By Laura Smith
Laura Smith is an Assistant Editor at Training & Conditioning.
Training & Conditioning, 13.8, November 2003, http://www.momentummedia.com/articles/tc/tc1308/painfulperiods.htm
In April 1996, Uta Pippig toed the line looking for her third Boston Marathon victory. With a 2:21:45 personal best—almost six minutes faster than her closest rival—Pippig wasn’t expected to have much difficulty achieving her goal.
From the very start, however, it was clear that she was struggling. By mile four, she was considering dropping out of the race. The reason? Excruciating menstrual cramps. When Pippig came back late in the race to win, every media outlet covering the marathon marveled that she had run through the agonizing menstrual pain for a victory.
Winning the Boston Marathon was a highly visible feat, but many female student-athletes who will never reach Pippig’s elite status also fight a monthly battle when they get their period. Whether they’re facing a major competition or simply trying to train effectively, menstrual problems can interfere with athletes’ aspirations at any level.
Individual experiences vary greatly. For some female athletes, the physical and emotional changes during their menstrual cycles are a minor inconvenience, while for others, they cause major disruption. The good news is, athletes don’t have to simply live with it. There are a variety of ways to manage the symptoms, starting with solutions as simple as anti-inflammatories and nutritional changes. For those who choose a hormonal strategy, birth control pills offer another management option. And doctors are finding it’s even okay to use birth control to completely skip having a period for several months, an approach called tri-cycling that’s gaining popularity with athletes.
TABOO TOPIC
As many as 25 percent of high school and college female student-athletes experience menstrual cycle-related problems severe enough to disrupt their training or competition and warrant a doctor’s help, according to Terrill Bravender, MD, MPH, Director of Adolescent Medicine at Duke University. But the vast majority of them don’t seek help, either because they don’t know it’s available or because menstruation is a taboo topic that can be difficult to bring up.
“The biggest mistake female student-athletes make is thinking they have to suffer in silence,” Bravender says.
“Athletes who are proactive and forthcoming about menstrual cycle problems are few and far between,” agrees Kris Ring, LAT, ATC, Head Athletic Trainer at Texas Woman’s University. “Unfortunately, a lot of them still see it as an off-limits topic with a stigma attached.”
“Since athletes are reluctant to bring the issue up, it’s important for athletic trainers to address it,” says Bravender. “If an athlete is suffering in silence, it’s going to affect her performance and her well being.”
Ann Grooms, MD, Team Physician at the University of Florida, finds that team talks can provide a forum for breaking the silence about menstrual difficulties. “It’s an issue that we’re very proactive about,” Grooms says. “I do a series of meetings with every women’s team, and we talk about a variety of women’s health issues. I take that opportunity to bring up menstrual concerns. I tell them, ‘Almost 100 percent of the time, we can find something that will help you. There are lots of options—but first, you have to let us know you’re having trouble.’”
Preparticipation physical evaluations are another good time to broach the subject, according to Randa Ryan, PhD, Associate Athletic Director for Student Affairs at the University of Texas. Most PPE history forms include questions about amenorrhea, but few query athletes about issues such as cramps, fatigue, and emotional ups and downs. “We find it’s helpful to ask those questions and get them into the mix right away,” Ryan says. “That way, we can make sure we catch athletes who are having problems but who are unlikely to bring up the issue on their own.”
If male athletic trainers feel awkward addressing the topic, Bravender suggests they acknowledge the male-female gulf up front. “One approach I recommend is using some self-referential humor to ease the situation,” he says. “If you say, ‘I can’t exactly say I’ve experienced this firsthand, but I’ve heard it can be a real problem,’ you can often get a smile and the athlete will let down her guard.”
Regardless of their gender, athletic trainers need to remember just how much menstruation can effect some athletes. “Be sensitive and listen carefully,” advises Rebecca Morgan, MD, Team Physician at the University of Tennessee. “A lot of people, even other women who don’t experience severe symptoms with their periods, lack empathy in dealing with this issue. If an athlete comes to you, the best thing you can do is take her seriously.”
PHYSICAL SYMPTOMS
For most student-athletes, symptoms that disrupt training and competition appear during the latter half of their cycle and are most intense during the perimenstrual period—the days just before and the first few days of menstruation. Perhaps the most common physical complaint is of cramps.
“When student-athletes come to me with problems related to their menstrual cycles, it’s usually because they have dysmennorhea, or painful periods,” says Morgan. “And the pain is not just abdominal—they often complain of pain radiating into their legs and lower back. They’ll tell me, ‘I’m in so much pain that I can’t train effectively for the first few days of my period.’”
Menstrual cramps are caused by contractions of the uterine muscles in response to molecular compounds called prostaglandins, designed to constrict the blood supply to the uterine lining so that the tissue dies and can be shed. Studies have shown that women who experience menstrual cramps have prostaglandin blood levels several times higher than women who don’t.
Student-athletes are particularly likely to experience severe menstrual cramps during their high school and college years. “For the majority of women, the severity of their cramps tends to fade over time,” says Bravender. “By the time they’re in their mid-20s, it’s not as bad. But college and high school women often experience a degree of pain that can really disrupt their lives.” Other commonly reported symptoms that affect athletic performance include fatigue, headache, and breast tenderness.
Iron deficiency, which occurs more in athletes with lengthy or heavy menstrual periods, is another concern. “About one out of five teenaged girls will become iron deficient at some point during their teenaged years,” Bravender says. “The normal amount of blood loss per menstrual period is less than 80 milliliters. That’s considered a normal period, because that’s the amount of blood the average person can replace each month. But if a woman loses more than that, and doesn’t eat an adequate amount of iron, she’ll become iron deficient. An athlete who is anemic will not be able to perform as well, because of the decreased oxygen-carrying capacity of her blood.”
When a student-athlete experiences problems related to her menstrual cycle, the first step should be to encourage her to see a physician. Not only can the doctor discuss options for managing the symptoms, but an exam may be needed to rule out an underlying pathology.
“There are several serious conditions that can lead to dysmennorhea,” Morgan says. “While they’re rare in women in this age group, no pain management strategy is going to be effective if the student-athlete is suffering from one of them.”
Once serious health conditions have been ruled out, there are two general strategies physicians typically recommend for dealing with menstrual symptoms. One involves the use of anti-inflammatory drugs to control pain combined with nutritional and other lifestyle modifications that may alleviate symptoms. The other involves the use of oral contraceptives or another form of hormonal birth control.
NSAIDs & NUTRITION
Prescription or over-the-counter pain relievers are a simple solution when cramps get in the way of training. However, it’s important to choose the right type of medication. “One very common mistake student-athletes make is using acetaminophen for menstrual pain, ” Bravender says. “Remind them to use non-steroidal anti-inflammatory drugs (NSAIDS) like ibuprofen and naproxen instead. Acetaminophen works to block pain in the brain, but NSAIDs work directly at the site of the pain, and can also help to decrease the actual amount of cramping. And if you treat the cramping and the pain that goes with it, you’ll often treat the fatigue, breast tenderness, and other symptoms as well.”
Using the medication correctly is equally important. “The key is for the student-athlete to begin taking the medication the day before she expects her period to begin, and to take it on a scheduled basis, whether or not she’s experiencing pain,” Bravender says. “It’s much easier to prevent the pain from starting than to stop it once it’s started, so if she waits until she’s having severe cramps, she’s already lost the opportunity for good pain control.” Ibuprofen should be taken every eight hours, and naproxen every 12 hours, through the third or fourth day of the menstrual cycle.
A student-athlete’s diet is another relatively simple place to look for solutions. “For an athlete who experiences fatigue and mood swings around her period, it’s very important to make sure she’s getting adequate carbohydrate in her diet to support serotonin and blood glucose levels,” says Leslie Beck, RD, a Toronto-based dietician and author of Leslie Beck’s Nutrition Guide for Women. “Advise her to eat five or six times a day, and make sure each meal or snack contains some carbs. Focus on choosing carbs that get digested and converted to blood sugar slowly, like fruits and whole grains, because they last longer and keep blood sugar more stable.”
Calcium is also vital. “Studies have shown that women who are given 1,200 mg of calcium a day have as much as a 50-percent reduction in menstrual cramps, back pain, mood swings, fatigue, and food cravings,” Beck says. “Women need 1,000 mg of calcium every day, and most student-athletes don’t come close to that. Each serving of milk or soy milk has about 300 mg, so for every serving a student-athlete isn’t getting, I recommend a supplement.”
Studies have also shown that magnesium helps reduce menstrual-related depression, anxiety, fluid retention, and breast tenderness. A daily dose of 200-360 mg is recommended. “Get a calcium supplement with magnesium in it,” Beck says.
Vitamin B6, at 50-100 mg per day, has also been shown to significantly reduce menstrual symptoms. However, it’s important not to exceed 100 mg per day, to avoid vitamin toxicity. “Student-athletes who are taking a multivitamin or a B complex vitamin should check before they add more,” Beck cautions.
Beck also recommends that menstruating athletes take a daily iron supplement. “They need 18 mg every day, and that’s virtually impossible to achieve through diet,” she says. “Most multi-vitamins with minerals will provide 18 mg of iron, and I advise every woman to take one.”
Herbal supplements can also offer help. “One remedy that has been shown to be very effective, especially for athletes who find that breast tenderness gets in the way of their training, is evening primrose oil,” Beck says. A typical dose is 2-3 grams per day. As with all herbal supplements, it is important to look for a product that is standardized. Beck advises using a product that is standardized to nine percent of the active ingredient, gamma-linolenic acid (GLA).
Beck recommends avoiding caffeine, alcohol, and foods high in sodium during the perimenstrual period, as they can worsen symptoms. Staying well-hydrated can also help ease symptoms.
When a student-athlete opts for a nutritional approach to managing menstrual symptoms, it’s important not to look for instant results. “Tell her not to try something for a month and decide it’s not working,” Beck says. “Modifying the diet is effective, but it takes at least three cycles before she’ll see the full effect.”
HORMONAL OPTIONS
When NSAIDs and nutritional strategies fail to help, birth control pills can often lessen menstrual symptoms, according to Grooms. “If an athlete is really struggling, I recommend she try birth control pills,” she says. “They often lessen cramps and lessen flow, making periods lighter, shorter, and more predictable.”
“Birth control pills contain both estrogen and progesterone in higher amounts than would normally be present in the body,” explains Michael Randell, MD, FACOG, an Atlanta-based physician specializing in women’s health. “The pills feed information back to the brain and the brain shuts down the normal cycling and release of hormones. That prevents the ovary from ovulating. A typical prescription for birth control contains 21 days of combined estrogen/progesterone pills, followed by seven days of placebo pills that contain no hormones. During the week of placebo pills, withdrawal from progesterone causes menstrual bleeding, and then a new pill packet is started.”
The amount of estrogen and progesterone, as well as the form of progesterone, vary depending on the type of pill, so it’s important to find the one that works best for each individual athlete. “Some people have significant menstrual symptoms on one pill that resolve completely on another pill,” Grooms says. “I tell my student-athletes that they need to tell me how it’s going. I always see them within a few months of starting the pill, and I tell them to keep track of the symptoms they have that they don’t like. That will help us choose the pill that’s going to work.”
For student-athletes who want to have fewer periods, physicians recommend using a hormonal contraceptive method continuously for three months, without taking the traditional week-long break each month. This method is known as continuous use or tri-cycling and results in the athlete having only four menstrual periods each year.
Although it’s a relatively new idea, most physicians believe that tri-cycling is a healthy practice. “Studies have shown that it’s quite safe,” Randell says. “There is nothing physiologically beneficial about having a period every month. In fact, having a period every month is really something that’s unique to modern women. Going back in the history of our species, women spent much of their reproductive years either pregnant or breast feeding, and they weren’t having periods during that time. Nowadays, women are having more periods in their lifetimes than we’ve ever had as a species.”
Morgan agrees. “As long as a woman cycles every three months, there really are no negative side effects,” she says. “Going longer than three months can lead to irregular bleeding for some women, because of the build up of endometrium. Otherwise, it appears to be a very safe thing to do. Gynecologists have been doing this for years to treat women with conditions like endometriosis, and we haven’t seen any adverse effects.
“I’ve used this method very successfully with my swimmers for a long time,” she continues. “They can look at their meet schedule and manipulate their pills so they don’t have a period in the middle of NCAAs, for example. It’s very helpful from that respect.”
Randell also feels confident that there are no long-term negative effects. “The risk of thromboembolic disease appears to be no higher than with traditional use of birth control pills,” Randell says, “And there is no evidence that it affects future fertility. I would be perfectly comfortable with a student-athlete using the practice for her entire college career.
“Once women get to age 35, we start to caution them against being on birth control pills,” he continues, “but for a woman in her 20s, this is a perfectly safe practice.”
Eliminating periods may even bring some health benefits. “It’s particularly helpful for student-athletes who have heavy periods and bad cramps,” Grooms says. “If you do the tri-cycles, she has to deal with those bad times a whole lot less frequently. And fewer periods means less risk of anemia.”
Morgan advises her student-athletes interested in tri-cycling to begin by using birth control pills the traditional way first. “Particularly with those who have never been on birth control before, I find it’s important to see how they do for a couple of months,” she says. “Once we know they’re going to tolerate it and they’re not going to have any mid-cycle bleeding, I will teach them how to use it so they can cycle every three months.”
With the FDA’s September approval of Seasonale, an oral contraceptive manufactured by Barr Laboratories of Pomona, N.Y., doctors will soon be able to prescribe a birth control pill designed specifically for tri-cycling. Seasonale contains three months worth of tablets, with 84 active pills followed by seven placebo pills.
Bravender adds one cautionary note for student-athletes who use hormonal contraception and the athletic trainers who advise them. “The use of birth control pills, traditionally or for tri-cycling, can mask amenorrhea, because you eliminate the warning sign of a missed period,” he says. “When a woman is suffering from the female athlete triad, birth control pills may help slow the bone loss, but they don’t stop it. When a student-athlete is on birth control, it’s critically important to pay close attention to her weight and monitor her body composition to ensure that she isn’t suffering from an eating disorder or inadequate energy intake.”
SIDEBAR
HOW THE CYCLE WORKS
The normal menstrual cycle is divided into three phases: the follicular phase, ovulation, and the luteal phase. Two areas of the brain, the hypothalamus and the pituitary gland, control the hormonal changes that drive the cycle. The cycle begins when the hypothalamus sends gonadatopin-releasing hormone (GnRH) to the pituitary gland. GnRH tells the pituitary to release luteinizing hormone (LH) and follicle-stimulating hormone (FSH). LH and FSH target the ovaries, where they stimulate the development of follicles. Each follicle contains an ovum, or egg. As they grow, developing follicles release estrogen, which rises gradually and peaks just before ovulation.
Mid-cycle, around day 14, ovulation occurs when one of the growing follicles bursts, sending an egg through the fallopian tubes on its way to the uterus. After ovulation, the luteal phase begins. The outer walls of the burst follicle form a structure called a corpus luteum within the ovary. The corpus luteum produces progesterone that causes the lining of the uterus to proliferate.
“The progesterone acts like mortar in a brick wall, to maintain the uterine lining,” explains Michael Randell, MD, FACOG, an Atlanta-based physician specializing in women’s health. “If pregnancy occurs, the progesterone level remains high to maintain the pregnancy. But if pregnancy does not occur, the corpus luteum begins to break down after about 14 days and progesterone falls. That has the effect of pulling the mortar out of the uterine wall—the lining is shed through menstruation, and the cycle begins all over again.”
SIDEBAR
PMS OR PMDD?
For some student-athletes, adverse physical symptoms during their menstrual cycles take a backseat to psychological side effects. “I have some student-athletes who are very concerned about changes in their mood and how that is going to affect their competition,” says Kris Ring, LAT, ATC, Head Athletic Trainer at Texas Women’s University. “They can battle through the cramps, but if they’re feeling depressed, anxious, easily frustrated, or extra sensitive to criticism, they’re going to have a harder time performing at their best.”
“The transitional stress of being away from home, the academic stress, new teammates and coaches bring a huge amount of pressure, and that can cause a worsening of premenstrual emotional symptoms for a student-athlete,” agrees Randa Ryan, PhD, Associate Athletic Director at the University of Texas.
Taking birth control pills can help some student-athletes, but it’s not a surefire solution. “Some women with premenstrual depression respond the opposite of the way we’d expect when they start to take birth control pills,” says Rebecca Morgan, MD, Team Physician at the University of Tennessee. “They become even more depressed.” Studies suggest that calcium and magnesium supplements, and a carefully managed carbohydrate intake offer help for premenstrual emotional difficulties.
Teaching student-athletes coping strategies for dealing with premenstrual emotional symptoms can help, Ryan believes. “A female student-athlete who’s suffering from premenstrual depression is likely to engage in a lot of negative self-talk,” she says. “One of the biggest things we work on with female student-athletes is their confidence and self-esteem, so they can silence that negative self-talk.”
“When a student-athlete is suffering from PMS and facing a big competition,” says Ring, “I get her to focus on all of the work she’s done to prepare. Getting her to focus on something she can control—the skills she’s developed and how well she uses them—goes a long way toward restoring her confidence.”
However, an athlete whose emotional symptoms are very severe may be suffering from Premenstrual Dysphoric Disorder (PMDD). Its symptoms are similar to PMS, but much more pervasive. The Diagnostic and Statistical Manual of Mental Disorders outlines the following criteria for a diagnosis of PMDD:
• Depressed mood or dysphoria
• Anxiety or tension
• Unstable, rapidly changing emotions
• Irritability
• Decreased interest in usual activities
• Concentration difficulties
• Marked lack of energy
• Marked change in appetite (overeating or food cravings)
• Hypersomnia or insomnia
• Feeling overwhelmed
“The biggest difference between garden variety PMS and PMDD is how much it affects the student-athlete’s day to day life,” says Morgan. “Ask her how she is getting along with her roommate, her boyfriend, her teammates. Is it affecting her school performance? If her symptoms are causing trouble in all aspects of her life, she could be suffering from PMDD.”
A major part of the PMDD diagnosis is determining whether symptoms have occurred during most cycles of the past year and are clearly documented for at least two consecutive menstrual cycles. The use of a class of antidepressant drugs called serotonin reuptake inhibitors (SRIs) is becoming increasingly common for the treatment of depression related to the menstrual cycle. According to Morgan, a student-athlete who may be suffering from PMDD needs to see a doctor who can provide a diagnosis.