The Fears of a Recreational Runner

Over the past ten years I have developed a deep love of running, gradually increasing my (typically) daily runs from 30 minutes to 45-60 minutes, sometimes longer. My burgeoning joy of running seemed to develop alongside my career in which I now spend the bulk of my days sitting at a desk. After long periods in front of the computer, my back and shoulders begin to ache and my legs twitch in anticipation of movement. Over time, I grew to desire the rhythmic flexion and extension of my limbs, the breath in my chest, and the breeze on my skin. Running helps me clear my mind, and gain some clarity and perspective on issues of the day. It also gives me a sense of connection to the people and places in which I live or temporarily reside. Sitting back at the computer after a long run, my body may be fatigued but I feel refreshed and enthused to revisit the words on the screen.

RunnerWhen my monthly menstrual periods slowly disappeared, I didn’t think too much of it. After a few months passed, I lost track of the ‘cycles’, and to be honest, I didn’t really miss the monthly interruptions. Many of my fellow physically active friends had similar experiences and told me not to worry, supposedly ‘it’s normal when you’re running most days’. For a while, I accepted their explanations. I felt great, I seemed to embody ‘good health’, and I was happy in my body. Yet I also had a growing sense of unease, it just didn’t seem ‘natural’ or ‘normal’ to me. So, I followed up on my niggling uncertainties with a couple of doctor visits. But, I became increasingly frustrated when doctors in both New Zealand and the UK dismissed my concerns. A doctor in England told me I was ‘very healthy… it’s probably just a bit of stress from moving overseas’, and two doctors in New Zealand also told me it was nothing to worry about. I was disappointed by their apathy and seemingly simplistic understandings of ‘health’, whereas an ‘obese’ body is a sign of instant alarm, I wanted them to respect my concerns about the internal functioning of my visibly ‘fit’ and thus supposedly ‘healthy’ body.

The more research I did, the more concerned I became about the health of my bones and future fertility. I wanted to be able to run (or at least move freely) into old age, and my partner and I were considering having children in the next few years, so I followed this up with a series of blood tests to measure my hormones. Rather than accepting the medical ‘experts’ advice to use the contraceptive pill or other drugs to artificially trigger menstruation or take drugs to help me get pregnant when I wanted to conceive, I forced myself to run a little less and eat a little more. Somewhat ironically, I started policing my own running practices; when I pushed away from the desk, tied my laces and stepped out the door for my daily run, I was disciplining myself not to run too long. Throughout the run I would worry what it was doing to my progesterone and estrogen levels, and the longevity of my bones. I no longer felt good upon returning from a long run, rather I felt guilty. Over time, it became easier, and with a bit more weight and a little less exercise, my regular menstrual cycles returned. I have to admit, however, that I continue to struggle with achieving the balance between exercise and sufficient energy intake. It’s a daily battle with my desire to control my diet, my body, and my life.

 

Exercise addiction – one woman’s story

I never did stop menstruating completely, but for at least seven years it was just a trickle, two days at the most. But, despite knowing all the risks (and I was fully aware of them), I was glad. Secretly proud, in fact, of this ‘achievement’ that signaled my extreme fitness and implicitly, my mental toughness. During this time in my twenties, I rarely went longer than 10 hours between bouts of exercise. “Time off’ included working, sleeping, and eating. The fatigue that occasionally washed over me became just another challenge to conquer, another opportunity to prove (to no one in particular) what my body could do.

ExerciserNo one pushed me. I had no coach, no exercise buddy, no fitness guru, no teammates daring me to do more. In fact, the only external pressure, from my family, was directed toward an opposite end. But their attempts to get me to relax more only fueled my exercise obsession. I saw their pleas as proof that I needed to be vigilant and resolute in my disciplined pleasure. And pleasure it most certainly was – I loved to move. More was definitely what I needed. Granted, some days it was a need to just see how far I could go before I started feeling that “good pain”. Other days it was a need to burn off the extra cake I ate. And some days it was a need to stay ahead of the body fat I was certain would appear suddenly if I stopped moving for too long. But most days it was about reveling in the feeling of control and power that my muscles provided. How could being so fit have any down sides?

I had watched a close friend go through anorexia only a few years before, and could not see the parallels with my own obsessive behavior. I ate whatever I wanted, and running a little farther to ‘take care of it’ was just common sense. And as I say, the menstrual disruption did not cause me alarm, but was rather a celebrated convenience.

This story has a much happier ending than it might, and for that I am thankful. The lasting legacy thus far is restricted to my mouth: severe bone loss around my otherwise healthy teeth. Final note: a coherent assessment of how and why I regained a less frenetic approach to exercise would require access to more memory than I have available (and probably some psychotherapy).

 

Dr Stella Milsom, Endocrinologist

Dr Stella Milsom
Dr Stella Milsom, Endocrinologist
Fertility Associates

Bone mass and bone mineral density (BMD) in an adult, depends on both the peak bone mass achieved by early adulthood and factors that might cause accelerated bone loss. A female accumulates much of her total bone mass between puberty and her early 20’s. Therefore, if total bone mass achieved during this vital time is diminished for any reason, her final bone density will be lower placing her at increased risk for lower BMD and fracture risk later in life.

One of the most important contributors to normal bone mass in a woman is estrogen. Estrogen levels are low before puberty and steadily rise during the pubertal years to peak levels that remain steady until the onset of menopause. Any health issues which delay the onset of puberty, or even cause puberty to regress, will lower estrogen levels and compromise bone turnover.  Generally, the first period, known as menarche, should have started by age 14 years, Within 1-2 years periods should come in a regular 26-35 day cycle. Absent or irregular periods can be a sign that estrogen levels may be low which in turn places bone at risk.

Absent or infrequent periods are often associated with restricted dietary energy intake, failing to increase energy intake when physical activity/exercise training load is increased and being under too much personal, work or physical stress. These factors, individually or in combination, can lead to low estrogen levels and cessation of menstruation. Some women may be more susceptible to menstruation ceasing under these circumstances because of additional genetic factors. This problem is called hypothalamic amenorrhea (HA) and can happen at any age in reproductive aged women. When this condition occurs in adolescents, the peak bone mass achieved is compromised and almost impossible to make up later. When HA occurs in women in their 3rd and 4th decades, bone loss is accelerated, just like the accelerated bone loss that occurs at menopause. This means the risk for fracture later in life is significantly increased.

There are other health issues with HA. Fertility is compromised by inhibition of ovulation and there is increasing concern that the lack of estrogen in reproductive aged women may increase the risk of cardiovascular disease.

There are other causes of irregular periods but this is an important sign not to be ignored. Girls and women who are concerned should see their general practitioner who may perform some tests and possibly refer on to an endocrinologist.

What can girls, parents and teachers advise in order to maximise bone mass accrual and reproductive health during these years?

A net energy deficit is a major contributor to continuing hypothalamic amenorrhea so eat well, and include a variety of foods to ensure all micro and macronutrients are consumed. Girls and women with large exercise training loads should take particular care to get nutritional advice. Do not restrict food groups such as carbohydrates or fats, which are necessary for a balanced diet. Calcium and vitamin D are important for bone health. Aim for 1000-1200mg calcium per day (good sources include dairy products and brazil nuts) and enough sunshine to get adequate vitamin D synthesis (30 minutes in early or late part of day without sunscreen). Many dairy products are now fortified with vitamin D, so check nutritional information labels.

Keep a log of your menstrual cycles, if you notice menstrual cycles length increases or decreases as you increase exercise load, you need to eat more!

Report any of the following: menstrual irregularity or cessation >3 months; if periods have not commenced by the age 15 years; or if there is no bust development by the age of 13 years. 

Key to reversing HA:

  • consider changes to energy intake
  • reduce, stop or change the type of exercise being preformed
  • develop strategies to minimise both external and internal stress