Why women's sport cannot ignore the 'alarm bell' of missing periods

Bobby Clay remembers the tear that slid down her mother’s face in the surgery, trying to process the doctor’s earth-shattering words. She was 20.

“He turned to my mum and said ‘Your daughter will never have children’. She didn’t say a word. That’s when I decided to change,” Clay tells Telegraph Sport.

A successful middle-distance runner who had won countless vests for Great Britain, Clay was tipped to be athletics’ next big star.

She was fourth in the 1500m at the 2013 World Youth Championships, crowned European junior champion two years later and made the Great Britain under-20s team when she was just 15. Three years later, she was diagnosed with osteoporosis, a result of years of overtraining and undereating.

That merciless combination meant her body had been deprived of oestrogen, the female sex hormone which is crucial for bone density.  

Clay first realised something was wrong after fracturing her foot in a swimming pool doing a tumble turn. On another occasion, her shin snapped when she sat down in the gym. Both were clues that she was suffering from Relative Energy Deficiency in Sport (RED-s) Syndrome – formerly known as ‘the female athlete triad’ – which can cause devastating effects due to low energy availability.

In 2019, American middle-distance runner Mary Cain became the first high-profile female athlete to speak out about her experience with RED-s.

The condition isn’t found exclusively in women – Britain’s Olympic gold cyclist Chris Boardman retired in his early 30s due to weak bones and low testosterone.

In women, the condition manifests itself in an early warning sign – the absence of periods – which Clay maintains are still glorified in athletics. “I would have been mortified if I had had a period during my teenage years,” she said. “I would have instantly thought ‘I’m out of shape, I’m not race fit.’ I thought it meant that my body fat would be over a certain percentage. That mentality was the norm.”

Clay was put on hormone replacement therapy – usually used for older women to relieve the symptoms of the menopause – to kick-start her body, wake up its reproductive system and artificially induce her first period.

“I started taking it and within a week, I blew up,” recalls Clay. “My whole face was so much chubbier. It happened so quickly that I didn’t recognise myself. That’s when I really started to struggle with body image.”  

Clay had never struggled with her physique as an athlete, despite being known as the “chunky one” among her peers and “surrounded” by eating disorders in the sport.

She vehemently insists she never had a dysfunctional relationship with food as an athlete, so when she learned that her osteoporosis was linked with RED-s – commonly seen in athletes who are obsessively restrictive about their food intake – it was a shock.

RED-s is not exclusive to elite endurance athletes, although they are generally at a higher risk due to their increased energy expenditure. A study published last year in the British Medical Journal found that of 112 elite female Australian athletes from eight sports, 80 per cent demonstrated at least one symptom of RED-s.

“You can go through every bodily system and find a reason why under-fuelling is a bad idea for performance,” explains Dr Anita Biswas,senior sports physician at the English Institute of Sport   and co-lead of SmartHER, an EIS initiative promoting awareness of female athlete health.

“There is good evidence that your decision-making could be affected, that your adaptation to strength training can be reduced and it can impact your mood and concentration.”

Dr Biswas commonly sees RED-s in athletes transitioning from junior to senior programmes who, like Clay, simply underestimate the amount of energy they need.

However, the normalisation around missing periods is also a major contributing factor.

“It’s common for elite athletes to have irregular cycles, even if they’re fuelling adequately and their body composition is good,” adds Dr Biswas. “But missed periods or no periods shouldn’t be considered normal. It’s a really concerning myth.”

The oral contraceptive pill – which studies have shown is the most frequent type of hormonal contraception used by sportswomen – can also mask hormonal problems associated with RED-s. This is because the pill artificially induces a monthly bleed – not a period – at an athlete’s convenience.

“An athlete might think that because they’re having a withdrawal bleed, everything is fine,” adds Dr Biswas. “But when you’ve got a female athlete on the pill, you’re effectively putting them into the category where men are, where it’s much harder to realise that there’s a problem.”

• For women to truly belong in sport, they should not have to change who they are

After being pressured into changing her body composition by a coach, Cain lost so much weight while training at the now-disgraced Nike Oregon Project that she lost her periods for three years and broke five bones due to osteoporosis. Clay went public with her own battle with the condition after penning a harrowing testimony in Athletics Weekly in 2017, after which she received hundreds of messages from former athletes who had suffered in the same way.

“It makes me upset thinking about the number of people who had this happen to them. They’ve had to work out what their life is without running. They didn’t just drop the sport – that’s such a blase way to look at someone who’s gone through hell and back.”

As part of her recovery, she came across Train Brave, a campaign founded by Renee McGregor, one of the country’s leading sports dietitians who specialises in eating disorders. The project aims to raise awareness about RED-s and to change the fitness culture of overtraining and under-fuelling.

“I get so many emails from runners who think they need to lose another 5kg to reach their sub-three hour marathon PB,” says McGregor, who has noticed an increase in the number of recreational exercisers in her clinic who have developed dysfunctional relationships with food during the pandemic.

“The number on the scale is never going to determine how fast you run. It’s such an ingrained stigma in endurance sports and definitely one of the biggest fallacies out there.”

Now 23, Clay is already living with the long-term consequences of osteoporosis, which she has been told is irreversible.

With running now being too high impact for her body, she took up track cycling at Loughborough University, but ended up fracturing her femur on the bike last spring. “I don’t get these warning signs. Things just go with me.”

She is now producing natural periods – her first one came last year – after wondering what would happen if she came off HRT without telling her doctor.  

She recalls one of her early ones when her body “went to town” during a training session in the velodrome, emerging from the changing rooms with tampons “proudly stuffed down her skinsuit like bullet cartridges”.

Clay does not know if she is ovulating despite having natural cycles now. But she is on a mission to raise more awareness about the invisible condition and be a voice for those whose sporting dreams have also been crushed.

“I want people to know that you don’t have to be in the grips of an eating disorder to struggle with this problem. You can have a really great relationship with food, but not take note of how much energy you’re spending compared to how much you’re putting in.

“Women have a massive alarm bell with periods – men don’t have that – so they can keep travelling to a point where their body breaks. Women should utilise that alarm bell.”  

'Medal over menstrual cycles' approach damaging female athletes' health

By Fiona Tomas

One of Britain’s leading Olympic sports scientists has warned a “medals over menstrual cycles” approach in elite sport is damaging female athletes’ reproductive health.

Dr Emma Ross, who has spent more than a decade working in high performance sport, believes sportswomen are not being educated about long-term implications of Relative Energy Deficiency in Sport (RED-s).

The syndrome occurs in athletes who underfuel according to their training demands, leaving them with low energy availability.   In women, this can lead to menstrual dysfunction, such as missed periods, which can disrupt the production of oestrogen, which is essential for maintaining bone density.

Norway is the only country in the world which has set specific limits that prevent athletes with RED-s from competing. An athlete’s BMI, fat percentage and bone density is not allowed to fall below a certain level, while a woman must not miss her period for more than six months.

“RED-s is reversible if caught and treated, but we’re not sure how it impacts long-term fertility,” Dr Ross said. “There is some evidence that when a woman misses periods for a long time, there is some damage to her reproductive health. Even when their periods come back after months – sometimes years – because they’ve adjusted their training and nutrition, they might not be ovulating.”  

Dr Ross said Britain’s Olympic and Paralympic system must be “really mindful” of having a duty of care towards female athletes experiencing RED-s in a similar way to rugby’s management of head injuries.

A UK Sport spokesperson said: “UK Sport, in partnership with the English Institute of Sport, is committed to ensuring that all funded athletes have access to the very best sports science and medical support. Integrity, welfare and effective performance culture are at the heart of our high-performance community and how we win is more important than what we win on the global stage. 

“We want our community to be known internationally for its people-first approach and for upholding the highest standards of welfare and integrity.”  

English Institute of Sport, meanwhile, say they have taken a 'world-leading approach in this area establishing an Athlete Health directorate in 2017 to proactively address physical and mental priorities'.

They added: “This includes a dedicated female athlete health team, workstream and associated SmartHER campaign that encompasses several areas of work, one of which is aimed at normalising conversation around the menstrual cycle. “However, as with so many areas of health, there is always more that can be done, and we continue to seek ways to further support UK high performance system athletes.”