Female Fitness Myths Part 5 – That missing periods is normal, and that women are just small versions of men physically.

Once again this year we are returning to the topic of Female Fitness Myths. Myths around the female body are pervasive, often harmful, and bad for a personal trainer’s business. Understanding the female body, even just a little bit, will take your training of women to a whole other level, so this month we are going to bust more myths that have surfaced during the past few weeks…

Female Fitness Myth 1 – That losing your menstrual cycle is normal, fine, and harmless

This month’s topic is a return to the start of the year where we address some of the pervasive myths around female health culture in the fitness industry. Today I want to talk about one that literally kept me awake at night this year…

To give you some context, I was talking about the menstrual cycle being a vital sign of health, it was referenced with some of the latest research, and a female trainer said, and I quote “this has happened to me.. hasn’t caused any harm to me at all, I’ve been a body builder for over 8yrs, happened to my trainer also… it’s actually a known fact.. I had 2 children same for them… if it was harmful medical practitioners wouldn’t allow it”

The myth we’re busting today is that that losing your menstrual cycle is normal and fine and harmless. I’ll get to the second part of that comment next week!

Once again I will reference everything I say, when I put this in my blog at the end of the month, but before I even start with what we know through research, let’s think with our logical brain for a minute… If your body perceives sufficient danger, or is under sufficient stress that it no longer is fertile – is that a sign of health? If all our bodies stopped ovulating and menstruating, what would mean for the future of humanity??

This trainer went on to have children, and she didn’t answer my question about the timing of those children, because I asked if she had to stop or downsize her training in order to allow her fertility to return, but I don’t want to get stuck on fertility today – there are a hundred training reasons why losing your period is a bad idea, and a hundred more health reasons why you want to keep it as healthy as possible for as long as possible.

So, losing your period is NOT normal, NOT fine, and legitimately, measurably harmful. This is one of the big reasons why athletes should not be on hormonal contraceptive – because you can’t know when she’s in RED (relative energy deficiency), and therefore can’t tell if her performance is being negatively affected^{1 2}.

I will outline just 3 big reasons why losing your period is not fine:

• Bone health: losing your period, even just one skipped period, will begin the process of bone de-mineralisation in your body. Even in men Oestrogen plays a major role in bone metabolism³, and if you’re not ovulating or menstruating, your Oestrogen levels are low. This is of major consequence in sports like gymnastics, athletics, or simply going for a jog – women and men with low oestrogen, or in RED, are at higher risk of fracture⁴… not just while they’re in low energy state, but in to the future, increasing their risk of osteoporosis earlier in life, with a faster onset, and a more severe expression of the disease⁵.
• Heart health: losing your period puts you at greater risk of developing heart disease, even if you’re young and athletic. In fact, female athletes are often sent to sports cardiologists for evaluation when there’s a perceived decline in performance – what they find instead is altered electrical signals causing a mild heart blockage or autonomic dysfunction⁶, where the autonomic nervous system is damaged (the one that keeps your heart beating and your breathing occurring)⁷. This damage is permanent. Women who lose their period are predisposed to early onset cardiovascular disease⁸.
• Performance: if you or your client is in RED for long enough, it can deplete your glycogen stores, interfere with protein synthesis, and increase your risk of injury and illness^{9 10 11}. This has an immediate, negative effect on aerobic performance¹². There are not yet any studies on how this affects strength training performance, but we do know that low oestrogen, the precursor top amenorrhea, interferes with neuromusular function¹³. In the long term, women who have lost their period for a prolonged period of time will have a premature reduction in physical, psychological, and mental capacity^{14 15}.

So no. Losing your period is not fine, and not harmless. It is a big f*king deal and you should be seeing a doctor, coach, or nutritionist that is educated in this problem if you have irregular or non existent periods. Next week, we’ll talk about the second half of the above comment, that medical professionals wouldn’t allow it if it was harmful…

Female Fitness Myth 2 – “if it was harmful medical practitioners wouldn’t allow it” (losing your period)

So, to continue my rant from last week in bite-sized pieces… The trainer who thought I was “promoting” the idea that menstrual cycle dysfunction is harmful also said “sorry, I can’t take on board what your trying to promote… if it was unsafe so you think medical practitioners top Olympic coaches would allow this kind of thing to happen if it was due to health and what about pregnancy conceptions that stop your period, I say no more”

Well, yes I do say this. Keep in mind, I was an athlete in the Australian Sailing team. I have both trained at coached at NSWIS (albeit only briefly). I have coached Ex Olympians, current Olympians, and girls who went on to become Olympians. I have firsthand experience in this field.

Medical practitioners and Olympic coaches SHOULD know, but they don’t.

Education is lacking.

Awareness is lacking.

Research is lacking.

The drive to learn more about women’s health specifically in coaches is lacking.

However, there is enough information for us to know it’s harmful for health, and that coaches and doctors should know.

Proof that regulatory bodies and medical professionals are aware of the issue is in this paragraph: Relative Energy Deficiency Syndrome (RED-S) was recognized by the International Olympic Committee (IOC) in 2014 as an insufficient caloric intake, and/or excessive energy expenditure¹⁶. This syndrome is characterized by low energy availability (LEA), sufficient for body functions involved in optimal athlete health and performance are not adequately produced ¹⁷. It is for this reason that the main etiological factor compromising health status is LEA, which results in long-term and potentially irreversible damage to athletes’ health ^{18 19 20}.

If you lose your periods, and you go to a doctor, and they recommend birth control, then you’re at the wrong doctor²¹. The last part of this bodybuilder/coach/mum’s comment actually touches on contraception as “proof” that it’s harmless: “and what about pregnancy conceptions that stop your period, I say no more”. However, hormonal contraceptives are not harmless and actually carry their own health risks including:

• Negatively impacting bone mineral density²² ,
• Increasing risk of thrombosis (clotting)²³,
• Increasing prevalence and severity of mood disorders²⁴ and literally changing your brain and brain function more broadly²⁵
• Increasing your risk of cardiovascular disease²⁶

But perhaps more importantly for the point I’m trying to make is, going on the pill means you don’t get to the bottom of why the person has lost her period in the first place²⁷. To avoid the harmful health effects of losing your period, you need to get to the bottom of what’s causing it; usually, but not always, under-fueling or over-training, it can also be a sign or hormone dysfunctions, such as PCOS.

To be clear, losing your period is harmful, and those harms are permanent and will affect your body forever after, even when your period has returned. Going on the pill is the same as maintaining the status quo – you’re still under-fueling or over-training or suffering another health condition such as PCOS.

Doctors know this (or should).

Olympic coaches know this (or should).

Personal trainers… YOU KNOW THIS NOW.

Doctors and Olympic coaches do, or should, know the fact that the contraceptive pill carries its own risk. There are practitioners out there that can help you if you refuse your missing cycle to be dismissed as “normal” or to be placated by being handed a bandaid such as oral contraceptives.

To learn more about this, there’s a great book by Dr Nicky Keay called “Hormones, Health, and Human Potential” that is a GP’s perspective on the interplay between the environment, our minds, and our hormones in both the male and female body.

In short, the idea that losing one’s period isn’t harmful is a myth. The idea that doctors “wouldn’t let it happen” if it was harmful, is a myth. Doctors and coaches, like you and I, follow their interests when pursuing continuing education. Not all of them are interested in a woman’s best health. I’m sorry if that’s hard for you to hear.

Female Fitness Myth 3 – That Proper Form is the Same For Women as it is for Men…

It’s not.

Our body’s “normal” structures are fundamentally different. Think about how they identify women versus men (and children) in skeletal remains…. They can narrow down the age, sex, and health of human remains hundreds of years post death, and that is not because all our bodies are the same.

So, let’s super briefly talk about a bench press… On three body building websites I looked up, “proper” form was :

1. Lie on the bench with your eyes under the bar
2. Grab the bar with a medium grip-width (thumbs around the bar!)
3. Unrack the bar by straightening your arms
4. Lower the bar to your mid-chest
5. Press the bar back up until your arms are straight

However, the average woman has a different sternum, shoulder, and elbow angle to men. If we followed the instructions above, we’d be loading our anterior deltoids and just the top bit of the pec major. To make a “medium” width grip, we have to rotate our shoulders inwards due to our larger carrying angle. To solve these problems, we can take a wider grip, and arch our backs to move the emphasis to the bulk and belly of the pec major group.

So no, proper form is not the same. We have different vulnerabilities, we have different strengths, we have different needs from our personal trainers. If we revisit ACL injury, for example, where, depending on the sport women are between 2.5 and 9.3x more likely to do an ACL²⁸. The problem is multifaceted, theories about why this occurs include^{29 30 31}:

• Not being paid enough to participate in sport full time (thereby participating in injury prevention and rehab full time)
• Genetics (if someone in their family has done their ACL, they’re at increased risk)
• Hormones, and hormone fluctuations (oestrogen in particular makes women more mobile, and less stable)
• Lower quality playing and training facilities (hard, dry grounds puts more stress on the joints, and one facility was open to the public as a dog park on the weekends, making the ground uneven!)
• Structural differences, including wider pelvis and Q angle.
• Access to, and understanding the importance of strength training. Where men’s programs being working with weights at 12 years old, some professional leagues are still only participating in strength and conditioning haphazardly.
• Less muscle mass, generally around the knee (even when they’re strength training)

Sports scientists and professional sporting leagues such as AFL developing female specific movement and training protocols³² to address these issues one by one, and personal trainers need to do the same.

Key points of difference between the average male and the average female body that will affect what “proper form” looks like, includes:

• Women generally have flatter feet.
• Women have relatively wider hips vs shoulders
• Women have a differently shaped pelvis and pelvic floor
• Women have different rib cage structure and form.
• Women have different “normal” angles at the knees, hips, elbows, and shoulder

To name just a few…

So no, proper form will not only vary person to person, but it will be quite different for a female body than for a male one.

Female Fitness Myth 4 – That Movement Assessment is the Same for Women as it is for Men

It stands to reason that if women have bodies that are different shapes, that “proper form” will look different, and therefore movement assessment is different too.

Women have different bodies and a different hormonal system, and we know that sex hormones affect everything from the ovaries to the brain, so the way they move will be different, not only to their male counterparts, but to themselves depending on what phase of their cycle they’re in.

So to give you a general run down… and keeping in mind there’s a spectrum….

Women are generally more mobile than their male counterparts, so “normal” mobility ranges for them will be different, as will “good”, “average”, and “poor”.

Women are generally less stable than their male counterparts, so normal ranges in balance will differ too.

Women are generally smaller across their upper bodies, so while a “normal” weight might be lighter, they can usually move it through a greater range of motion safely, also affecting what the “normal” range of motion, or “proper form” is!

Women are generally better at endurance, so “normal” time to failure will be later.

Menstruating women will perform better at different tasks at different times of the month, so knowing where she is in her cycle will affect your fitness or movement assessment results.

Because of the structural differences we talked about last week, you’ll need to tweak your movement tests to factor:

• Women generally have flatter feet – this not only affects the hip and knee angle, it also means that “normal” foot placement will change.
• Women have relatively wider hips vs shoulders – some circles think this is why their balance is generally less effective (which is still trainable).
• Women have a differently shaped pelvis and pelvic floor – so when assessing a squat, her femur will move in a different way to a male one. Generally a wider stance with toes pointed out suit’s women’s pelvis, and thereby knees and feet as well, better.
• Women have different rib cage structure and form – we discussed last week how that impacts “proper form” in a bench press, but also explains why they fatigue so quickly in a plank or push up, they’re using smaller muscle groups to do the same movement.
• Women have different “normal” angles at the knees, hips, elbows, and shoulder – so machine’s where they’re locked in either need to be made for a woman’s body, or allow the freedom for them to move the way their body is meant to. Generally, cables and free weights accommodate the female body better.

Which is really just the tip of the iceberg, enough to get you thinking!

Most personal trainers, especially those who have a few years of pattern recognition under their belts, will be more than capable of tweaking their own movement assessments to meet their business and female client’s needs. Also, because you’re probably all using different movement assessment protocols (ie, those of you working with fascia lines will assess movement differently to someone using Grays or the Functional Movement Screen), it’s beyond a 5min live session to go into how I would tweak each and every one, so I am not going to go in to specifics today. Either way, you can’t have a “one size fits all” movement assessment for both male and female bodies.

However, in the interests of an open mind, be aware of the concept of confirmation bias – where you look for data that confirms your own beliefs. Just because ONE woman ONE time successfully lost weight on a calorie restrictive, high intensity, high volume exercise weight loss plan, doesn’t mean it’s good for all women. Just because one, or some, of your female clients are physically able to perform a “perfectly aligned” squat or bench press doesn’t mean it’s the best way to do it for them, or all women should conform to that “form”.

Listen to our full, Female Fitness Myths podcast here: https://www.youtube.com/playlist?list=PLeRAiXlvYPb6UYBn_Qa1qgSaIjoKXWjqe

REFERENCES

2Coelho AR, Cardoso G, Brito ME, Gomes IN, Cascais MJ. The Female Athlete Triad/Relative Energy Deficiency in Sports (RED-S). Rev Bras Ginecol Obstet. 2021 May;43(5):395-402. doi: 10.1055/s-0041-1730289. Epub 2021 Jun 2. PMID: 34077990; PMCID: PMC10304901.

3Khosla S, Oursler MJ, Monroe DG. Estrogen and the skeleton. Trends Endocrinol Metab. 2012 Nov;23(11):576-81. doi: 10.1016/j.tem.2012.03.008. Epub 2012 May 16. PMID: 22595550; PMCID: PMC3424385.

4Papageorgiou M, Dolan E, Elliott-Sale KJ, Sale C. Reduced energy availability: implications for bone health in physically active populations. Eur J Nutr. 2018 Apr;57(3):847-859. doi: 10.1007/s00394-017-1498-8. Epub 2017 Jul 18. PMID: 28721562; PMCID: PMC5861178.

5Popp KL, Cooke LM, Bouxsein ML, Hughes JM. Impact of Low Energy Availability on Skeletal Health in Physically Active Adults. Calcif Tissue Int. 2022 May;110(5):605-614. doi: 10.1007/s00223-022-00957-1. Epub 2022 Feb 16. PMID: 35171303.

6Dookham, Christina MD, FACC (2023) Cardiovascular Consequences of Relative Energy Deficiency in Sport (RED-S) – A Sports Cardiologist’s Perspective acc.org, retrieved 6^th November 2023 from https://www.acc.org/Latest-in-Cardiology/Articles/2022/12/20/18/25/CV-Consequences-of-Relative-Energy-Deficiency-in-Sport

7Hoch AZ, Dempsey RL, Carrera GF, et al. Is there an association between athletic amenorrhea and endothelial cell dysfunction? Med Sci Sports Exerc 2003;35:377-83.

8Rickenlund A, Eriksson MJ, Schenck-Gustafsson K, Hirschberg AL. Amenorrhea in female athletes is associated with endothelial dysfunction and unfavorable lipid profile. J Clin Edocrinol Metab 2005;90:1354-59.

9Melin A., Tornberg Å.B., Skouby S., Møller S.S., Sundgot-Borgen J., Faber J., Sjödin A. Energy availability and the female athlete triad in elite endurance athletes. Scand. J. Med. Sci. Sport. 2015;25:610–622. doi: 10.1111/sms.12261.

10Woods A.L., Garvican-Lewis L.A., Lundy B., Rice A.J., Thompson K.G. New approaches to determine fatigue in elite athletes during intensified training: Resting metabolic rate and pacing profile. PLoS ONE. 2017;12:e0173807. doi: 10.1371/journal.pone.0173807

11De Souza M.J., Mallinson R.J., Strock N.C.A., Koltun K.J., Olmsted M.P., Ricker E.A., Scheid J.L., Allaway H.C., Mallinson D.J., Kuruppumullage Don P., et al. Randomised controlled trial of the effects of increased energy intake on menstrual recovery in exercising women with menstrual disturbances: The “REFUEL” study. Hum. Reprod. 2021;36:2285–2297. doi: 10.1093/humrep/deab149.

12Drew M., Vlahovich N., Hughes D., Appaneal R., Burke L.M., Lundy B., Rogers M., Toomey M., Watts D., Lovell G. Prevalence of illness, poor mental health and sleep quality and low energy availability prior to the 2016 Summer Olympic Games. Br. J. Sport. Med. 2018;52:47–53. doi: 10.1136/bjsports-2017-098208.

13Keay, Nicky Dr (2022) Hormones, Health, and Human Potential , Sequoia Books, Edition 1, Page 135

14Logue D., Madigan S.M., Delahunt E., Heinen M., Mc Donnell S.-J., Corish C.A. Low Energy Availability in Athletes: A Review of Prevalence, Dietary Patterns, Physiological Health, and Sports Performance. Sport. Med. 2018;48:73–96. doi: 10.1007/s40279-017-0790-3

15Drew M.K., Vlahovich N., Hughes D., Appaneal R., Peterson K., Burke L., Lundy B., Toomey M., Watts D., Lovell G. A multifactorial evaluation of illness risk factors in athletes preparing for the Summer Olympic Games. J. Sci. Med. Sport. 2017;20:745–750. doi: 10.1016/j.jsams.2017.02.010

16Mountjoy M., Sundgot-Borgen J., Burke L., Carter S., Constantini N., Lebrun C., Meyer N., Sherman R., Steffen K., Budgett R., et al. Relative Energy Deficiency in Sport (RED-S) Br. J. Sport. Med. 2015;49:417–420. doi: 10.1136/bjsports-2014-094371.

17Mountjoy M., Sundgot-Borgen J., Burke L., Ackerman K.E., Blauwet C., Constantini N., Lebrun C., Lundy B., Melin A., Torstveit M.K., et al. International Olympic Committee (IOC) Consensus statement on relative energy deficiency in sport (red-s): 2018 update. Int. J. Sport Nutr. Exerc. Metab. 2018;28:316–331. doi: 10.1123/ijsnem.2018-0136.

18De Souza M.J., Nattiv A., Joy E., Misra M., Williams N.I., Mallinson R.J., Gibbs J.C., Olmsted M., Goolsby M., Matheson G. Female Athlete Triad Coalition Consensus Statement on treatment and return to play of the female athlete triad: 1st International Conference held in San Francisco, California, May 2012 and 2nd International Conference held in Indianapolis, Indiana, M. Br. J. Sport. Med. 2014;48:289. doi: 10.1136/bjsports-2013-093218.

19De Souza M.J., Koltun K.J., Williams N.I. What is the evidence for a triad-like syndrome in exercising men? Curr. Opin. Physiol. 2019;10:27–34. doi: 10.1016/j.cophys.2019.04.002.

20Miralles-Amorós L, Asencio-Mas N, Martínez-Olcina M, Vicente-Martínez M, Frutos JMG, Peñaranda-Moraga M, Gonzálvez-Alvarado L, Yáñez-Sepúlveda R, Cortés-Roco G, Martínez-Rodríguez A. Study the Effect of Relative Energy Deficiency on Physiological and Physical Variables in Professional Women Athletes: A Randomized Controlled Trial. Metabolites. 2023 Jan 23;13(2):168. doi: 10.3390/metabo13020168. PMID: 36837787; PMCID: PMC9962361.

21Keay, Nicky Dr (2022) Hormones, Health, and Human Potential , Sequoia Books, Edition 1, Page 134

22Ampatzis C, Zervoudis S, Iatrakis G, Mastorakos G. EFFECT OF ORAL CONTRACEPTIVES ON BONE MINERAL DENSITY. Acta Endocrinol (Buchar). 2022 Jul-Sep;18(3):355-360. doi: 10.4183/aeb.2022.355. PMID: 36699167; PMCID: PMC9867809.

23Shufelt CL, Bairey Merz CN. Contraceptive hormone use and cardiovascular disease. J Am Coll Cardiol. 2009 Jan 20;53(3):221-31. doi: 10.1016/j.jacc.2008.09.042. Erratum in: J Am Coll Cardiol. 2009 Mar 10;53(10):904. PMID: 19147038; PMCID: PMC2660203.

24Mu E, Kulkarni J. Hormonal contraception and mood disorders. Aust Prescr. 2022 Jun;45(3):75-79. doi: 10.18773/austprescr.2022.025. Epub 2022 Jun 1. Erratum in: Aust Prescr. 2022 Aug;45(4):147. PMID: 35755988; PMCID: PMC9218393.

25Joan Y. Song, Caroline Delbourgo Patton, Renee Friedman, Lakshmi S. Mahajan, Rachel Nordlicht, Rahman Sayed, Michael L. Lipton, Hormonal contraceptives and the brain: A systematic review on 60 years of neuroimaging, EEG, and biochemical studies in humans and animals, Frontiers in Neuroendocrinology, Volume 68, 2023, 101051, ISSN 0091-3022, https://doi.org/10.1016/j.yfrne.2022.101051.

26National Research Council (US) Committee on Population. Contraception and Reproduction: Health Consequences for Women and Children in the Developing World. Washington (DC): National Academies Press (US); 1989. 4, Contraceptive Benefits and Risks. Available from: https://www.ncbi.nlm.nih.gov/books/NBK235069/

27I should also note, that depending on who you are, and which contraceptive you’re on, there are health benefits for some methods and some individuals as well. This is why a doctor, when weighing up the cost/benefit of contraceptive methods needs to take in to account the individuals lifestyle, health history, illness history, and familial history as well.

28Macmillan, Carrie (2020) Are ACL Tears Really More Common in Women? Yalemedicine.org, retrieved 14^th November 2023 from https://www.yalemedicine.org/news/sports-injuries-gender

29ESPN (2023) Why Women’s ACL Injuries Need More Attention and Education espn.com.au, retrieved 14^th November 2023 from https://www.espn.com.au/afl/story/_/id/38341979/aflw-why-women-acl-injuries-need-more-attention-investmen

30AFL (2021) AFLW Injury Report: ACLs on the Rise, Concussions Stable afl.com.au, retrieved 14^th November 2023 from https://www.afl.com.au/aflw/news/998299/aflw-injury-report-acls-on-the-rise-concussions-stable

31O’Halloran, Kate (2022) Why AFLW Players are up to Six Times More Likely to Injure Their ACLs Than Men abc.net.au, retrieved 14^th November 2023 from https://www.abc.net.au/news/2022-03-20/aflw-acl-injuries-women-men-gender-inequality/100859924