Amenorrhoea: the next steps

Much has been written about RED-S (relative energy deficiency in sport) and the Female Athlete Triad - the causes and consequences in particular – but considerably less information has been provided on what to do next and where someone who is experiencing amenorrhoea can seek help.

Unfortunately, delayed menarche (primary amenorrhoea), and the absence of periods (secondary amenorrhoea) have all too often become accepted consequences of endurance training. While common, these hormonal imbalances, which have severe long-term consequences, should never be considered normal, or even an expected side-effect of training for endurance events.

RED-S and the Female Athlete Triad

The Female Athlete Triad – the co-existence of disordered eating, menstrual irregularities and sub-optimal bone health among female sportspeople – has been expanded over the years.  RED-S recognises that poor bone health isn’t the only consequence of energy imbalance; that males can be affected too; and that the energy imbalance resulting in menstrual disruption isn’t always due to an eating disorder, or even intentional energy restriction.

And while the shift in terminology removes the blame and has helped break down the taboo around the subject, there are some potential pitfalls. While not all energy deficit is the result of an eating disorder, the softer terminology associated with RED-S means that eating disorders are sometimes overlooked.

Eating disorders are a group of complex and serious mental illness, with potentially fatal consequences, which will not be cured by simply increasing energy intake. They must be treated with specialist support, including psychotherapy.

Amenorrhoea: a major warning

Another potential downfall of the softer language of RED-S is that we lose how big a red flag the absence of menstrual bleeding is.

Yes, in some cases, hormone levels can be reduced, and bone health compromised, long before menstrual function disappears. But amenorrhoea is the best single warning sign we have that something is not quite right, and should always be followed up.

As with eating disorders, the GP is the best first port-of-call, but, as with eating disorders, a GP may well explain amenorrhoea away as a normal response to endurance training.

Common? Yes. Normal? No. Serious? Absolutely!

Get your bone mineral density checked

Osteopenia - reduced bone mineral density - is the most common, significant, and long-lasting side-effect of reduced energy intake and low hormone levels. Low body mass, low body fat, and a limited variety of impact forces can add to osteopenia risk in distance runners.

Distance runners, particularly females, should have their BMD checked every few years. The short, pain-less DEXA scan can give you a good indication of your current bone mineral health, and relevant populations can often have these scans done free as part of research studies.

Treatment

Amenorrhoea can be caused by things other than energy deficiency, including genetics, and the first step a GP should take is to rule out underlying medical causes, such as Polycystic Ovary Syndrome (PCOS) and hypothalamus or pituitary gland issues.

Athletes experiencing RED-S, or the components of the Female Athlete Triad, are likely to be treated in a variety of ways. In the past individuals would have routinely been prescribed oral hormonal contraceptives and sent away, hoping for the best, and while this may often still be the case, it is not current best practice.

The best treatment is a return of regular menses. This may involve increasing energy intake, gaining weight and/or reducing exercise volume. For already obsessed athletes, missing training and increasing weight may be daunting, and this is where coach, family and peer group support is crucial, and long-term development must be emphasised.

Other dietary interventions, including increased calcium and vitamin D intake (or supplementation), are likely to also be recommended. As is some form of hormonal replacement therapy, particularly if bone mineral density is already impaired.

The sooner the issues are resolved, the better the outcome. Athletes experiencing primary and secondary amenorrhoea should seek medical help as early as possible. If your GP is reluctant to intervene, see the help of a specialist sports doctor.

Get involved in research

Research continues to be an important component in expanding our current knowledge and treatment of amenorrhoea and osteopenia. DEXA scans, while great for picking up osteopenia, are poor at predicting osteopenia in the future. Bone marker tests may be better.

Similarly, there may be better prevention and treatment methods than those currently applied. And if we enhance our understanding of why some athletes are more susceptible to menstrual dysfunction than others, then we can become better at prevention.

It is important, therefore, that athletic individuals donate their body to science as and when the opportunity arises.

What coaches, parents and other support staff can do

Coaches shouldn’t be afraid to ask female athletes about their current menstrual status. While this shouldn’t be a public conversation, the topic should be one that is openly discussed.

Stress fractures – particularly recurrent or slow healing ones – are often an indication of underlying low bone mineral density and hormonal or dietary issues. They can be used as a conversation starter, and a prompt to encourage an athlete to discuss RED-S with their GP.

Always encourage athletes to seek professional advice and treatment when they are experiencing some or all of the elements of the female athlete triad.

Be prepared to provide support around the treatment that they are receiving and any training adjustments that are required. As previously mentioned, reducing training volume or increasing weight may be a difficult proposition for some athletes.

Always take a long-term approach to training and development, and encourage athletes to do the same. Advising against dieting, sudden weight loss, and an obsession with being thin can help, and positive body image, no matter what an individual’s current shape or size, should always be encouraged.

Prevention is always better than cure, and we all play a role. Too many athletics careers are prematurely derailed by stress-fractures and other injuries resulting from RED-S.