My Full Inside Tracker Interview on Amenorrhea

Recently, Inside Tracker published an article on hypothalamic amenorrhea in female athletes, bringing more awareness to this subject, its prevalence and how to take action to heal. In the article they profiled Tina Muir and myself, sharing our stories from what led to our missing periods to how we recovered. Like any good journalist, writer Julia Reedy did a great job hacking away at my wordy responses and keeping the final article concise, to the point and very effective. But I do realize that many ladies out there often want to hear the full story. So in this blog I share the full interview transcript. Obviously I've shared my full story over and over, but why not share this too. Plus it includes links to relevant studies on the matter... Who knows, maybe someone new will stumble on this blog post and find it helpful. xo

PS - If you need/want more thorough blood testing, you can (and should!) get an Inside Tracker package here.

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JR: Hi Tawnee – Thanks so much for taking the time to share your piece on this subject. We hope this blog post will give readers the answers to some incredibly important questions.

Do you remember how you felt when you first stopped getting your period? Did you feel different physically/mentally/emotionally? (This question is meant for the person who is wondering if they’re truly suffering from amenorrhea)

TPG: My story is a bit more complicated because my amenorrhea started due to an eating disorder (anorexia) while I was a freshman in college, which was a few years before I started racing triathlons. I was still exercising a lot during my ED but for calorie-burning purposes, not training. So that said, during my ED, yes, I was noticeably stressed, emotional, and my brain always felt like it was in chaos mode due to being starved for fuel--especially considering that I greatly feared fat at the time. I went from being a carefree, healthy, athletic, and intelligent teenager to a disengaged, forlorn, secretive and incredibly frail shadow of my former self. I played it cool on the outside to friends--I still partied, got excellent grades and was out and about daily--but I was not in a good place mentally, emotionally or physically, and I was very chronically stressed over my issues with food and weight. Truthfully, losing my period was an afterthought next to all the other problems I was facing at the time.

That said, when I got into triathlon I was in a much better place, but I was still not getting a period, and that started to weigh on me more heavily. I didn’t like that my body wasn’t operating as a woman’s body should. My relationship with food and my body had improved immensely -- triathlon taught me that food is fuel, and athletes need fuel -- but I still hadn’t learned how to truly listen to me needs and I was simply still not taking in enough calories for the demands of half-ironman training. I was still very lean and always hungry, clearly in need of more. I was eating probably 1,800 to 2,500 calories a day and I figured that should be enough, it was certainly more than I ate years prior! A couple years into racing, I started doing longer distances, in particular half-Ironmans, and I remember feeling like I was fit but borderline frail and always on the verge of injury, especially injuries related to weak hips and core. My engine was great but my frame was not sturdy, and my nutrient intake was sub-par. Years later, I connected the dots that my fueling and too lean frame held me back from getting closer to my potential.

Endurance athletes think that being lean is synonymous with better performance, but there is a fine line where being too lean (and underfueling to maintain this) is not going to be conducive for performance or health. You may still be performing well when you’re super lean and experiencing amenorrhea, and you may have no problem executing your workouts or races, but if you peel some layers you will see red flags that things aren’t all right and eventually the body will suffer from this imbalance. For me some other red flags were feeling like I was chronically “high” on cortisol that manifested in a revved up sympathetic state 24/7 -- even negatively affecting my sleep -- and an inability to relax into a parasympathetic state. Second, even though I was eating more as a triathlete it wasn’t enough and I was always hungry because I was constantly in an energy deficit (at the time I was still relatively low fat, which just made the “hanger” worse). Third, I still had a mental obsession with my incessant need to train; I wouldn’t let anything get in my way of training and I despised rest days and also purposely ate less on rest days (in other words, I let my workout load determine how much I could eat). Fourth, I was getting injured a lot and didn’t have the nutrient support to recover properly. Lastly, I was an aspiring coach and sports podcast host, so I felt embarrassed and ashamed that my body was not operating as it should and felt inner turmoil over my lack of menstruation. I only talked to my doctors who suggested that I quit exercising so much and eat more, and at the time that was not something I wanted to do, mostly it was the “exercise less” part that freaked me out since I was so in love (and obsessed) with sport and my training. I let my need to train trump everything else, and this is something I now see all the time in female athletes who are going through the same struggles. Thankfully, there are often other options!

As for the re-occurring injuries I faced, one study showed that “a lower daily fat intake and lower percentage of total energy from fat were associated with increased injury risk among competitive female runners.” (http://jissn.biomedcentral.com/articles/10.1186/1550-2783-5-1) And thankfully I never experienced a stress fracture, but I know plenty of athletes who have and this injury is associated with low energy balance and amenorrhea. (http://www.ncbi.nlm.nih.gov/pubmed/16089273?dopt=Abstract)

JR: What health implications worried you most during your struggle with amenorrhea?

TPG: Most of all I was worried about infertility and whether I’d be able to have children in the future. This became more of a concern when I began dating my now-husband and said to myself, “This is a guy with whom I could have kids.” Before him, I had thought about having kids but not seriously. While infertility is certainly an issue that comes with amenorrhea, it’s one from which we can recover. At the time, no one was there to tell me that there is nearly a 100% chance you can recover from hypothalamic amenorrhea and that starting a family would be completely possible given that I take the right steps to recover my hormones. So I was spooked for a long time about our future, and alternatives like adoption even crossed my mind, that is, until I sought help from alternative health doctors, did more research and was able to get better answers from the proper professionals.

Second to that were concerns over my bone health, and this became a more prominent thought after I had a bike crash in 2013 in which I broke my wrist; a distal radius fracture. I was able to get in for DEXA scans, which showed my bone density in the spine and hips was normal, a huge relief and the broken wrist was just one of those freak things. I stacked up my good bone health to all the strength training and load-bearing exercise I had been doing for years. I really think the strength training saved my body and bones from getting too fragile during these formative years. Sadly, I do know athletes, even male athletes, who have suffered from osteoporosis in their 20s and 30s due to hormonal imbalances in the body related to being too lean and overtraining. I got lucky, but bone health is a very real concern and not easy to recover from, if it all.

Other long-term health complications honestly didn’t even cross my mind at the time (I didn’t even know there were additional risks), but after studying the research and learning more I discovered that there are important potential long-term health complications to be aware of that I now point out to women with amenorrhea. They include a higher predisposition to heart disease and cognitive diseases in later years of life.

JR: You mention that your PCP, like many doctors, recommended that you go on birth control, exercise less and eat more in order to regain your period. Now that you have so much knowledge on the subject, especially in the context of endurance athletes, what do you think would have been better advice?

TPG: Amenorrhea recovery is absolutely all about the psychology of what a woman is going through, and to tell a female athlete to exercise less and eat more is, in most cases, terrifying to hear and not something they’d be willing to do when it’s blatantly put like that--unless they're at their wit’s end. Amenorrhea is more complicated, mentally speaking, and it’s not so black and white. We have to be able to understand the female athlete’s unique psyche and work with her needs and use compassion and patience. As for taking birth control, most girls will realize this is only a band-aid and not a solution, and that’s why I personally chose to stay off the pill after a while and keep it natural.

It’s not that the advice of “eat more exercise less” is wrong, it’s the delivery in most cases. Female athletes may feel like their doctor does not understand that they are an ATHLETE and that their training and competitions are everything to them, as is adhering to a  healthy or “strict” diet. So in my experience, I’m not a doctor, but I’ve had immense success helping female athletes getting their periods and hormones back by simply relating to them, talking through their fears, answers questions that are unique to athletes, and providing emotional support during the process. The rest as far as actual recovery goes is pretty simple--find the appropriate energy balance and weight that allows you to menstruate, and this requires managing stress, exercise intensity/volume and food intake. Once an athlete is ready to tweak these things it’s not hard to get back on track. Only a couple times have I had more complicated cases that involved further health issues that required medical attention.

The success I’ve had started with coaching myself through the recovery process. I got my period back within 10-12 weeks of making the decision to heal. However, I also took a more gradual approach and didn’t quit training and racing to retire to the couch; thus, it took my body a while to achieve full hormone recovery and get back to regular monthly cycles. During my “transition phase” I got periods again, but they were not normal or monthly until about a year after my initial decision to recover. Every woman I’ve worked with has been slightly different in their recovery process, but usually with more food intake alone all will have signs of ovulation, a spike in hormones and a bleed. Research shows that women can usually maintain some level of training and get their period back if they just eat more (http://www.ncbi.nlm.nih.gov/pubmed/25090245) and are ok with adding a bit more body fat to their frame. Often tweaking exercise habits (not necessarily quitting) are needed too, since I work with “extremist” endurance athletes. For women to make these voluntary changes, it’s all about mindset and they cannot fear the process or that in itself will hold them back. Likewise, I can’t force someone to take action, nor can their doctor--these women have to want to pursue recovery and teaching them that it’s not so scary adds to the success rate. We have to get them to want to love and respect their bodies and be comfortable in their own skin regardless of how fast they run or how much body fat they have.

We are working with sensitive, living, breathing human individuals, not just numbers or test results. And while doing the health tests are invaluable--all my clients are required to get bloodwork and often additional testing*--those data points are only a piece of the puzzle. Don’t get me wrong, a doctor is important and all my clients are working with a doctor or functional medicine practitioner, but what female athletes also need is a mentor, a friend, and someone to whom they can relate. Someone they can ask scary questions like, “What is it like to cut back on or stop training they way you know it?” “What if I don’t want to stop training completely, what can I expect?” “How long will it take” “You want me to eat what? But I eat ‘x, y, z’ for my training!” “Will I get fat if I eat more?” Also, I assure women that I’m not trying to steal their training away forever nor ask them to get fat and lazy, which is what it feels like you’re being told to do sometimes and that’s just wrong for this group of women. It’s about finding a better balance and exercise can be included in a recovery plan as well as a healthy diet--we just have to prevent these variables from continuing at unhealthy extremes.

*Blood tests for female should include the following markers: LH, FSH, Estradiol, progesterone, DHEA, testosterone, prolactin, TSH, T4 and free T3. I aso run a urine hormone and adrenal panel on my clients in addition to blood work, as this takes a closer look at the relationship between adrenal function, cortisol levels and sex hormones. TSH, or thyroid stimulating hormone, T4 and T3 are important to test because often we mess up our thyroid in the process of developing amenorrhea and it should not go ignored.

JR: It’s common for OBGYNs (including my own!) to claim that menstruation is not biologically necessary, and that not having your period is not detrimental to your health. From what you have learned, what’s your position on this claim?

TPG: Technically, it’s not a death sentence to not menstruate. Infertility and low bone density are some of the biggest side effects, and quite frankly there are probably women who don’t care about that if they’re more concerned with race performance. But I argue that menstruation is a normal part of the female existence, and why mess with Mother Nature by shutting down this process? Also, I mentioned the potential negative health consequences earlier; why take a risk on hurting your well being long-term? I understand that in the moment, we may not care what our life will be like when we're 70, but maybe we should. I didn’t care at the time, I only cared about performance and my body size, and I actually don’t regret that because I can at least educate women on why I was wrong and how to do it better. Now if you’re an athlete and you happen to skip a period once or twice a year while stress and training loads are high, and you know you’re not pregnant, I would not freak out over this, but I would take it as a warning sign and indication as to how much is too much for your body and proceed with caution (and try to eat more).

Also, a missing period is a symptom of more intricate problems related to the hypothalamus, pituitary and gonadal function. I work with a lot of athletes not just on hypothalamic amenorrhea but also hypothalamic-pituitary-adrenal (HPA) axis dysfunction, thyroid issues, and other health complications from extreme training and low energy intake, and these problems often do not lead to sustainable careers in sport and also make day-to-day living much tougher when you’re chronically stressed, fatigued, worn down and feeling like junk because your body is not operating optimally and is in crisis mode. So amenorrhea is a symptom of potentially worse issues going on inside, and I do not advocate that any athlete continue on this path long term. Women are actually lucky that they have a clear indicator they are pushing too hard (i.e. if period is absent); men do not have this luxury and often it’s gone too far before they realize they’re in a deep hole that they have to dig themselves out of. The longer your wait to change, the harder it may be to fully heal if there are other issues at play like HPA axis dysfunction, adrenal fatigue, varying degrees of hypothyroidism, gut dysbiosis and other complications that often are present in women with amenorrhea.

JR: Your recent pregnancy announcement (congrats!) almost feels like a flag stuck in the summit of Mt. Amenorrhea. What did your road to recovery look like and what advice do you have for women who are struggling with amenorrhea/attempting to heal?

TPG: Thank you. Becoming pregnant is not only exciting for my husband and I, it is also a victory for all women who’ve been through or are going through amenorrhea--there is hope. I was in a bad place for many years, my progesterone and estrogen were that of a postmenopausal woman, and I am proof that you can get your body back to functioning normally and start a family if you so wish. I hope my message gives hope to those who need it right now (I could have used it back then).

As for my recovery, I took a more gradual approach. When I first started making changes to regain health and hormones I had zero desire to get pregnant at the time; rather, I just knew it was time to repair my damaged body and be in a place where one day I could get pregnant when we were ready. I didn’t want to wait until we were ready to get pregnant and have to “cram” my recovery process; that sounded stressful. So, I didn’t go “all in,” and I still trained and raced for another couple seasons. However, I drastically changed my approach, mindset and the “environment” in my body. I took a bunch of pressure off myself, worked on stress management, fed myself better, raced a ton less (like 2-3 races a year instead of 10-12) and incorporated more parasympathetic mindful activity like yoga, walking, meditation, HRV measurements, and so on (those things were not easy at first since I was used to pushing hard all the time and striving for better performances each time I raced). I also stopped training so intensely and relentlessly as well, and started focusing more on recovery as well as an intuitive approach to training (before I would train no matter how I felt--it had to get done!). I started eating what my body craved in a healthy sense of cravings, rather than denying urges to eat certain foods and stick to a strict diet and caloric intake. Over the years, I had gradually switched from a low-fat diet to more of a low-carb high-fat diet, but when I began recovery I just focused on clean healthy eating and not so much on macros or calories, still including tons of healthy fats and moderate carbs. Sometimes the approach for amenorrhea recovery is to eat “all the food” (including sweets and junk) but I still wanted to keep it clean with an 80-20 approach.

Ultimately I quit doing any fasted training and really addressed my chronically high cortisol levels to get in a more balanced state--it was hard not to get at it early each morning as I was used to doing for years, but it was the best thing for me.

By this point I had “ditched” conventional medicine because I felt like I was going nowhere with them. I sought out functional health practitioners to help me and guide my health plans. They ran tests and recommended any supplements I needed (which expanded beyond hormonal issues and included gut repair, thyroid regulation, detox, HPA axis, and general health support). For hormones, I briefly used bioidentical progesterone when initially regaining my period. Then before getting pregnant, I went on vitex for a while to regulate my ovulation and cycle length. I would not suggest starting any supplements unless directed by a healthcare professional.

I continually ordered new health tests to monitor progress over the years; this included blood tests, urine hormone tests, saliva tests and gut tests (stool). It was actually very fun and exciting to see my hormones get back to normal levels for a woman of my age, and I’m glad I have that data. I would suggest quarterly or bi-annual blood tests and/or urine hormone tests for women in the recovery phase. I also tracked my menstrual cycles and ovulation and kept detailed notes on my personal recovery. I share this info with my clients.

Believe it or not, my actual weight didn’t change that much from 2013 when I started my recovery to 2016 before we started trying to conceive. I’d guess it was less than 10 pounds gained, which shows that for me it was more about balancing other issues in my life not that I was still too lean. (For the record, I had gained back 20+ pounds already by 2013 from my ED days.)

My periods were normal for about two years when we finally started trying, and I felt ready. Although, I was still at a low-normal BMI so I thought it’d help to gain a few extra pounds and I did, increasing my BMI to 22-23, which is known as the “fertile zone” according to Nicola Rinaldi, PhD. What I didn’t realize when we started trying was that I put a ton of pressure on myself to get pregnant right away since I was so “normal” again. It took a few months to relax, let go and take off all the pressure, and that’s when I got pregnant. Putting pressure on myself and creating stress within has never worked out well ;)

JR: How do you believe InsideTracker can help women ward off/recover from amenorrhea?

TPG: Absolutely, IT is a critical component to a female’s recovery. As I’ve mentioned numerous times already, having the data from blood testing is invaluable to set the baseline for where a woman is starting at and most importantly monitor progress and see if the changes she is making are working on the inside! As mentioned, I’d suggest quarterly or bi-annual blood testing during the recovery and even when the period returns, get blood work to measure hormones and set a new (healthy!) baseline. The feedback from bloodwork is invaluable.

JR: Anything else you’d like to say about the subject?

TPG: I was at a sports nutrition conference recently (and actually speaking on this very topic) and one of the presenters mentioned her study showing that elite female swimmers who were not menstruating ended and in an energy deficit had poorer performances relative to their menstruating teammates. (https://www.ncbi.nlm.nih.gov/pubmed/23846160) We know through the research that underfueling doesn’t work out well for female athletes, and I know athletes want to perform so EAT!

Also, this issue can not be narrowed down into just the female athlete triad, which is most traditionally cited in research and textbooks. The issues a female faces are on a spectrum and wide-ranging. They can vary in severity. For this reason, I like to look to and reference RED-S when discussing this topic. RED-S includes a broader range of symptoms and doesn’t narrow it down to just three issues as the triad does; it also ties in males as well.

Plus from a social standpoint, i can see why this is continuing to be such a big problem. It’s tough to be an athlete this day in age. With social media, we’re constantly inundated with images of the perfect body and perfect performances, and we feel more pressure than ever before to be perfect and achieve PRs every time we race. We compare ourselves to others and often go to unhealthy extremes to achieve the “impossible.” I’m hear to blast the message that moderation is ok; moderation is SEXY--you don’t have to be perfect, you don’t have to be the fastest, you don’t have to live by the “no pain no gain” mantra, and you can be your best self with an approach of moderation. What I want for women (and men) is to just be happy and comfortable in their own skin.

Also, it’s getting better, but amenorrhea has for so long been a taboo issue and not something that women want to discuss, so they hide it and let it prolong (I get it, I was there). I want to change that notion--it’s ok for us to talk about our periods, or lack thereof, and you can hear me doing just that on my podcast enduranceplanet.com along with female counterparts who share wisdom and experience on my show.

Lastly, if someone is ready to get started but doesn’t know where to look next: 

I have a ton of resources on this subject for women on my holistic inner-circle website lifepostcollective.com and also on my free podcast enduranceplanet.com. If there are women out there who are still a bit afraid to make changes but just want a reliable source to turn to for information, I’d encourage them to check out lifepostcollective.com; you can get your first month free with code lpc4me. 

Or you can take the next step and work one-on-one with me; I offer consultations and coaching for female athletes on all things health, hormones and nutrition, and I've helped many women recover from HA. 

Last but not least, buy the book No Period Now What. This is another invaluable resource from my friend Dr. Nicola Rinaldi and this book alone may very well change your life. I read it long after my recovery but still learned a ton, and I continually use it as a resource. 

Thank you for the opportunity to contribute!