Editors Note: At Gnarly we feel it is important to bring awareness to RED-S (formally referred to as the Female Athlete Triad) as it relates to the health and performance of athletes (including men). Readers must know we are not attempting to diagnose or treat any medical conditions in this article. It is a two-part series that explores a sensitive subject through the personal experience of the author. Please be advised there is mature content within.
“It’s referred to as the female athlete triad,” my gynecologist told me on my follow-up visit.
The “triad” refers to a syndrome that manifests due to three interrelated conditions. Intense exercise and under fueling, intentionally or unintentionally, can reduce energy availability to a threshold below that needed to maintain normal menstrual cycles. As periods become irregular or absent, levels of estrogen and progesterone, hormones crucial in bone formation, drop. In 2014, the International Olympic Committee coined RED-S (relative energy deficiency in sport) to replace the female athlete triad, emphasizing that men are also affected by energy deficiency.
Jasna on Fish Crack (12b), Yosemite
Photo: Chris Weidner @christopherweidner
My low bone density and irregular periods were two signs of a third inevitability — I had inadequate nutrition to meet my metabolic needs. My body was stopping basic processes and I felt fine, with enough energy to excel in graduate school, socialize, train and progress in climbing. My mind felt slippery, ricocheting between my perception of my health and the reality unfurling before me.
Professional rock-climber Mina Leslie-Wujastyk touched upon her experience with RED-S in this excellent piece. While Mina noticed low energy levels yet maintained healthy bone density, I had the opposite presentation. However, we both had a normal BMI, abnormally low estrogen levels, lost our periods and hadn’t noticed due to hormonal birth control.
The consequences of RED-S are severe. If left untreated or diagnosed too late, a patient is left susceptible to osteoporosis and potential cardiovascular issues related to poor hormonal health. I wasn’t only gambling with my athletic career, but with my long-term health.
Fortunately, since I was still young enough to put down bone, I could reverse the osteopenia.
I was referred to a nutritionist. A vegan for four years due to environmental reasons, I had a restrictive diet. I couldn’t avoid the question — did veganism cause my RED-S?
According to the nutritionist, the answer was probably not. I wasn’t a vegan when my periods first disappeared and I was eating well. I increased my caloric intake and took calcium and vitamin D supplements. Eventually, I decided to eat meat, eggs and some dairy products, though transitioned away from veganism slowly. To increase intake, I had to eat when I wasn’t hungry, behavior which I had always viewed as inadvisable. My weight stayed the same as my body funneled the calories to returning to physiological normalcy, not to adding weight.
Changing ingrained habits or opinions is always daunting. As I paid precise attention to what I ate, I realized I was probably not objective about my diet. Though I always felt I had a good relationship with food, obviously something was not right. It took me a long time to admit this to myself.
Changing my eating habits forced me to consider the consequences for climbing.
A climber’s performance is affected by his or her strength to weight ratio. Easier and quicker than increasing strength, weight loss is a popular tactic climbers employ. Though I never tried to cut weight, I, like most, considered it a viable and normal strategy. Now, it felt like a playing card had been taken from my hand. In the context of greater concerns for my health, the strength of this frustration felt out of place and immature.
I briefly went off the pill to monitor my period. However, a month after it returned, I got a hormonal IUD. While the IUD masks my period it is also remarkably beneficial in my life. Choosing between sexual freedom, a basic right that is very important to me, or receiving cues that tell me I am healthy is a rather irritating conflict that I have given much consideration.
To decrease my susceptibility to chronic stress, another major cause of energy deficiency and an insidious tendency of mine, I tried to calm my mind via guided meditation and also socialized more. I was advised to exercise less, a catch-22 since climbing and running have always been a form of therapy for me. I compromised by stopping my habit of cycling everywhere. Otherwise, I did not reduce my exercise and climbed some of my hardest routes in the middle of treatment. However, I did become more regimented in my gym climbing; by making plans ahead of time, I sometimes avoided staying there for hours and using the gym as an emotional outlet.
After two years, I received another scan. My bone density increased; I was at 91% of normal for the spine and hips, yet at 85% for the femoral neck, meaning I still have minor osteopenia in my neck, and, as I near my 30’s, I likely always will.
I had wanted to try an IUD for a year prior to my doctor’s visit, but I put it off due to a busy schedule. Had circumstances unfolded differently, I might have walked into the gynecologist’s office in my late twenties, when reversing osteopenia is potentially impossible. While only a frightful hypothetical situation for me, finding out about RED-S too late is likely a reality for many young athletes.
Jasna on Kings of Rap (12d), Smith Rock State Park
Photo: M. Humphrey @noskinleft
Today, I always consider RED-S when I plan my diet or training. This requires discipline, as my major symptom is a silent one and my birth control effectively removes my ability to monitor my hormonal health. It can be easy to fall into cycles of stress or of believing uncomfortable notions that I am eating “too much.”
So, months after the diagnosis, I printed the initial report and put it in my climbing notebook. That paper can turn the hollow pain I felt on the first day — fearing I made a mistake I couldn’t recover from — into a physical presence I can carry within me.
Sometimes, it is roused when I stress over jobs, climbing or relationships. It reminds me that health is fragile, though easy to ignore in pursuit of other goals, even something as trivial as a climbing grade.
On good days, I realize that what is on the line is often far greater than what I might lose, or, more simply, what I might not achieve.
Jasna Hodžić is an avid rock-climber, runner and researcher. When she began to climb, she became fascinated by the processes that shaped the ecosystems around her. Following this muse, she began graduate school at the University of Washington to study plant ecology. Prior to this, she worked as an accomplished and award-winning photojournalist.
You can find more of her writing and photography at www.jasnahodzic.blog.
1 Nazem, Taraneh Gharib, and Kathryn E. Ackerman. “The female athlete triad.” Sports Health 4.4 (2012): 302-311.
2 Mountjoy, Margo, et al. “The IOC consensus statement: beyond the female athlete triad—Relative Energy Deficiency in Sport (RED-S).” Br J Sports Med 48.7 (2014): 491-497.