By Leda McDaniel
If you are a female endurance athlete and have ever felt fluctuations in energy, recovery, and performance at different times of the month or through key developmental periods (e.g., starting menstruation, peri-partum, or perimenopause) hormones may be at work! If you have ever wondered how to adjust your training and nutrition to accommodate for these important changes in your body (and mental and emotional states!), then read on!
In Episode #30 of the More Than Miles Podcast, physical therapists Dr. Kate Mihevc Edwards and Dr. Kacy Seynders interview Emory Sports Medicine physician and advocate for female athlete wellness, Dr. Courtney Gleason. Dr. Gleason has a passion for female athlete wellness and researches ways to encourage young women to stay involved in sports due to the many health benefits this can bring. She has also been instrumental in helping to start Emory’s annual Women’s Sports and Wellness Conference. Dr. Gleason has a unique interest in RED-S and along with Val Schonberg, a registered dietician, staffs Emory’s multidisciplinary clinic for female athletes that seeks to provide comprehensive care for these individuals from different disciplines.
The acronym “RED-S” stands for “Relative Energy Deficiency in Sport” and refers to the interrelated components of insufficient energy availability, hormonal changes, and reduced bone mineral density. These factors were referred to in the past as “Female Athlete Triad,” but the newer term “RED-S” has been adopted because of the necessary inclusion of male athletes who may still struggle with these issues. Understanding and treating RED-S has the potential to be complex due to the many body systems involved as well as the psychological components that may include long periods of time away from sport (i.e., bone stress injuries could take a long time to heal), pressure to compete if a scholarship athlete, and body dissatisfaction or disordered eating behaviors. Please See Figure Below for all the body systems that could contribute to someone developing RED-S as well as the potential negative health consequences of this condition.
Figure Above from Holtzman & Ackerman, 2021
In the podcast interview, Dr. Gleason discusses some of the physiology related to RED-S and how best to treat this group of interrelated conditions as well as treat and prevent bone stress injuries. Even though RED-S could affect male or female athletes, many of the athletes Dr. Gleason works with are females. As mentioned in the podcast, there are many fewer female sports medicine physicians and that is part of what makes Dr. Gleason and Emory’s Multidisciplinary Clinic so special. As Dr. Gleason says, “…I think that one of the things about being a female sports medicine physician…understanding the female athlete mindset. There might be something to that for some athletes that is important!”
As mentioned above, RED-S often emanates from low energy availability, and this can be unintentional or intentional. An athlete could be in a situation where they are unaware of the calorie or nutrient needs of their body, especially as these increase with high levels athletic activity. Or an athlete may be knowingly dieting or restricting their eating due to body image dissatisfaction or other psychological factors at play. Ultimately, addressing these issues is important to obtain appropriate fueling and building blocks for body tissues to recover from training loads. This under fueling could lead to hormone imbalance and oligomenorrhea (irregular menstrual cycles) or amenorrhea (absence of all menstruation).
Absence of menstruation should always be taken seriously. Dr. Gleason emphasizes this point saying, “Not getting your period is not normal and means something is wrong…and how do we change the culture and narrative within these female athlete sports settings?” What she is referring to here is the misconception that is perpetuated in some endurance sports cultures, that the absence of normal menstrual cycles is an indication that an athlete is training at a ‘sufficiently high intensity,” and that if an athlete does get a period it may be suggested that the athlete is not training hard enough. Dr. Gleason says, “I think that sort of idea that, ‘oh if I get my period I’m not working hard enough.” …I think first educating people that that’s not normal, that’s your body’s way of saying something’s off…and it is important to get a regular period.”
Later in the episode, they discuss how to negotiate training through menopause, which can be a difficult time for women as their hormone levels are changing and causing other body systems to change. Dr. Gleason recommends that women during this time really prioritize some sort of strength training and cardiovascular exercise. Briefly, she discusses the importance of strength training to prevent or reduce sarcopenia (reduced muscle mass) and weight bearing exercise to prevent or reduce osteopenia (reduced bone mineral density). Dr. Kate and Dr. Gleason also comment that these perimenopausal hormone changes could reduce a women’s ability to dissipate heat during training and so acclimating more slowly to training at high temperatures (i.e., taking more time to warm-up) and using cool towels or other cooling methods could be necessary.
As you may be able to tell, this podcast episode is rich with health information for female athletes! If you care about female athletics and the female athletes in your life, I guarantee you will enjoy listening to the full podcast episode here:
Also, check out the figure below and the linked resources below to find out more about RED-S and Dr. Gleason’s work with Emory’s Female Athlete Program and Multidisciplinary Clinic.
Figure Above from Holtzman & Ackerman, 2021
Resources:
Holtzman, B & Ackerman, K. Practical Approaches to Nutrition for Female Athletes; Sports Science Exchange (2021) Vol. 30, No. 215, 1-5. https://www.gssiweb.org/sports-science-exchange/article/practical-approaches-to-nutrition-for-female-athletes. Accessed 6/29/2022.
To schedule an appointment with Dr. Gleason or a consult with one of the nutritionists with Emory’s Female Athlete Program; athletes can send an email to womens.msk.admin@emoryhealthcare.org
Check Out Information on Emory’s Female Athlete Program Here:
For Information on the Women’s Sports and Wellness Conference:
Also, check out More Than Miles Episode #31 for more on Bone Stress Injuries: