly higher in athletes vs non-athletes and was found to increase with the duration and intensity of exercise. It’s hard to extrapolate that “athletes experience more PMS” as a potential confounding factor here is that athletes tend to be much more body-aware than non-athletes and may detect PMS symptoms more frequently.

PMS Symptoms

Physical: abdominal bloating, extreme sense of fatigue, breast tenderness, headaches, hot flashes, and dizziness.

Affective/Behavioral: mood swings, irritability, anxiety/tension, sad or depressed mood, increased appetite/food cravings, sensitivity to rejection, or diminished interst in activities.

Interventions to Lessen PMS

Non-pharmacological options:  

• dietary changes* (less salt, caffeine, alcohol, sugar)
• exercise
• cognitive behavioral therapy
• herbal supplements* such as vitex agnus-castus. One study showed a 50% decrease in PMS symptoms in 170 women who took a small dose of this everyday compared to a placebo.

*data is limited and may not be applicable to adolescent gymnasts

Pharmacologic therapies:

• NSAIDs for pain
• Diuretic for fluid retention (would never recommend this for a gymnast)
• Oral contraceptives to reduce breast tenderness, bloating, and acne
• Anti-anxiety and anti-depressant medications for severe PMS-related symptoms*

*Would never jumps straight to medication, most likely other areas of life are out of balance and better self-care, more nutrition, more recovery, etc need to happen.

Hormonal Conditions than can make PMS worse

PCOS- Polycystic Ovarian Syndrome (PCOS) is a hormonal disorder common in woman among reproductive age. This is a “syndrome”, meaning diagnostic criteria is made up based on having 2 or more of 3 listed symptoms: irregular periods, excess androgens, and polycystic ovaries. In the female athlete, this is often confused with another condition called Hypothalamic Amenorrhea which is based on inadequate energy availability, though both can co-exist. Women with PCOS can sometimes have very heavy, painful periods and thus may be looking for ways to lessen those symptoms through their diet.

Birth Control- The answer for PMS?

Birth control works in several different ways, depending on the type. This article will focus on the oral contraceptive pill as this is most commonly used in adolescent gymnasts. Oral contraceptive pills provide an exogenous hormone amount that suppresses the ovaries natural production and provides steady levels throughout the month when taken. Traditionally, this form of birth control has 21 days of active pills and 7 days of placebo which is where the “period” occurs which is in fact something called a “withdrawal bleed”. This is not a real ovulatory period, and thus cannot be used to gauge the female athlete’s health.

• How it doesn’t “Fix” a missing period– Birth control can’t make up for a “missing” period which for the athlete is likely due to inadequate energy availability and or stress=
• How it can lessen the symptoms associated with PMS-Some physicians prescribe birth control to help lessen PMS symptoms. It’s important to note that oral contraceptive pills (OCP) are not the first-line therapy for PMS. What matters most is that the athlete’s fueling status is not ignored since she’ll no longer have her natural period to provide feedback on her health status (specially energy availability). It’s understandable if an athlete needs relief from intense PMS symptoms that are distracting from fueling and performance, but this is often overprescribed as a way for athletes to just not have to “deal” with their period. Again, nothing wrong with this choice, but it makes it harder to gauge adequate energy availability and overall health.
• How it doesn’t protect bone health– Birth control (specifically the pill) is often advertised to athlete as “protection for their bones” especially in the setting of injuries like stress fractures (which are likely due to inadequate energy availability). Research shows that the hormones (estradiol and progestin) in birth control are metabolized by the liver and do not have the same effect on the bone as ovarian produced hormone.

Nutritional Approaches to PMS

Nutritional Approach to PMS

A “food first” approach should be taken vs blindly supplementing for several reasons. First, the food matrix within which vitamins/minerals are found provides so many other nutritional benefits that are lost when nutrients are extracted. For instance, oranges contain anti-cancer compounds in the pith (the white part) that are largely lost when the orange is juiced. The good news is that not only are all of these foods potentially helpful for PMS, they aren’t harmful and should already be included in the gymnast’s diet from a health and performance standpoint.

Foods to Include: Those rich in calcium, vitamin D, magnesium, riboflavin, thiamine, and vitamin B6

Calcium—There is good research supporting adequate calcium intake lessening PMS symptoms. An adolescent needs 1300 mg Calcium per day, which is 4-5 servings of dairy or fortified plant-milk/yogurt per day. I talk a lot about this nutrient in my 1:1 coaching program and my course as most gymnasts are not hitting the mark.  A lot of the plant-based products don’t have the calcium that dairy products do, so be sure to check the label (this is one way that label reading can be very helpful). If you’re not getting enough on average through your daily meals/snacks, would be helpful to supplement especially around “that time of the month”.

Calcium-rich foods: dairy products, dark green leafy vegetables, nuts, grains, beans, canned salmon and sardines

Vitamin D– This goes hand in hand for bone health as well as inflammation/soreness and PMS symptoms. A high-level gymnast should have their vitamin D checked yearly. You don’t want to just randomly take a supplement for this vitamin as that may be inadequate or excessive depending on the body stores. Test, don’t guess.

Vitamin D-rich foods: eel, salmon, trout, tuna, mushrooms, and eggs, or fortified foods

Iron–As discussed in this article, high level gymnasts should be their iron levels check at least yearly to screen for iron insufficiency or iron deficiency anemia. Not only is iron involved in blood oxygenation, but it is involved in the synthesis of serotonin which is a “happy hormone”. From a PMS standpoint, there is one study that looked at participants iron intakes (heme from animals vs nonheme from plants/supplements) over 10 years and found that those who had a higher intake of nonheme iron had lower risk of PMS. These studies are difficult to draw conclusions from because A) 10 years is a long time and B) there are likely so many other confounding factors here aside from the kind of iron in a person’s diet. Specifically supplementing iron for PMS symptoms is unlikely to be helpful (and too much iron is not good), but getting a variety of iron-rich foods in the diet with regularity and checking labs yearly is something I’d recommend for all gymnasts.

Iron-rich foods: red meat (beef, lamb), dark poultry (turkey, chicken thighs), legumes, spinach, egg yolk, raisins, fortified cereal

Magnesium–This mineral is involved in many processes in the body like bone mineralization, muscle protein synthesis, nerve regulation, blood glucose control, blood pressure regulation, and so much more. For PMS, one study showed that daily supplementation of 200 magnesium oxide per day reduced complaints of weight gain, swelling, breast tenderness, and bloating after 2 months vs placebo. From a nutrition perspective, this is a very low dose of magnesium and most athlete are already found to be magnesium depleted, so likely a safe option that may or may not help with actual PMS symptoms (bloating, etc) that the gymnast worries the most about.  

Magnesium-rich foods: dark leafy greens, nuts, seeds, fish, beans and legumes, whole grains, avocados, and low-fat dairy

B Vitamins– The B vitamins are known as the “energy vitamins” and play a huge role in day-to-day life. They are involved in energy metabolism, maintaining healthy hair/skin/nails, nervous system function, and much more. Two specific B vitamins (thiamin and riboflavin) have been studies related to PMS and there is a possible reduction in development of symptoms with higher dietary intakes. Again, these are weak studies that are difficult to make conclusions from but adding food sources rich in the B vitamins to the diet will do no harm.

Vitamin B6 is involved in the synthesis of two neurotransmitters, serotonin and dopamine, which both affect mood. Some theories support that low vitamin B6 may cause high levels of prolactin which can increase edema (water retention) and some of the mood symptoms associated with PMS. There is more research on this vitamin for PMS compared to the others, but again it’s hard to draw conclusions.  

There is limited evidence that higher intakes of dietary B6 (from food, not supplements) is associated with lower levels of PMS in women.

riboflavin-rich foods: fortified cereals, almonds, organ meats, whole grains, wheat germ, mushrooms, soybeans, dairy products, eggs, and dark green vegetable

Thiamine-rich foods: fortified cereals, legumes, nuts, and red meat

Vitamin B6-rich foods: meat, poultry, fatty fish, whole grains, fortified cereals, soybeans, avocados, baked potato with skin, bananas, and peanuts

Foods to Possibly Lessen for PMS

If you “google” how to lessen PMS, you’ll often come across lists of foods to increase and reduce. You’ll read things like “reduce sodium, sugar, caffeine, and alcohol”, but we should be careful giving this kind of blanket advice to gymnasts who are likely already micromanaging their nutrition.

These lists of “good and bad” foods are often quite unhelpful as they are very overgeneralized and overlook the additional factors that may be at play.

For the gymnast, drastically reducing sodium intake before the menstrual cycle may compromise their training and hydration status, especially if they weren’t consuming excess amounts to begin with (like if every single meal was fast food or highly processed with a lot of sodium added for taste and preservation).

Reducing sugar is often suggested as it’s thought that sugar is inflammatory, but this is often taken out of context. It’d be one thing if a gymnast was drinking gallons of soda each day and had really horrible PMS symptoms, but it’s a whole other issue if that’s not the case. All carbohydrates break down into sugar (glucose) which is the gymnast’s fuel. If a gymnast wants to try and reduce their sugar to help with symptoms, I’d first start with the added sugars though this may not be super relevant in the context of their overall diet.  It’s the dose that makes the poison, and most gymnasts aren’t consuming an excessive amount of sugar that could be blamed for their symptoms. It’s important to note that more often than not it’s the over-restriction of sugar that is causing your gymnast to struggle with her diet. Not the opposite.

Caffeine limitation is always a good idea for a gymnast under 17 as this is in line with the American Academy of Pediatrics stance on caffeine usage in minors. My main concern would be sleep disruption and a false sense of energy which should come from food, not caffeine. For older gymnasts with intense PMS symptoms, they may have rebound headache from caffeine withdrawal if they cut out caffeine right before their period, so a gradual progression of decreasing caffeine intake over a few weeks and replacing with a decaf source if needed would be more ideal. You also have to think about what else is going on in someone’s life that may be making PMS symptoms worse (like inadequate sleep or nutrition) that are masked by caffeine use. Those should be corrected as well.

Alcohol is similar to caffeine usage as you have to consider the other dietary and lifestyle factors associated with use. If a college age or professional gymnast is having bad PMS symptoms and they are also going out several nights a week, the alcohol and associated behaviors may be impairing sleep, providing inadequate nutrition, etc. which again also would need to be addressed as could be contributory to symptoms.

In Summary

As you can see, just adding certain foods to the gymnast’s diet may or may not lessen PMS symptoms which are multifactorial and complex.

It’s always a good idea to include more foods in the diet rich in calcium, vitamin D, B vitamins, iron, magnesium, etc. It’s also likely a good idea to keep a mindful eye on sodium, sugar, caffeine, and alcohol though this may not really apply to most high-level gymnasts who are already quite vigilant with their diets.

If your gymnast has bad PMS symptoms, I’d first ensure she’s got the “Big Rocks” in place, meaning adequate nutrition, sleep, stress management, and recovery.

I would not jump straight to birth control as this will take away the ability to know if she’s adequately fueled and also doesn’t protect the bones like advertised.

My 1:1 coaching program provides a very comprehensive approach to optimizing your athlete’s nutrition and health for performance and longevity in the sport. You can apply here if you want to schedule a free 20 min Discovery Call to talk about your athlete and see how we can work together.  If you’re not needing individual help but more so want to attain more education, my course The Balanced Gymnast Method is the perfect thing for you and your athlete. Click here to get on the waitlist and be notified when enrollment is open again.