On a fall day in 2011, Jessie Nordin’s* doctor asked her when she last had her period. The question seemed irrelevant; she was there because of an ankle injury. She had rolled it in volleyball practice at McGill University.
She told her doctor she last had her period six months ago, April 2011. She sat patiently on the examination bed, her ankle swollen and purple.
Her doctor explained the good news: her ankle wasn’t broken. The bad news: a lack of menstruation is common in female athletes and can affect bone density.
Nordin was suffering from amenorrhea.
Amenorrhea occurs when a previously menstruating female stops menstruating for three months or longer, a phenomenon common in female athletes. This lack of menstruation causes an imbalance in hormones necessary for bone mineralization, and can cause irreversible bone loss. Although typically associated with aesthetic sports like gymnastics or figure skating, where low body weight is encouraged, it can affect athletes from any background. Studies reported on the Sports Women Fitness website show that 1.8 to five per cent of the female population suffer from menstrual problems. In athletes, the numbers are far higher, and studies of women engaged in aesthetic sports record a range of 25–60 per cent suffering from menstrual problems.
Coaches’ concerns
According to Catherine Gaul, faculty member in the School of Exercise & Physical Health Education at UVic, the main causes of amenorrhea are intense training and a lack of adequate energy or fuel to compensate for this training.
Banners adorn the walls of UVic’s McKinnon building, home of the Vikes basketball and swim teams. The sharp scent of sweat permeates the building, extending into Gaul’s second-floor office. Within its close confines, Gaul seems like a caged animal: her trim runner’s body vibrating, knee bouncing vehemently even while seated, as if at any second she might run away.
She explains that amenorrheic patients can suffer from bone loss because they have inadequate estrogen and progesterone levels. Along with their role in reproduction, these hormones are also necessary for bone mineralization. Gaul encourages athletes to talk to their coaches, trainer or health practitioner after the first missed period. “Most coaches know something about this, but it’s hard to bring it up with the athletes,” she says. Even if a woman is only amenorrheic for a few months, the condition still causes irreversible bone loss and can lead to osteoporosis if it persists. “You can get a healthy 25-year-old woman with the bones of an 85-year-old,” Gaul says.
Brent Fougner, head coach of the UVic track team, knows how difficult it can be to communicate with athletes about these issues. In his 14-year tenure as coach of the female track team, several of his runners have suffered from amenorrhea. Each athlete must undergo a medical examination when she first joins the team, and Fougner can request a medical test at any time if there is a concern. For Fougner, a very low body fat percentage is a warning flag that there could be a problem — be it amenorrhea or an eating disorder, both common in runners. He offers skin fold fat analysis to the women to gauge their body fat percentage, but is careful to remind them, “It’s to make sure they’re not at a dangerous level — not because I think they’re too big.”
Fougner fidgets with the zipper on his navy Vikes tracksuit, zipping it up and down while delving in to what is undoubtedly not the most comfortable topic: menstruation. “It’s not easy having a young girl in your office and asking, ‘So are you regular?’ Not exactly everyday conversation,” he says. Fougner encourages his runners to talk to the medical staff or the team captain so he can get a heads-up if there is a problem.
In one extreme case, a runner was dangerously thin and had stopped menstruating. The medical staff told her she needed to start eating more and training less, but she refused because she didn’t want it to affect her performance. Because of her lack of co-operation, Fougner banned the athlete from practice until she started returning to a healthy weight. He says, “Sometimes you have to take away what they want more than anything, and what they want is to train.”
One of the main reasons that amenorrhea is so common in female athletes is that they are unwilling to eat more and reduce training, thinking it will affect their success in their sport. Although banning an athlete from training can be necessary for her to get better, some coaches are reluctant to take such measures, despite the risk faced by their athletes. Fougner explains that even though the women are dangerously thin, the ratio of body weight to muscle mass is relatively low, and this often leads to improvement in performance. This improved performance is dangerous because it reinforces the athlete’s behaviour. “As a coach, you have to think of the health of the runner first, not rankings or team points,” Fougner says. “There are some universities that I think are ethically doing the wrong thing; the girls are skeletal but still running.”
In fact, during a recruiting camp a couple years ago, there were a few runners who Fougner deemed underweight, and he told their parents they wouldn’t be allowed to run right away because they were too thin. “The parents just said, ‘Fine, we’ll just bring them somewhere else.’ I still see those girls running at competitions for different universities, and I just wonder what their coaches are thinking,” he says.
More than missed periods
Nordin had always been thin growing up, and at five foot eleven had earned herself the nickname “The Gangler” for her gangly arms and legs. During high school, she fell in love with volleyball and started lifting weights to increase her muscle mass. When she started playing for McGill’s university squad in her first year, she headed back into the weight room for long workouts. These workouts, combined with her many team practices, left Nordin with a very low fat percentage of 16 (the average for women being 21–25).
“I stopped getting my period regularly; actually, I just stopped getting my period altogether,” says Nordin. She was not concerned about her lack of menstruation because it seemed like a gift. “I knew it might not be normal, but there were other girls I knew who weren’t getting it either, and I wasn’t really itching to get my period again,” she says.
This outlook, according to Gaul, is common in young female athletes. “There’s an urban myth out there saying that it’s okay, that we don’t need to have our menstrual cycle. Girls look at it like it’s a blessing, but it’s not. It’s a sign there’s a serious problem,” she says.
In “Secondary Amenorrhea leading to osteoporosis: incidence and prevention,” published in the U.S. National Library of Medicine, Dr. Cheri McGee of the University of Maryland explains that amenorrhea causes adverse effects on skeletal strength that can devastate the woman in question. Although osteoporosis is commonly accepted as a “woman’s disease,” McGee states that “the fact that this disease can affect premenopausal women experiencing menstrual dysfunction is less commonly known.”
Amenorrhea can also be linked with infertility. According to the article “Infertility: Amenorrhea and Female Fertility” from sharedjourney.com, a fertility website, some women afflicted with amenorrhea are “anovulatory,” meaning that they are not producing viable eggs. Although this may not be a concern for a young athlete, over time their amenorrhea could cause other fertility conditions, like uterine fibroids (muscular tumors in the uterus, usually benign, that occasionally cause infertility). Having children may currently be the last thing on these focused athletes’ minds, but they may want that option in the future.
After Nordin’s doctor diagnosed her with amenorrhea, a bone density test revealed lower results than are normal for her age and gender. The T-score compares bone density to the optimal peak bone density for your sex — one being normal. Nordin’s T-score reading was minus one, which is categorized as osteopenia and leaves her at risk for developing osteoporosis. Nordin was forced to cut down her training sessions and increase caloric intake.
For many high-performance athletes, this would be a hard pill to swallow. Most athletes attribute their success to the long hours spent sweating in practice or pushing themselves in the gym, so reducing training may not seem like an option. Gaul disagrees with this view, saying, “Is having a career-ending fracture an option? Is developing osteoporosis at 18 years old an option? I don’t think it is. Sometimes it’s better to choose moderation than to risk it.”
Fougner knows the importance of recovery for his athletes, so he builds recovery days into the runners’ training program. When in training, the women are running six days a week, but two of those runs are focused primarily on recovery. They also do strength-training workouts in the gym, but are required to take a day off once a week to let their bodies rest. “If you don’t recover and refuel the body, you can never train to full potential; your improvement comes in your ability to recover,” says Fougner.
Three months after Nordin’s diagnosis, she managed to put on five pounds and, after consultation with her coach, cut down two of her weight-training sessions. Even though her period has restarted, the bone density she lost during this amenorrheic period will never be regained. Nordin no longer sees her period as a curse, and she is glad to know that her hormonal system is back on track. “Of course, I wish I had done something about it sooner, but at least I know that I am moving in the right direction,” she says.
Even though discussing your period, or lack thereof, with a coach or doctor may be the last thing you want to do, it is important that young women realize that menstruation is a natural process, and not something to be ashamed of. Amenorrhea causes irreversible bone loss and threatens fertility, and it should not be taken lightly.
Nordin believes that public awareness about amenorrhea is crucial. “If I had known the damage I was doing to my body, I would never have let it go on so long. I don’t want other girls to make the same mistake.”
*Not subject’s real name
