In writing this post I had a hard time starting. Putting the words down on paper felt awkward and scary. I felt like a fraud. But when I found the courage to post about it a month ago, the response from women dealing with the same thing was bigger than I had expected. Seeing how that post impacted others made me realize that I needed to put myself out there. Hypothalamic Secondary Amenorrhea is more common than most think and that is likely because it is either not discussed or is misunderstood. Runners are wired to think that more is better, but in reality, balance is what runners really need. So here it is, this is my story.
My freshman year in college I struggled to adjust to life as a collegiate athlete, but it was more than just the freshman 15. I was exhausted all the time, had stomach-aches after almost every meal, had gained weight (was 5’0” and 124 lbs at my highest), and the list goes on. I began obsessing over everything I ate because eating had become such a pain (literally & figuratively). The big boost in performance I had expected with the focus on running, didn't come and I felt like a letdown. It wasn't until about midway through cross-country season my sophomore year that things changed. Our sports dietitian suggested I cut out gluten to see if maybe that was the root of all my problems. Turns out, it was. I cut out gluten and things changed drastically. I began running much better, felt better, and things started clicking. But that wasn't all, in around just 2 weeks I lost about 10 lbs and that is where my story begins.
The change in weight triggered the beginning of my secondary amenorrhea. I didn't mean to lose weight, it just happened. I don't know the exact last date of my cycle but I do know it was around this time. So from 2009 to 2017 I maybe had my period a total of 3 times. The quick weight loss is known to be a trigger for it, but my diet after the fact was the reason it continued to stay dormant year after year. My obsession with food prior to diagnosing my gluten issues continued and the stress of eating became worse. In 2009 eating gluten free was certainly not easy. Being scared I would accidentally eat something with gluten before a race made me anxious. When I started running well, I began worrying about gaining the weight back and having a relapse of freshman year. But I loved food and the diet change brought out my love of cooking. Even with the weight loss I was a normal weight for my 5’0” frame and I never had an eating disorder but I was chronically under-eating, and displayed disordered eating patterns. Under-eating is a hard thing to understand because normally you would think if you eat less you will lose weight. Well that's not always the case. There is a calorie deficit zone where you are eating just barely not enough. Your body stores more of the food you take in as stored fat to use in case it is "starved." I was living in this state but didn't quite understand it.
Every time I would go to the doctor they would ask the date of my last period. I would respond with "I don't know" and the typical responses were either nothing, "that's just what happens to runners", or "you're not eating enough." At the time, the latter made me angry. How could I not be eating enough? I was a normal weight and felt as though I couldn't keep weight off. But the doctors were right, I wasn't eating enough. It would have helped if they would have explained what was really happening. The overlap between under-eating and secondary amenorrhea can be explained by Relative Energy Deficiency in Sports (RED-S). Formally there was only the Female Athlete Triad, but the triad was limited and didn't always capture what was going on. RED-S broadens the definition and spectrum of dysfunction. To learn more about REDs check this link. Basically, when you are not eating enough to meet your energy needs, the body is unable to support other main functions you need for optimal health and performance. So, it shuts down other systems, one such being your endocrine system. If you can’t meet your own energy needs, then your body sees reproduction as non-essential because you wouldn’t be able to support another life.
The other thing I was doing wrong in college was not prioritizing my post-workout nutrition. In an effort to not over-eat I would wait for my next meal to refuel. Not getting the protein and carbs I needed within 30min to an hour of working out, meant that my muscles weren't adequately recovering creating more internal stress on the body and elevating my cortisol. Excessive stress either physically or emotionally contributes to hormonal suppression and even a weakened immune system.
After college, I learned more about nutrition and its particular role in my training regimen. I started working with a sports dietitian and InsideTracker. I made it a point to have enough protein and carbs after runs & started using UCAN & BiPro. But despite all of these things I was still slightly under-eating, especially with how much I was doing. Between running twice a day, biking to work, going to the gym, working 40 hours, and not sleeping enough, I was expending a lot of energy, over-stressing myself, and not meeting my energy needs. I was working harder than ever because I was living my dream and wanted to do whatever it took. Then the Olympic Trials happened.
The trials finally taught me the lesson I have needed to learn from the 1st day I set foot on NC State's campus. The trials taught me what my coach meant when he said, "You have to slow down to speed up." It taught me the physiological things that happen to the body when you go too far. When hard work turns into a curse. When the harder you push the worse you feel. Performance suffers, you can catch a cold from a mile away, you begin to gain weight, your hormones get out of wack, and the chronic inflammation wreaks havoc on your digestive system. I didn't know what over-training was at this point but now I do. Your body needs the chance to recover just to function normally. Not giving it the chance to do this not only won't help you become a faster runner, it can lead to a variety of other consequences, including hypothalamic amenhorrhea. In my case it just made recovery a step farther away.
I took a month off from training and started focusing on recovery. I wanted to get over this period by fully healing and making the best of my fall season. I started by testing with InsideTracker prior to getting back into training to make sure my body was ready. I also started using Scivation Xtend Free BCAA’s after training and before bed. And then I started training a little smarter. It all culminated in winning my first marathon. But coming off that win my lack of period was still looming. I stumbled upon a podcast on Endurance Planet discussing Hypothalamic Secondary Amenorrhea and I knew I needed to do something.
Not having a menstrual cycle can have an effect on fertility, increased risk of injury, decreased bone density, digestive issues, and higher predisposition to heart disease and cognitive diseases later in life. In college I had two places where my bones were considered in the osteopenia range (pre-osteoporosis) and I certainly still struggle with digestive issues. My passion and love of running would eventually be side-lined if I didn’t do something now. I could have continued to ride the high of my successful first marathon win, and continue to run fast but it would be like a ticking time bomb. Living in fear of when my time would run out. So after my marathon I made the decision to work towards recovery. I knew going into this I would have to become uncomfortable. I was going to have to be patient and okay with some weight gain, a diet change, and not racing as well as I would like. It would be a lot of changes but making the hard decisions would make me better in the future, both mentally and physically.
So I booked an appointment with my endocrinologist, started to reach out for help, and made a lot of changes. This topic is a complicated and hard to grasp so I wanted to be thorough when I released this post. There isn't one single thing you can do to fix the problem. It involves several different parts and pieces of your life and requires a little help from those around you. I began this process in December/January 2016-2017 and as of June recovered my cycle and have consistently had it now for the past 3 months, but my battle is still not over. Note that you will likely have to go above and beyond to get your cycle back. Don't be afraid to look for help. You are not alone, secondary amenorrhea is much more common than many women think. But everybody’s path to recovery is different, just as everyone’s story runs a different course. As for me, these were the things I did that got me back on the right path:
I got an appointment with an endocrinologist to begin the conversation. To see what was going on that could be causing my lack of a menstrual cycle. Part of me hoped that I had some underlying issue wrong with me that was causing it but we determined that my estrogen and progesterone levels were practically non-existent. Luckily my endocrinologist didn’t jump directly to birth control as many doctors do. Birth control does not fix the problem, it merely masks it. It also doesn’t help your bone density if you are already in the red. I wanted to continue to train so her suggestion was to cut back a little bit on mileage and intensity, and begin using an estrodial patch and progesterone pill. The regimen is a low dose (0.075mg) patch, which I change out twice a week, and a 200mg progesterone pill for the first 12 days of every month. This is not a full fix but it is meant to start helping my estrogen and progesterone levels begin to increase. The benefit of this method over birth control is that it is the right formulation of hormones that your bones can use. Estradiol is the active form of estrogen that allows for calcium absorption. It took from January to June to actually get my period back but I also stopped using the patch and progesterone for about a month in mid-March to mid-April. Now I just need to get in to see what my levels are now and determine whether or not I can begin tapering off.
I also reached out to Tawnee, the host of Endurance Planet, after recommendation from one of my wonderful Oiselle teammates going through some similar problems. Tawnee is a holistic health and endurance coach and sports nutritionist who herself battled disordered eating, hypothalamic amenorrhea, and gut issues while training as a top triathlete/runner. Check out her story here and check out her in-depth interview with InsideTracker. She had me fill out an extensive questionnaire and send in any blood testing I had done, results from prior doctors visits, and any other relevant info I had. I also kept track of everything I was eating as best as possible for her to evaluate and give me recommendations. We scheduled a talk and in this she told me the things I needed to hear. Some of it was a little hard to accept but keeping in mind what really mattered made it easier. She gave me some clarity on some things I didn’t understand about my previous blood tests, like my chronically low white blood cell count. She was also able to explain how my amenorrhea related to my gut issues. In addition to our call, Tawnee analyzed my diet and wrote an extensive plan custom to me with recommendations on healing, nutrition and suggestions for some further testing I likely needed. The first test was a stool test to see if there was any inflammation or gut dysbiosis (imbalance of good and bad gut bacteria), and the second was a DUTCH test which provides more detail on adrenal and hormone health (i.e. the HPA Axis) than blood testing alone can. I have now done the stool test and things were not too bad but I do have a bacterial overgrowth of both candida and Citrobacter freundii. Clearing these up could potentially make a big difference in performance and rid me of my stomach issues but the protocol to get rid of it requires cutting out all grains, sugars, starchy vegetables, and eating very low carb so this will wait until after this fall season.
Between my engineering job, training, and everything in between, I was over-stressed. I couldn't keep my house clean because I was too busy. I missed out on time with friends, and felt bad saying no to anything. I constantly felt stressed in my career. I wasn't confident in my abilities and I didn't have the time to commit as many hours in at the office as fellow coworkers. Waking up early to squeeze training in every morning was wearing on me. I couldn't do it all. In March this year I quit my engineering job to move into a role as a Real Estate Appraiser. I am not saying if you are struggling with secondary amenorrhea or excessive stress then you need to quit your job but for me that was a large source of stress in my life and I needed to make a change. Running has become the place that I feel the most power, the most in control, and the most at peace. Not everything you do in life will be your favorite thing but in order to be the best you, you have to make time for the things that matter most to you. For me that is running and my family and friends, 2 things I felt I had been neglecting. The new career gave me the flexibility to sleep, train, and work as I needed to.
The early mornings coupled with 80-100 mile weeks left me exhausted about 80% of the time. I was happy to get at least 7 hours of sleep but probably averaged around 5-6 hours. Sleeping helps your body recover and I wasn't getting that. Sleep also has an affect on your immune system and your demands for energy. If you aren't sleeping, your body needs more energy intake to keep it functioning. Plus, not enough sleep is another stressor for the body.
Reduce Caffeine Consumption
This was a suggestion that Tawnee prescribed. I didn't necessarily want to because I love coffee but it was a rather easy change to make and would certainly save me money. It was also much easier with the change in jobs. When I was working at my engineering job I had to drink coffee just to get through the day. Now if I feel myself getting tired during the day, I try to squeeze in a nap. My coffee consumption is now limited to pre-race and pre-workouts. The connection here is that coffee elevates cortisol similar to levels associated with acute stress. I have been fine without it and I get the boost on my harder effort days.
Increase Calorie Intake
I started increasing my calorie intake across the board. Tawnee's assessment of my diet showed that I just wasn't eating enough to balance my energy demands. I was skimping a little on fat which is often the case. Healthy fats are important and I had an appreciation for that. I feel deprived when I go a day without avocado. I was eating a balanced diet but I had a true energy deficiency. I increased my fat, carb, and protein intake and in the process gained about 8 lbs. I found that when I started eating more, I felt hungrier. She warned against not trying to put on weight by eating high-sugar foods or junk foods. I already had digestive issues and sugar just makes the problem worse especially in my case with the bacterial overgrowths. She suggested I add more nutrient dense carbs (gluten-free whole grains), add anywhere from 300-800 calories to increase energy availability, up the protein, and gave me suggestions on how to add more healthy fats. I started eating more nut butter, started cooking with avocado oil, began using grass fed butter, and went heavy on the oil with veggies which in turn helped to absorb more of the nutrients within them.
Improve Gut Health (if this is an issue)
Often times, if there are underlying gut issues, the body succumbs to malabsorption and nutrient deficiencies. I dealt with this prior to cutting out gluten and my menstrual cycle was irregular because of it. Dysbiosis is common because the immune system is often suppressed and the elevated cortisol levels from excessive stress divert energy away from the digestive system. Add in any need for antibiotics and you can end up killing a lot of your good bacteria throwing your entire system out of balance. Tawnee prescribed a few digestive enzymes and adding probiotics. As I mentioned I did a stool test to address what was causing my digestive issues. To increase my probiotic intake I began drinking kombucha regularly, which I love, and Lifeway Kefir yogurt which is 99% lactose free (I am lactose intolerant) and low in sugar. I also am a big fan of Purely Elizabeth who creates a dark chocolate probiotic granola which is also low and sugar and amazing! I also have been strictly trying to stay away from known gut irritants (soy and lactose), and have been more aware of anything I notice gives me any problems. The nature of running can cause inflammation in the gut so some of the things I will have to focus on solving during break periods from training.
I was simply doing too much and with too much intensity. For most of 2016 I was waking up, running for at least an hour, biking to work, then often doubling at lunch, biking to the gym after work for 30-45 min of strength, and biking home. That wasn't my schedule everyday but it was enough to be to be problematic. In college I did all of my regular training runs fairly fast. I didn't have a GPS but I am almost certain I maintained 6:30-7:15 mile pace on days when I wasn't doing intense workouts. I was also doing 60-75 miles a week on average through this time and my goal for each workout was to run faster than my coach prescribed at the end. This type of training just doesn't last. My body wasn’t able to take on the training adaptions that it needed in order to keep getting faster because I was over-reaching far too often and not giving my body the proper recovery time to adapt. Instead of becoming faster I was likely just wearing down my body little by little. No wonder I also felt so drained at the end of each season. It is also no coincidence that my final collegiate season didn't pan out exactly how I would have liked it. Post graduating I got a GPS watch (bad idea at the time) and would stress when I would run slower than 7 min mile pace. I eventually tossed the watch aside and this was the best thing I did. The year I did that I stopped worrying about pace, began running easier on regular runs, and went on to run a 1:12:50 for a half-marathon. Now I run 8-8:30 pace on easy days and listen to my body on days in between. I don't let the pace affect me; I just listen to what my body is telling me. I also give my body a break more often. I take advantage of cross training tools like the Elliptigo when necessary. I also got a VO2 max test done at RunRaleigh PT in order to determine the right heart zones I should be training within. This will definitely help with recovery and growth as an athlete.
I began working with Stephanie Bruce for coaching after training with her through my first successful marathon in November. This decision has made a huge impact on how I think about training. This year has been a gradual build, working to slowly increase my threshold over time which is a much more efficient plan for long-term success. Early in this season we were doing workouts I would have thought were too easy in college. I'll admit sometimes now and even at the time I didn't like that it felt like everything was too easy and would run too fast expecting praise. Praise was not what I got. The best way to progress and get faster is do so over time. It creates a more resilient athlete. We also changed the structure of my training weeks. I used to fit my 60-90 mile weeks into 6 days and it was exhausting. I killed for the 1 day off each week. We changed things around and I don't feel the high mileage as much. I actually enjoy it! The change in training has been a little hard confidence wise because in the past I was reliant on the times I was hitting in training to determine exactly how fast I was going to run. I have been working on putting that aside and just doing what I can but this is certainly a work in progress!
This spring I began finding ways to incorporate UCAN into my everyday diet. UCAN wasn't just a pre-workout drink, an in race fueling strategy, or a recovery aide; it was something I wanted to have as a snack in between meals. UCAN helps to keep blood sugar steady and thus energy levels and most importantly, it doesn't bother my gut. That is a big advantage that UCAN has over gels, it doesn't cause GI distress because it is not a concentrated carbohydrate derived mainly from sugar. As I have mentioned above, keeping energy levels steady throughout the day is essential for meeting energy demands. If blood sugar spikes and crashes there is a hormonal response, particularly cortisol. When cortisol is being overproduced, other sex hormones are underproduced. The foods you eat and the carbs you consume play a big role in how well you meet your energy needs. I have begun packing a UCAN snack bar or some homemade something with UCAN to take on the road with me for busy days. Avoiding situations where I go too long without eating is key here.
Blood Testing with InsideTracker
As briefly mentioned, the role that stress plays in this whole secondary amenorrhea equation has to do with the hormonal response. Cortisol, also know as the stress hormone, elevates whenever the body is either physically or emotionally stressed. From regular testing with InsideTracker I saw elevated cortisol during times of high emotional stress and physical stress. High cortisol can suppress the production of other hormones. Cortisol is released as a healthy and normal response to stress as a coping mechanism for the body but when this is constantly happening, too much energy is diverted from other areas of the body that need it. The immune system and digestive system suffers, the body has a harder time absorbing different vitamins and minerals from food, and inflammation typically increases.
Through testing I also saw my vitamin D level dropping, I wasn't absorbing iron as well, and I had found myself having to take several different vitamins just to keep things steady. I also couldn't pin-point a reason for some of my fatigue when everything was normal. When I was overtraining there were indicators within my blood testing that showed what was happening internally. Check this previous post for more on that. Either way having more self-awareness on nutrition, the affect of training on the body, how my blood levels affect each part of my well-being, and why I need to keep an eye on my levels throughout the year has made this process much more manageable. All thanks in part to InsideTracker. InsideTracker will continue to be a part of my training in the years to come. Especially as they continue to add more and more resources for athletes of all levels and in all sports. Most recently they announced their latest InsideTracker goal, Female Reproductive Health. Plus, they recently released this great post on Tawnee Prazak Gibson & Tina Muir and their stories on how they overcame amenorrhea.
All in all, I still have much more work to do in my recovery journey. I am blessed to have the resources I have and the support system to keep me moving forward when things have been tough this year. I like to think of this year as a year of vulnerability and change. I’ve had to be open to being uncomfortable but through it I have worked through a lot. This year will leave me in a place where I can only get stronger. I know that I am capable and even though I will continue to have my doubts some days, I can take solace in knowing I am physically healthier. I love running for what it is and not how it defines me. This year will just be about enjoying the ride. #headupwingsout
Running & Racing Schedule
- September 23rd - Genworth Virginia 10-Miler
- End of September - Flagstaff
- October 15th - Columbus Half-Marathon (focus race)
- Oct. 16-22 - mini break/down week
- Oct. 23rd - Begin CIM Marathon Build up!
- November 4th - Indy Monumental Half-Marathon - Marathon Steady State
- December 3rd - CIM Marathon in Sacramento - GOAL RACE