beating RED-S
My effort to beat RED-S (Relative Energy Deficiency in Sport) essentially started with the diagnosis of a femoral stress fracture in August 2018. My periods were missing for 3,5 years prior to that and, although it was bothering me during that time, I hadn’t really realised what the risks were, nor what it takes to recover. Initially the problem was masked by having come off the contraceptive pill which made me assume that at some point my period would return. But I was led to believe that it was safe to think that, so long as I didn’t want children ‘yet’, it was ok to deal with this issue ‘later’. Notably this was with the blessings of my GP and private gyno whom I had repeatedly raised the issue with. As I had been on the pill years prior, hence according to them ‘I should have had enough oestrogen to have strong bones’, and my options were to either get back on the pill or ‘simply, put on some weight’.
The cause for my amenorrhea was initially weight loss which was followed by exercise obsession and ultimately involvement in the sport of running. By the time I started to run more consistently I was trying to fuel my body, but the gap was always there, created by the fear of gaining weight. My BMI was borderline normal; however my body fat percentage was extremely low and I was restricting severely to maintain that.
Soon enough and as the training load went up, the fracture happened. ‘You’ve created the perfect storm’, my physiotherapist said, and it was so true. This was a result of my own making. But I was fortunate to have it happen relatively early, before worse damage could be done.
I was lucky to be directed to a very insightful sports doctor who immediately suggested a DEXA scan. I almost laughed as I found it hard to believe my bone strength was in question! I had been athletic all my life, involved in dance and various sports, including weight training. Growing up I would drink more milk than water and despite my severe restriction, I wasn’t excluding any food groups. The results, however, spoke for themselves and this is when it hit me for real. ‘Osteopenia’, the report quoted, with the doctor’s advice being to put an effort to ‘maintain’ bone mass, as, at 32, it was ‘unlikely’ I’d be able to reverse the damage.
A period of panic followed, trying to identify if strengthening my bones was even at all possible. Would I have to give up my running dreams, just as I was getting started? Still all I cared about at the time was how long it would take to get off the crutches and get running again. Surely my period would come back in the meantime, even though I kept swimming and cycling like mad, to maintain my precious fitness. Little did I know about how many times I would have to reset my expectations regarding how long that would take. But I was in for the long term, and I knew it was time to face my demons, especially mentally in relation to body image and my relationship with food. I realised all I really wanted was to be a good athlete and enjoy my sport, so I got to work.
First call was a dietician who encouraged me to gain some weight. Although I got some good advice on food choices, some supplements and mainly encouragement to increase my carbohydrate intake and take as much rest as possible, that was it at that stage. Weight restoration came quickly, and within 3 months I had dropped the crutches and was actively working on rehabilitation of my hip. But no sign of period... At about that time I attended the first #trainbrave event where I met Dr. Nicky Keay and Renee McGregor. I gained hope to restore bone density and, as my period was nowhere to be seen, I knew I had to consult these experts to understand more in detail what’s going on internally.
At the same time, I read Nicola Rinaldi’s book ‘No period, now what?’ which led me to the realisation that, despite having had my weight ‘restored’, continued high intensity exercise could have been the reason my periods were not coming back. This was probably the toughest part of the journey, as I couldn’t fathom giving it all up completely, especially at that point when I was getting ready to get running again.
Seeing Nicky and Renee was the best decision I made, as their combination of expert knowledge and understanding of the athletic mindset was exactly what I needed. It gave me the confidence that I was doing exactly what was appropriate for me, including some form of exercise, mainly weight training. This helped me shed any guilt in doing so, as I was comparing myself to the methods described in Rinaldi’s book which, albeit correct in principle, doesn’t necessarily strike the right balance for everyone, mentally. After two months and still no signs of period, we decided that it was time to cut back all the running as it was, at that time, by exclusion, the only thing remaining to do. And indeed, after another five weeks, including a two-week holiday, my period came back. Although a massive relief, I once again had to readjust my expectations as it seemed I had a long way to ‘freedom’ as I would call it, which would mean essentially being able to train without worrying about my period going missing again. For that, my body needed enough ‘assurance’ that I wouldn’t starve it again.
This process took another five months where I would gradually increase my exercise and track my cycles. By trial and error, I would take a step back whenever there were signs of delay in ovulation. Increasing food intake as the exercise increased was key and I got it wrong many times, even unintentionally. It was within these months that I finally found peace mentally, mainly relating to body image as my body got stronger and more athletic, I no longer cared about being a smaller size. I was only grateful I was able to do the things I want. This was very liberating and I never thought would happen for me.
A huge milestone was my one-year DEXA in September 2019. Notably it was hard to get arranged, as most centres would not allow a repeat DEXA scan within a year, quoting that it was too short a period to see any significant change in bone density, really the last thing a patient wants to hear. We managed to justify this by explaining that there were safety concerns for my return to training as an athlete and the results only sealed a tough year with success: An average 8% increase in bone density that brought me back into the normal range, essentially reversing osteopenia.
I was now more ready than ever, to take on sport, listen to my body and see where it could take me, functioning properly! It is incredible looking back and realising, how far I was from peak performance, when I actually believed to be at my fittest. And how encouraged I was by societal norms when in reality I was hurting myself. The journey was 100% worth it. This was the hardest thing I’ve ever done and I am forever grateful to the people that helped me along the way, the incredible work that they do and their generosity.
RED-S awareness is much more elevated now and so many athletes have been speaking up about similar experiences. Hopefully this will lead in long-term change which I’d like to contribute as much as I can, by raising awareness.
Resources:
https://www.trainingpeaks.com/blog/the-risks-of-relative-energy-deficiency-in-sports/