Missing periods are something that more and more of us are living with – despite the fact that we’re fitter and stronger than ever. Here, Strong Women editor Miranda Larbi explores the tweaks she made that resulted in a bleed after a two-year hiatus.
I’m on my period. “And what?” you might be thinking, if you’re the sort of person who’s always menstruated like clockwork. For anyone who has lost and regained their periods, propecia 1mg vs 5mg however, every bloody week counts.
This is my 16th consecutive period in a row, after going two years without a drop. That first period came back as I was cycling to work one morning; I was so relieved that, despite the slight inconvenience, it was one of the best mid-week days ever. And it’s interesting that it happened while cycling because I’m convinced that exercise was one of the reasons my periods went missing in the first place.
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Within the fitness industry, the noise around relative energy deficiency in sports (RED-S) is growing louder and louder; a few years ago, no one was writing or talking about it. Today, more and more women are admitting to going for years without menstruation, having worked out regularly and eaten healthily for years – and I was one of them.
One of the issues is that period loss still isn’t taken that seriously by GPs. In my case, I was told to “come back for IVF” when I was ready to have kids, or go back on the pill. Neither of those suggestions seemed helpful, but unfortunately, they’re commonplace, says leading sports dietician and RED-S expert Renee McGregor.
“Sadly, this is something we hear too often. It seems that our reproductive health is not of interest unless we want to have children. This is a huge oversight because having healthy hormones and periods is so important for more than just reproduction.”
She explains that regular menstrual function is necessary for our bone health, cognitive function, mood and athletic performance: “The importance of periods on our long-term health and wellbeing is something that we should be teaching girls at school.”
Since getting them back, I’ve been on a mission to ensure that they never go AWOL again – and that’s led me to meet and chat with a number of women going through the same ordeal. RED-S is so much more common than you might think and yet, no one’s talking about it.
One issue, McGregor says, is that RED-S is a relatively new term that’s most commonly known within the sports medicine world. The other big problem is that “individuals that often present with RED-S, both male and female, technically look ‘healthy’ on paper, in that they ‘eat well’ and are exercising – two parameters we measure health by.” Because of that, you’ve got to see someone who has the prior knowledge and gumption to ask additional questions and facilitate the assessment of bloods. It’s those that “are so critical to actually identifying what is going on with that individual.”
She stresses that it’s “never OK to not have a period unless there is a legitimate medical reason (pregnancy, breast-feeding as two examples).
While there’s a dearth of scientific research on the subject and many medical experts are conflicted about the best treatment and reasons for amenorrhea, here’s how I tweaked my fitness and nutrition habits to support the return of my periods.
I came off the pill
The first sign that something wasn’t ‘right’ came about when I decided to stop taking the pill. After a decade of daily Microgynon, I wanted to take a break. A few months after I’d stopped, I realised that no period had come. The pill had masked what was going on in my body (the bleeds you get on Microgynon are ‘withdrawal bleeds’ rather than proper periods) and I had no idea how long whatever was happening had been going on for.
It’s interesting that when my periods did finally return, I started to experience classic symptoms that I’d never had before – energy dips, cravings and cramps. For over 10 years, I’d had exactly the same level of energy and mood all month, which was why I was able to work out at a high intensity for so long. I felt the same every day, which while convenient, isn’t really how the female body is designed to work.
Nikki Michelsen and Leah Remfry-Peploe, founders of period brand OHNE, tell Stylist that mine is a “very common scenario”. “Many bleeders go on hormonal contraception such as the pill in their teenage years, and are offered little-to-no information about what it’s actually doing to their bodies.”
They explain that each person responds differently to contraception and as a result, it depends on the person how long it may take for things to settle once they come off the pill: “There’s no blueprint for how long it should take your body to get back to its regular cycle.”
Quitting ‘Clean’ eating and excessive exercise happened
I turned vegan when I was 27, a year or so before my periods ground to a halt. That transition towards plant-based living saw me not only ditch halloumi and chicken, but also gluten, refined sugar, saturated fats and anything processed. In a bid to be the healthiest and fittest I could be, I ate ‘clean’, ran to work (eight miles each way) twice a week, went on long runs at the weekend and regularly did five-day gym challenges before work.
That all changed after a series of life-changing things happened (I was hit by a car, had a break-up, changed job and moved house). Because things were so hectic, I couldn’t control what I ate and didn’t have the time or energy to exercise like that. Moving back home, I was forced to confront my fear of carbs, sugar and other ‘bad’ foods.
“If you noticed (your periods) returned after you adapted your nutritional intake and changed how much you were moving, it would suggest that the stress associated with low energy availability was the root cause of your periods disappearing,” McGregor suggests. “When our body is under stress, we produce more of the stress hormone cortisol. If this is chronically raised, it shuts down the hypothalamus which then down-regulates biological processes, such as reproduction.”
Rest days and lower-impact exercise became a priority
That break in routine also forced me to think about how I was moving and how much. I broke up with the gym I used to go to and stopped running to work. Instead, I cycled everywhere which allowed me to gently move in the fresh air while mulling over the day or working through any little stresses before I got to the office/home.
I also got ClassPass, which allowed me to try yoga, boxing and strength classes when I felt like it. That, in turn, meant taking days off when I wanted to, rather than pushing through because I needed to make the most of a gym membership.
Stress management was key
After a year or so, I consulted a women’s health nutritionist who advised getting a series of blood tests done that went beyond the usual testosterone check. We discovered that while my generic blood tests were ‘healthy’ and my testosterone levels were well within ‘normal’ limits, my cortisol levels were sky high and that my other sex hormones were barely registering. That, my consultant said, was proof of total burn-out.
“Missing periods can be a consequence of a number of things. Stress is a huge factor and relates directly to your menstrual cycle, so if you’re feeling overwhelmed or anxious it can delay your periods or even extend your periods,” explains OHNE.
To keep cortisol to an all-time low, I not only changed my exercise regime and quit a miserable job, but also gave up coffee for six months. I’m not sure if that made a difference or not but all I can say is that all of those factors (combined I’m sure with the cycling and subsequent brilliant nights’ sleep that came about as a result of cycle commuting) seemed to come together in bringing back a bleed.
Speaking about my problem made it easier to deal with
In an era where we talk about mental health with more ease than ever, it feels wrong to say that I was embarrased by my issues – but that’s the truth. Every time I heard friends moan about their periods or read an advert that equated womanhood with menstruation, I felt broken.
It was only after opening up about the issue on social media that things started to feel better. Other people messaged me to say that they’d gone through exactly the same thing and felt the same way. My family offered support, my friends were great.
Opening up also helped me to come to terms with something important: I did have a disordered relationship with food and exercise – something that I didn’t want (and still don’t want to) admit. But opening up about it, as with many mental health issues, helped enormously.
I questioned diagnoses that didn’t feel right
After the initial fob off, I was diagnosed with polycystic ovarian syndrome – a condition that presents in a number of symptoms including excess hair growth, weight gain, acne, low mood and infrequent or missing periods. I mention weight gain because that is really the main symptom that many doctors look at; because I actually weighed in as being slightly underweight at the time, I was told that there was nothing clinical that could be done to help me. Had I been ‘overweight’, however, the GP could have recommended steps for reversing PCOS. This kind of advice is (predictably) not the advice many women’s health specialists dish out.
None of my blood work suggested PCOS and I didn’t have the common symptoms associated with the condition – so why was I diagnosed with it? At McGregor’s own clinic, “over 50% of the women that we see have been told they have PCOS, when it is clear they have hypothalamic amenorrhoea because of low energy availability or RED-S.” The mix-up tends to happen when the woman is of “normal weight, and it is assumed that she must be fuelling appropriately. However, in all cases we have seen, these women report that their history and relationship with food and/or training is rarely asked about.”
Generally speaking, PCOS diagnosis should only really have been made if you present two of the following symptoms, as outlined by the Rotterdam criteria: clinical or biochemical evidence of androgen excess (high testosterone levels), menstrual dysfunction, or multiple follicles on ultrasound. And even that is caveated by the fact that those symptoms should only be considered in the proven absence of any other conditions that might be present. “A history of low energy availability and/or excessive exercise load, resulting in HA would be one key clinical situation,” she explains.
After receiving my diagnosis, I consulted a PCOS nutritionist who almost immediately suggested that I didn’t have the condition but was probably living with RED-S. Many of the principles are the same for both conditions: stress is a huge factor in both, as is eating well and moving gently.
I became an advocate for my own wellbeing
In my experience, GPs often don’t have the time to explore all the possibilities for issues like this. Like many other women, I was told to “wait and relax”, “go back on the pill” or “come back when you’re ready for IVF” – unsatisfactory answers for someone who should be at the peak of their fertility. However, visiting your GP should be where you start and from there, you can explore other avenues. They can order tests to rule out anything more sinister; I had an ultrasound and a range of simple blood tests which I then took to a women’s health expert who ordered more – building a really comprehensive picture of my overall health.
“If you find that your period hasn’t returned within three months, and you’re certain you’re not pregnant, we would recommend heading to a GP or specialist for further testing, as it could be a bigger issue,” says OHNE.
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Learning to say ‘no’ was crucial
The very last thing that I wanted to do was go back on the pill. Don’t get me wrong, contraceptives have been one of the biggest advancements in female liberation history but if you’ve got a period problem, masking it with hormones probably isn’t going to help in the long-run.
Again, this goes back to being an advocate for your own wellbeing and having the confidence to push against advice. Your GP definitely should be the first port of call for receiving help but you are allowed to disagree if you don’t want to try something.
“The Endocrine Society guidelines clearly state that the contraceptive pill is not the choice of treatment in those that have hypothalamic amenorrhea (HA). This is because the contraceptive pill down-regulates hypothalamic activity, something that is already occurring in women with no periods. In addition, it has been shown that the synthetic oestrogen in the contraceptive pill can be detrimental to bone health in women who have HA due to low energy availability.”
McGregor explains that the key to getting your periods to return – if RED-S is the issue – is “looking at lifestyle, ensuring that you’ve got sufficient energy going into the body – particularly carbohydrate; modifying training load and achieving a body composition that is aligned with fertility. In most women, this will need to be 21% body fat or above but will differ based on race, genetics and your body phenotype.”
How to start promoting better menstrual health
“Diet, over-exercising, stress, weight loss and gain can hugely affect your cycle,” explains OHNE. “Increased levels of cortisol get released when you experience situations of danger or high emotions and if you have prolonged stress or anxiety, this can lead to your ovaries not receiving the signals it needs from your hormonal system to release the egg. This scrambles your menstrual cycle, and can lead to the period being missed.”
With that in mind, here are three very simple ways to start calming down the system. No one is saying that these are a cure – they might make no difference whatsoever – but they are worth trying, if not just for a calmer mind:
- Track your cycle alongside your diet, stress and workout routines. This may help you to spot patterns that will help you understand your cycle. For instance, if you have a particularly stressful month and your period stops, you can pinpoint where that feeling came from and it may give you a greater understanding of why your cycle has changed.
- Scheduling out time for yourself. This could mean putting your phone in a different room and painting, reading, doing something that you love. It could mean going for a walk, calling a friend, just blocking out time to focus on you and things you love is so vital.
- Listen and respect your body. Sometimes a 45 minute HIIT class is what you need, sometimes a 30-minute breathing workshop will do the trick – other times, the best thing you could do is sit on the sofa eating chocolate. Don’t feel like you need to push yourself if your body is telling you to stop.
- Reduce stress. “Managing emotional stress is essential for balancing the sex hormones,” explains nutritionist Pauline Cox, author of Primal Living in a Modern World. “Practice positive stress management techniques such as spending time outdoors and in nature, mediation, deep breathing and laughter. Positive self-image and self-confidence are all key aspects of emotional stress management.
- Ensure you are eating a nutrient-dense, balanced diet. Cox goes on to say that when we are stressed, “our body burns through key minerals at a higher rate. Magnesium and zinc are particularly important minerals for helping to remain calm as well as helping to balance sex hormones (they’re involved in the production of progesterone). “Magnesium is also key for making GABA, a calming hormone that allows us to relax and sleep deeply.” She suggests eating a variety of magnesium-rich foods such as nuts, dark chocolate, avocados and leafy greens, and if needs be, supplementing a high-quality magnesium to help improve sleep and reduce the anxiety and depression associated with low progesterone.
As with all things medical, consult your GP first if you do find that your periods have stopped. For help with disordered eating, visit the Beat website.
For more well-being stories, healthy recipes and low-impact exercises, visit the Strong Women Training Club.
Images: Getty/Miranda Larbi
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