Veronica Ewers stated nothing, regardless of all of the indicators, regardless of the blood take a look at outcomes staring again at her, telling her the hormones in her physique have been barely current. Because the outcomes got here with an all-too-familiar indifference from her physician.
“Based on this person being an elite athlete, they don’t have their period and that’s fine,” the 31-year-old American bicycle owner says, reciting her 2022 medical report back to The Athletic with a somber half-smile. “So I didn’t flag it.”
The outcomes ought to have been Ewers’ disaster level. Instead, she continued to consider that “when a woman loses her period, she’s at peak fitness.”
That is how she operated when taking part in soccer at Willamette University, a small liberal arts school in Salem, Oregon. She shrugged off indicators then, too, resulting in wan performances, her physique toiling to maintain up with calls for. Eventually, Ewers was benched.
For practically a decade after, as Ewers grew to become entrenched within the biking neighborhood and joined the skilled peloton, she appeared wholesome sufficient to compete. She completed ninth general within the 2022 Tour de France Femmes. While some round her expressed concern over her consuming and train habits, no dialogue was had across the ongoing absence of her interval, she says.
It took a damaged collarbone in 2023, ending her season, earlier than the results lastly manifested. After being medically cleared to train once more, she fractured her heel whereas working and had her bone density ranges checked. She was tipping into osteoporosis.
This time, rationalizing the medical outcomes was unimaginable.
Ewers is aware of her story isn’t distinctive. Swapping tales of comparable experiences has grow to be a bonding train for a lot of feminine athletes the world over, she says.
Ewers earlier than the beginning of the Liège-Bastogne-Liège biking race. (Luc Classen / Getty)
According to a survey performed by The Female Athlete Health Report from Project RED-S and Kyniska Advocacy in 2023, 36 % of feminine athletes ignored missed periods, pondering it was regular or, in some circumstances, helpful for their athletic endeavors.
The survey, which centered on responses from 769 athletes within the United Kingdom assigned feminine intercourse at delivery, with questions regarding their menstrual cycle and physique picture, additionally discovered that 30 % of respondents had been instructed by a medical skilled that interval abnormalities, together with absences, have been “normal” given their exercise stage.
“Elite sport first, period later.” Kerry McGawley, a professor and senior sports activities physiologist on the efficiency optimization firm Orreco, remembers the pithy mantra recited to her by an expert Swedish cross-country skier greater than a decade in the past.
“It was shocking hearing that for the first time,” she says. “But the amount of times I’ve heard it since? That’s more worrying. Athletes coming up to me, one by one. They’re not having any period. Another is told if she’s getting her period, she isn’t training enough or hard enough. Nobody is taking care of that for them. Nobody is caring at all.”
The origins of the misunderstanding that elite sports activities would possibly require missed periods are multifaceted, in accordance with researchers whom The Athletic spoke to for this piece. There’s the historic lack of scientific analysis into, and training round, menstrual well being and its affect on sporting success; bygone or unrealistic beliefs of elite sporting physiques; a dearth of training amongst coaches and athletes; and the historic taboo of discussing sexual well being brazenly.
Also at play is the tradition of sport itself, an area of final corporeal sacrifice — and a multi-billion-dollar enterprise.
The repercussions for athletes, researchers say, can embody long-term well being implications — and the curbing of some careers, like Ewers’, altogether.
There is hope, nevertheless, for a extra knowledgeable future, a better understanding of how data of the menstrual cycle could be an elite athlete’s “superpower.”
Temporarily losing a interval for a brief period of time, quantified as one to a few months, in accordance with researchers, isn’t considered an immediate cause for alarm.
However, long-term absence of an athlete’s interval can usually point out wider problems, reminiscent of disordered consuming, being underneath an excessive amount of stress, or working inside the RED-S framework (Relative Energy Deficiency in Sport) — that means an athlete’s vitality consumption is inadequate to assist the calls for of their physique.
The penalties could be manifold, together with negatively impacting bone well being, fertility, metabolism, iron ranges, price of restoration, sleep, profession longevity, and emotional well-being.
Secondary amenorrhea (while you don’t have your interval for greater than three cycles) or primary amenorrhea (the whole absence of a interval in a feminine of reproductive age) can compromise a younger girl’s bodily maturation as a result of lack of normal development hormones. Some girls might consequently not attain peak bone well being, which usually happens across the age of 30, probably rising their threat of osteoporosis later in life.
The normalization of losing a interval has impacted athletes throughout the sporting gamut for many years. Athletes in endurance sports activities reminiscent of biking, working, snowboarding and swimming, aesthetic sports activities reminiscent of synchronized swimming or gymnastics, and weight-bearing sports activities, reminiscent of mountaineering or rowing, are significantly susceptible as a result of arithmetic of lighter usually equaling sooner or extra nimble performances, say researchers.
Psychological and bodily signs of a interval — from cramps, fatigue, cravings, bloating, and temper swings, to fears of bleeding via white shorts — have helped painting the interval not as a vital bodily operate value understanding and harnessing, however as an inconvenient, painful, even shameful hindrance to success.
Underfueling, extreme weight reduction, and contraception, reminiscent of contraception drugs, have been used as techniques to control and even keep away from periods throughout intense seasons of coaching or competitions, in accordance with practitioners and athletes spoken to for this piece.
Indeed, the preliminary lack of a daily interval can usually be adopted by an addictive uptick in efficiency.
“Before things started going wrong, losing iron, losing energy, finding myself fatigued, everything was pointing in a positive direction,” stated Pippa Woolven, founding father of Project RED-S — a company that works to extend consciousness and prevention and assist athletes in their restoration.
Woolven represented Britain on the 2018 European Cross Country Championships and was a part of the women’s silver medal-winning staff. Coaches and friends praised Woolven for her physique and work price, she says, reinforcing the concept that the absence of her interval symbolized one thing constructive.
“That’s the sad reality of the mathematical equation and the physics behind it,” Woolven says. “If you’re looking for a shortcut to success, then weight loss or restriction is the answer.”
Demi Vollering prepares for the fourth stage of the 2025 Women’s Tour de France. (Julian de Rosa / Getty)
This summer time’s Tour de France Femmes introduced issues over shortcuts into the highlight. After ending second, the 2023 Tour champion Demi Vollering stood in entrance of the media, fielding questions not about her efficiency, however somewhat about weight — particularly: Had she misplaced sufficient, given her runners-up end to Pauline Ferrand-Prévot within the Tour?
Vollering, who’s 5ft 8in, describes herself as a “heavier rider” in comparison with Ferrand-Prévot, who’s 5ft 4in. The 28-year-old turned the script: Why was jeopardizing one’s well being nonetheless anticipated within the pursuit of victory?
“Sport is all about being in perfect balance,” the FDJ-Suez bicycle owner tells The Athletic. “That’s what we should show the world, to the young girls watching us. We all have different bodies. You need to understand yours, find your limits and accept them.
“I don’t want to be good for only two years, so I need to take care of my body as best as I can. Because if you don’t, there will be a limit where your body says, ‘That’s it. I’m done with all the years of you tearing me down.’”
In the wake of Vollering’s feedback, the Cyclists’ Alliance — the consultant physique for skilled cyclists — this 12 months renewed its calls from 2024 for the game’s world governing physique, the Union Cycliste Internationale (UCI), to introduce obligatory screening for RED-S and bone mineral density for ladies and men. In a press release to The Athletic, the UCI stated it took the problem of RED-S “very seriously” and was finalizing risk-assessment questionnaires and screening instruments that would assist staff medical doctors.
Vollering’s feedback didn’t happen in a vacuum. Against a backdrop of tales just like Ewers’, sports activities stars reminiscent of American rugby participant Ilona Maher are advocating for body positivity in sports activities, whereas federations and sporting our bodies are being known as on to behave.
“Before we’re athletes, we’re women,” says 24-year-old French bicycle owner, and Ewers’ EF Education-Oatly teammate, Cédrine Kerbaol.
“We’re not trying to control what women can and can’t do with their bodies. We want to make sure that young athletes, men and women, are aware of the potential consequences.”
The United States women’s nationwide staff (USWNT) famously built-in menstrual cycle monitoring into efficiency methods forward of its 2019 World Cup triumph, underneath the steerage of high-performance coach Dawn Scott and Dr. Georgie Bruinvels (Orreco’s Female Athlete Lead and the developer of interval monitoring app FitrWoman).
A 12 months later, Chelsea grew to become the primary soccer membership to tailor coaching to gamers’ menstrual cycles, spearheaded by present USWNT head coach Emma Hayes and Bruinvels.
Tracking apps and applications have now grow to be staples for groups within the WNBA and NWSL, in addition to prime worldwide sporting federations. The International Federation of Sport Climbing (IFSC) launched RED-S and different well being screening necessities final 12 months, the primary of their form.
However, inadequate training and costly screening strategies imply many sporting organizations and groups nonetheless depend on coaching, restoration regimens and monitoring applications modeled after, and designed for, the male physique, says McGawley.
That’s the results of a historic lack of ladies in analysis areas, each executing the research and being studied, she says. Science usually pursues a path of “least resistance,” she says. “Accounting for hormonal fluctuations was not that path.”
Dawn Scott (left) and Georgie Bruinvels (far proper, pictured with USWNT head coach Emma Hayes) included menstrual cycle understanding into efficiency teaching for the USWNT (Meg Oliphant / Getty, Brad Smith / Getty)
While a PhD pupil at University College London in 2015, Bruinvels requested for blood samples for her analysis into iron metabolism in endurance athletes. She was handed blood samples from solely males.
“I asked, where are the females?” she recalled. “Why aren’t we recruiting females?”
Weeks later, Bruinvels stood amongst a crowd on the 2015 London Marathon, asking runners about their periods. “And literally, excuse the pun, the floodgates opened,” she says. “Everyone was asking questions. I spoke to over a thousand people in four days. I realized people don’t understand anything about their body.”
Bruinvels additionally found a well-recognized layer of embarrassment quietly coating these conversations. “My biggest ‘why’ for what I do now really was I was so ashamed to have a period,” she says.
That disgrace has deep, historic roots. Where some early civilizations portrayed menstruation as a strong, god-like phenomenon (some historic Egyptian texts counsel that menstrual blood was utilized in potions or therapeutic rituals), many considered menstruation with awe and concern, resulting in the ostracization of these menstruating from common society.
Centuries later, regardless of sanitary napkins current earlier than tv was invented, ads of such objects have been banned from TV till 1972 within the United States.
The Venus of Laussel, a statue from Bordeaux Museum’s assortment, estimated to be round 20,000 years previous, holds a curved horn or cornucopia that has 13 notches. This might symbolize the variety of moons or menstrual cycles in a single 12 months. (CM Dixon / Getty Images)
It took one other 13 years earlier than “Friends” actress Courteney Cox uttered the phrase “period” in an American tv industrial. Actress Anna Chlumsky’s notorious “I’m hemorrhaging!” line within the 1991 movie “My Girl” captured the fashionable notion of menstruation as a terrifying tableau.
But a lady’s interval represents its personal form of “vital sign,” says Bruinvels, and within the case of elite sport, could be a margin-mover.
“I always say, the period is an additional biomarker that’s free that males don’t have,” says Bruinvels.
The rhythms of the menstrual cycle usually replicate steadiness in different bodily techniques and features. Periods are the results of a coordinated dialog between the mind and the ovaries, with the adrenal glands, thyroid and intestine all concerned at factors. Missed or irregular periods could be the primary tell-tale signal of disrupted signaling alongside these pathways.
According to some studies, the follicular phase — which brings a rise in hormones — is also known as the “feeling on fire” or “superpower” part: restoration can appear to occur shortly and vitality ranges really feel supercharged.
Meanwhile, the luteal part — occurring on the finish of the cycle with greater ranges of the hormone progesterone — is considered very best for relaxation and restoration.
This ongoing fluctuation is essential.
According to analysis performed by McGawley, high-level amenorrhoeic runners missed extra days of coaching, recorded extra accidents, and skilled drops in efficiency rankings.
Further analysis, particularly long-term research following athletes all through aggressive seasons, is required to show the perceived “superpower” nature of the menstrual cycle, says McGawley. But athletes’ perceptions of how they really feel throughout any explicit part of their cycle — gleaned from surveys, interviews, focus teams and different qualitative research — shouldn’t be dismissed or trivialized if no numerical knowledge but exists to assist their claims, she says.
“It matters what this particular Olympic champion feels she can and can’t do month after month, even if the physiological metric doesn’t necessarily show it,” says McGawley.
Understanding the physiology of 1’s physique — why heavy bleeding happens, how sure signs could be assuaged (from anti-inflammatory smoothies to opening a window whereas sleeping to assist regulate will increase in physique temperature), what “regular” means to you — is what McGawley considers the “superpower” of the menstrual cycle.
“The period itself is not the superpower,” she says. “It’s understanding how to confront it, to have that power to make decisions and adapt to empower yourself during that time.”
McGawley notes that missed periods amongst elite endurance athletes competing at a excessive stage, or what she refers to as “periodization,” is, to some extent, regular, significantly earlier than an enormous race when stress or bodily load is larger. The human physique is an intricate and clever set of combat or flight responses. When the physique feels it’s underneath stress — whether or not bodily or emotional — it can flip off non-essential techniques.
According to Renee McGregor, elite sports activities dietician and best-selling writer of “Fuel for Thought”, 21 % physique fats is considered a minimal threshold for sustaining common menstrual cycles and ovulation in girls. Elite athletes, although, are sometimes outliers, transcending physiological norms, that means many can and do carry out at decrease physique fats percentages and stay wholesome.
“However, I think we have a role in identifying when that is true and when that is not,” McGregor says. “We need to consider an individual’s genetic physique, their history, their phenotype.
“Many athletes I’ve labored with, particularly from Afro-Caribbean backgrounds, have been requested to suit a Caucasian physique. That’s not attainable. We can get them to some extent the place their physique is perfect, however I refuse to push them past that.
“But it’s still controversial. Should we be asking female athletes to be a particular body composition in order to perform?”
A 12 months from now, Vollering, Ewers and Kerbaol don’t need to be talking about periods.
But proper now, their social media inboxes overflow as a lot with gratitude from strangers for talking out as requires assist from involved mother and father and athletes at numerous ranges.
“The reason we’re talking about it now is because there’s proof of the consequences, but it’s becoming worse,” says Kerbaol. “We need to act.”
That motion must be multifarious. The numerous researchers The Athletic spoke to level to a obtrusive dearth of analysis into menstrual cycles and optimum hormone ranges of various ethnicities. The pure incidence of myriad hormone irregularities in feminine athletes, reminiscent of Differences of Sex Development (DSD), Polycystic Ovary Syndrome (PCOS) and endometriosis presents points for correct screening.
Demi Vollering (second from left) and Cédrine Kerbaol (far proper) compete throughout the fourth stage of the 2025 Tour de France Femmes. (Szymon Gruchalski / Getty)
Most researchers and athletes The Athletic spoke to supported types of screening and intervention rooted in holistic athlete assist from a younger age, emphasizing longevity over short-term good points and educating, with the purpose of prevention somewhat than a remedy.
“It’s a whole cultural movement that needs to change,” says McGregor.
“We can’t just thrash athletes until their bodies’ metabolism is down-regulated. It’s also about athletes understanding from a young age that they’re at risk and getting support.
“It’s about coaches listening to the broader staff and appreciating that perhaps we have to take 5 years to get this athlete the place they must be somewhat than push them to the brink now.”
Bruinvels also emphasizes a duty of care belonging to stakeholders and investors entering women’s sport. She points to American businesswoman and entrepreneur Michele Kang’s $25 million investment in U.S. Soccer in April this year, integrating the Kynisca Innovation Hub into the Soccer Forward Foundation, and actively investing in female health sciences as an example of positive investment.
“Lots of people desire a piece of the pie of ladies’s sport. But I do not suppose essentially persons are backing that up with, ‘OK, we need to assist you,'” she says. “That’s the place there are some gaps that must be closed.”
Ewers still does not have her period back, but her hormone levels have improved significantly. Recent bone density scans indicate she is now in the osteopenia (low density) realm.
“Sport can also be a enterprise,” she says. “We’re all replaceable. There could be a lack of endurance with regards to getting higher as a result of it’s so unknown. ‘When is she going to have the ability to carry out higher? When is she going to begin adapting to coaching?’ I do not know the reply. No one does. A hormonal and metabolic harm isn’t seen. You can take a look at blood assessments all you need, however that will not inform you how long restoration will take.”
In February, she returned to the professional peloton after more than a year away. “Mentally, I’ve climbed out of the outlet,” she says.
But without more research and education, the danger of tumbling back in remains.
“I actually need to win the Tour de France,” says Ewers. “Everybody does. There are methods to have efficiency good points. But there’s a threat.
“So the question becomes, if there are no rules or regulations, how do we stop young athletes from doing that in a way that risks them falling into those really deep holes?”