We only get one chance to set our adult skeleton. Peak bone mass—that is our “bone bank account”—is achieved in our youth. There aren’t any do-overs. This is why physical activity is so important, especially for kids.
About 50% of the global population will experience amenorrhea (the loss of a menstrual period) as they transition into middle age, but sometimes it happens earlier, for other reasons. Most commonly, Functional Hypothalamic Amenorrhea occurs when one’s level of physical training is not supported by the right food intake.* The body, in its state of low energy, suppresses menstruation—an ancient survival technique we have stored in our genes.
A while back, I skimmed a Substack article that went whizzing by, about how a stress fracture the writer was experiencing as an adult, related to time in their youth as an under-fueled athlete with amenorrhea. The article stuck with me because the tone of the piece was kind of pissed. Not at the injury as much as pissed at the coaches or doctors that didn’t inform them back in the day, that their lack of menstruation could create future health issues.
I was surprised at the irritation, mostly because I assumed this was common knowledge. Studying kinesiology, doing my graduate work on pelvic floor disorders and having worked in the undergraduate and graduate human performance labs while at university, we were all trained in and regularly discussed what was then called the Female Athlete Triad:
1. energy intake is too low for the level of physical training,
2. this results in a hormonal suppression that disrupts menstruation, and
3. ensuing bone loss follows, due to the lack of certain hormones (i.e. increased risk of future osteoporosis and fracture).
And, it’s not only that under-fueled athletes can have poorer bone than appropriately-fueled athletes; despite the high level of physical activity, their bones can be weaker than those of well-fueled non-athletes.
So, as always in support of more folks understanding how their body works, I dedicated an entire Move Your DNA podcast episode to this phenomenon, updated to Relative Energy Deficiency in Sport (RED-S) in the early 2000s—a more holistic model encompassing many aspects of health and wellbeing.
RED-S is more complete because it turns out that future bone issues like osteoporosis or fractures aren’t the only things affected by not fueling well-enough for sport. Those with RED-S can have also have cardiovascular, digestive, immunity, and psychological issues, as well as other injuries and decrease in overall performance right now.
Take note, athletes, coaches, parents and alloparents; the right now is important when dealing with young adults. The state of future bones—the state of future anything—is not always part of a teen or twenty-something’s decision tree. This reframe of RED-S, as something with immediate consequences that an athlete might find meaningful, is key.
Also, the solution is fairly simple (with a terrible acronym): FUEL—Food and
nUtrition for Endurance athletes-Learning program. In short, learning more about how to fuel athleticism, including which foods to eat more of, how to better distribute food around training and then following that protocol, can help to reverse this issue.
I know that I take a particularly nuanced look at movement, physical activity, and exercise. For some, that’s probably annoying. Why over-complicate something so simple? Just do it already! But for others, who may be already be “doing it”, but experiencing confusing symptoms, this nuance is what helps them solve the mystery of what’s going on in their body. For me, nuanced takes are my way and I’m comfortable with myself :)
*Chronic stress is also a thing to consider here. Listen to the full episode for more information.
My podcast co-host, biologist Dr. Jeannette Loram, and I explore the science of the absence of menstruation, with a focus on Functional Hypothalamic Amenorrhea linked to energy deficiency in athletes, in the the latest episode of Move Your DNA. The conversation expands into evolutionary perspectives, comparing Western menstrual experiences—from menarche to menopause—with those of hunter-gatherer populations like the Hadza, and questioning what “normal” really means. Ultimately, this episode reframes intense athletics as a nuanced practice that must be supported by adequate nutrition and recovery. Have a listen to the full episode below or wherever you get your podcasts.
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