Polycystic Ovarian Syndrome (PCOS) is a very common cause of abnormal menstruation. It can become apparent as early as puberty and is characterized by irregular or absent menstrual cycles often accompanied by coarse midline hair growth on the face, chest, abdomen, and buttocks resulting from excess production of androgens (“Male” hormones) from the ovaries and adrenal glands. It is also often associated with insulin resistance and an increased risk of developing the metabolic syndrome (High blood pressure, high cholesterol, and diabetes).

According to the World Health Organization (WHO) PCOS affects an estimated 8-13% of reproductive-age women with 70% of affected women going undiagnosed worldwide. It is the most common cause of ovulatory dysfunction and is a leading cause of infertility.

This condition exists on a broad spectrum of severity and demographics. PCOS can be mild with minimal to no excess hair growth and slightly longer menstrual cycles, or it can be more severe, where menses are completely absent, and with facial hair growth that requires shaving or other modes of mechanical removal. Women with PCOS can be obese or they can be lean. They may have small cysts or other characteristic findings on ovarian ultrasound examination or they may have completely normal-appearing ovaries. This broad range of presentations has posed a challenge for the medical community in agreeing on the criteria for diagnosis.

Today’s post will focus on the “essentials” for understanding this condition and review the implications for overall health and athletic performance.

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What Causes PCOS?

The symptoms and physical findings seen with PCOS result from an over-production of androgens by the ovaries and the adrenal glands. Laboratory testing will often show elevated testosterone and/or dehydroepiandrosterone sulfate (DHEAS) levels, and elevated fasting insulin and blood sugar levels, but many times this testing will be normal.

The cause-effect relationship between hormonal aberrations that cause disruption of the menstrual cycles and overproduction of androgens and the physical findings of obesity, leanness, insulin resistance, and metabolic syndrome remains elusive and contributes to the challenge of diagnosing and treating this condition.

How is PCOS Diagnosed?

When a female reports a change in her menstrual pattern or loss of menstrual cycles, the first step is to exclude other causes such as thyroid dysfunction, hyperprolactinemia, premature or perimenopause, and fueling/training imbalances, to name a few.

If you are a recreationally or elite athletic female, the first and most critical step is the assessment of low energy availability (LEA) and relative energy deficiency in sport (REDs) as a cause of irregular or absent menstrual cycles. Truth be told, most mainstream OBGYNs and Primary Care providers are not familiar with these conditions, yet, it is a problem that can range between 20%-70% of competitive female athletes across various sports. It is thus critical to involve coaches, trainers, and nutrition specialists when active and athletic women experience menstrual cycle irregularity.

The Rotterdam Criteria is the most widely used diagnostic guideline for PCOS. The criteria for the diagnosis of PCOS include TWO out of three of the following:

1. Irregular menstrual cycles - loosely defined as cycles <21 or >35 days for at least three consecutive months.

2. Clinical or laboratory evidence of hyperandrogenism (elevated male hormone levels) - this can include coarse midline hair growth (face, chest, buttocks), and/or elevated serum testosterone, or adrenal androgens such as DHEAS.

3. Ultrasonographic findings of ≥ 12 follicles measuring 2‐9 mm in diameter and/or an ovarian volume > 10 mL in at least one ovary. This also has been referred to as the “String of pearls” configuration of small follicles within the periphery of the ovaries.

Several other findings are often associated with PCOS that are not part of these criteria for diagnosis including, insulin resistance, elevated serum Luteinizing Hormone (LH) to Follicle stimulating hormone (FSH) ratio on day 3 of the menstrual cycle, and elevated serum anti-mullerian hormone (AMH) levels. Hyperprolactinemia can also be seen in women with PCOS physiology.

Lastly, a rare condition called non-classic congenital adrenal hyperplasia often presents with symptoms nearly identical to PCOS, but is caused by a genetic mutation in genes involved in the steroid hormone metabolic pathway resulting in excessive accumulation of androgens. It is important to identify this condition as it may have implications for pregnancy and the health of the unborn child.

Clinical Implications of PCOS

• Prolonged abnormal menstruation has implications for suboptimal bone density, endometrial hyperplasia (overgrowth of the cells of the lining of the uterus), and infertility.

• Obese women with PCOS have an increased risk of developing metabolic syndrome. The data are mixed regarding whether lean women with PCOS are also at increased risk, however, consensus favors an increased risk of insulin resistance and lipid abnormalities, but to a lesser extent than the obese population.

Implications for Athletic Performance

There is not a lot of study on athletic performance in females with PCOS, however, the data that is available is mixed. Some studies suggest impairment of cardiorespiratory performance in females with PCOS as compared to females without PCOS while other studies suggest greater athletic performance due to higher circulating testosterone levels, particularly in strength-based sports. These studies, along with our clinical knowledge of PCOS raise several questions relevant to female athletes.

1 - How do we optimize fueling in female athletes with PCOS? If women with PCOS experience a predisposition toward insulin resistance, how does this influence recommended carbohydrate intake? Are fatty acids a more favorable fuel source?

2 - Energy Balance. LEA and REDs are common problems that athletes face across the spectrum of competitive sports. According to the 2023 IOC Consensus Statement on REDs, deficient carbohydrate intake is a major culprit in developing LEA and subsequently REDs. The question arises as to how we best keep our insulin-resistant female athletes in energy balance given the potential differences in carbohydrate processing compared to athletes without PCOS.

The answers to these questions are not straightforward as there is a wide spectrum of degrees of insulin resistance (if any) in these athletes, differences in the types of sports that these athletes engage in, and body type (ectomorph, endomorph, mesomorph). I am told by Dr. Stacy Sims (world-renowned expert in nutrition science and exercise physiology and expert on sex differences in athletes) that she is writing a blog post on this very topic. So we should all stay tuned to learn more about the nutrition science and exercise physiology behind this condition in female athletes from Dr. Sims.

Management of PCOS

PCOS has a broad range of severity, physiologic features, and physical demographics. Some women have more profound elevations in serum androgens. Others have notable insulin resistance. Some women with PCOS have neither of these issues and struggle only with irregular menstrual cycles and infertility. Some women are lean. Many are obese. This necessitates an individualized approach to the management of this condition.

• Lifestyle management - In women with PCOS who struggle with insulin resistance and obesity, nutrition management and physical exercise are the foundation for improving symptomatology and reducing the risk and impact of the metabolic syndrome. Implementing a nutrition program focused on low-glycemic carbohydrates and an increase in physical activity can result in weight loss and improve insulin sensitivity leading to more regular menstrual cycles and a lower risk of metabolic syndrome. Lean women with PCOS can also struggle with insulin resistance and lipid abnormalities which may benefit from fitness and nutrition consultation.

• Oral contraceptive pills (OCPs) - The need for the exclusion of other medical causes and ensuring that active women are adequately fueled cannot be overstated. Optimization of fitness and nutrition are essential first steps in managing PCOS. However, optimizing fueling balance, nutrition, and fitness alone may not resolve menstrual cycle regularity or the metabolic effects of this condition. For women who are not interested in conceiving, OCPs can be beneficial for providing cyclic estrogen and progestin exposure for bone and endometrial health and creating more predictable bleeding patterns for convenience. The use of OCPs also can reduce hair growth and acne due to the increase in sex hormone-binding globulin production in the liver.

• Insulin-sensitizing agents - Metformin (a.k.a glucophage, Axpinet, Diagemet, Glucient, Metabet) is a medication used to treat type 2 diabetes and has decades of safety and efficacy data supporting its use in the treatment of PCOS. The use of insulin-sensitizing agents like Metformin can result in more regular menstrual cycles, improvement in blood sugar levels weight loss, and improved fertility.

• Inositol - Inositols belong to the vitamin B complex group and are considered insulin sensitizers. They have a positive impact on menstrual cycle regularity, carbohydrate metabolism, and hyperandrogenism. There are several types of inositols. Myoinositol is the most commonly used and is taken as a dietary supplement. A recent review and meta-analysis of randomized controlled trials showed that inositols were effective in treating symptoms associated with PCOS and showed non-inferiority to Metformin, which is considered the gold standard of treatment.

Female endocrine health is sometimes a complicated landscape to navigate during the normal changes associated with different phases of hormonal life and during times when imbalances in hormone health exist. What is critical regardless of the circumstance is the need for a multi-disciplinary approach to care for athletic women from the avid recreational to the elite professional. Engaging trainers, coaches, nutritionists, and endocrine specialists brings together the needed expertise for optimizing health and athletic performance as women navigate the hills and valleys of their hormonal lifespan.

A Revolution in Women’s Healthcare is coming this November!

Click HERE to join the waitlist for priority booking

Over nearly two decades of medical practice, I am perplexed and disheartened by how mainstream medicine often overlooks the very foundation of good health: nutrition, physical fitness, and mental well-being.

Women of all ages experiencing changing menstrual cycles, fatigue, and even bone fractures are often handed a prescription and sent on their way with not a single question about their training and nutrient intake. Midlife women experiencing menopausal symptoms are met with the mere “you’re getting older” without exploring simple nutrition and movement strategies that could significantly improve their well-being.

Well, help is on the way! Starting in November 2024, I will be launching a women’s specialty telehealth medical practice serving the reproductive endocrine needs of active and high-performing women from puberty through menopause.

For a special “Sneak peek” into the practice, check out my Consultation Services and the Crown Jewel of my practice, the Health and Wellness Concierge service!.

JOIN THE WAITLIST to be among the first to access appointment bookings prior to the official practice launch!

Team! 
Today's edition of Performance Edge is intended to level up your training in virtually any sport or high-performance occupation. Hip extension is a foundational functional movement that drives jumping, running, lifting loads off the floor, and generating momentum for moving loads from the floor to overhead. By training the origination point of these movements, we can improve the execution of any movement rooted in hip extension translating into greater overall performance. 
Enjoy!
-Carla

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Hip extension occurs when you rise from the bottom of a squat to the standing position. In this case, the hip joint “opens” as you rise to a standing position. In simple terms, the “hip joint” is the ball and socket joint where the head of the femur meets the pelvis. Flexion at the hip occurs, for example, when you do a sit-up. As your torso approaches your knees, the hip joint is “flexed” or closed.

The primary muscles involved in hip extension are the gluteal muscles and the hamstrings. This movement is important for walking, climbing stairs, and hiking on uneven surfaces. If you are an athlete, hip extension capacity is helpful for explosive movements such as jumping and running, for weightlifting movements such as squats and deadlifts as well as the Olympic lifts such as cleans and snatches.

Many of us do a lot of sitting during our daily lives. Spending a lot of time sitting where the hips are flexed, can weaken the hip extensors. For this reason, it is important to focus on increasing strength and capacity for hip extension for longevity in performing our activities of daily living and to optimize performance in our athletic endeavors.

Below are 3 workouts that target hip extension strength and power in different ways. Adding one or two of these workouts to your weekly training and rotating among them will help you build overall capacity and power in this movement translating into a level up in your sport or occupation.

Workout #1

Featured movement: Sumo Deadlift High Pull (SDLP)

• The first part of this movement is a deadlift. It is very important to get this part of the movement right to keep your lower back protected. Be sure to keep your back straight- your legs, glutes, and hamstrings are doing the lifting, NOT the muscles of the lower back.

• Next, review the sumo deadlift high pull progression video paying close attention to the mechanics tips in the text.

• Practice! At first, you may want to do a deadlift, pause, then the high pull. This is ok! As you practice and become more familiar with the movement, the two parts of the lift will flow together. Don’t pull too soon! Be sure you are fully extended at the hips (standing up straight) before pulling the bar up.

  • The “shrug” then the “pull” happens the second the hips fully extend. When the hips are extended with some speed or “pop” this begins to move the bar upward which signals the start of the pull. The upper extremties simply guide the bar upward.

TIP! When setting up for the SDLHP, set your eye gaze to a point on the ground 10 ft in front of you. You do not want to be looking straight ahead as this will hyper-extend the neck. Keep the neck neutral by setting your gaze as above.

HOW TO: Set a timer and perform 21 repetitions of the SDLHP, then 1 repetition of your push-up option. Then perform 15 repetitions of the SDLHP and 3 push-ups, and so on until you complete the repetition scheme. Your score is the amount of time it takes to complete the workout.

For Time:

21 - 15 - 12 - 9 - 6 - 3 - 1

Kettlebell Sumo deadlift high pull

1 - 3 - 6 - 9 - 12 -15 -21

Strict Push-up

Workout #2

Featured movement: The Kettlebell Swing

This workout utilizes higher volume in two movements that require hip extension: The kettlebell swing and running! Workout #1 was more strength-based. This workout targets muscle stamina.

Movement Practice: Watch the demo video and take note of the mechanics of the kettlebell swing. Select a moderately heavy weight allowing you to do 15 swings unbroken.

For time: (Break up sets as needed to complete the repetition scheme)

45 kettlebell swings
400-m run
35 kettlebell swings
800-m run
25 kettlebell swings
1,200-m run
15 kettlebell swings

*For advanced-level athletes, the suggested kettlebell weight is 24 kg (35#) for women

Workout #3

Featured movement: The Squat Jump

This workout is about explosive muscle power in the hip extension, which is important for jumping and sprinting. “Power” is the ability to move load quickly. This is quite the opposite of Workout #2 which focuses on higher rep volume and longer duration. Both are important for sports and occupations where physical demands can change abruptly and unexpectedly.

Movement Practice

Practice 5-7 repetitions of each movement, using this practice to select your weights. Once you have selected your weights, perform 8 repetitions of each movement in sequence to simulate the flow of the workout. Once you are confident in your selections and your movements, start that timer!

For the Hip Bridge, choose a moderate weight (plate, dumbbell, or barbell) where you can do the 12 repetitions unbroken. For the squat jump, start in a squat and jump as high as you can. For the OH lunges, select a lighter dumbbell (no less than 10#) and do 24 alternating lunges in place with the dumbbell extended overhead. Switch arms as needed.

How To

Perform each movement in sequence (hip bridge, then jump, then lunge, then rest 1 min = 1 round) at a moderate pace. Don’t be afraid to push the intensity as you have 1 minute of rest at the end of each round.

5 Rounds – For Time

• 12 Weighted Hip Bridge

• 12 Squat Jump for height

  Movement alternative: 12 moderately heavy dumbbell thrusters

• 24 alternating single-arm overhead lunges

• 30 Mountain Climbers (R+L = 2 reps)

• Rest 1 min

Target time: < 20 minutes

Active Recovery

Post-workout recovery is a critical element of training for all ages and fitness levels. Hip extension work requires coordination among some of the largest muscle and joint complexes of the body and thus generates more fatigue and requires more recovery. Active recovery days are essential for the body and mind. Below is a 40-minute yoga sequence from 5 Parks Yoga to help you round out your hip extension training.

Deep Stretch Yoga: Hamstrings and Hips

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Upper body strength can be a trouble spot for many females and for certain sports and high-performing professions, it is essential. Focusing on upper body strength training also “builds a base” of functional capacity and stability surrounding the shoulder joint and the core muscles of the upper back (scapular muscle complex) which lends stability to the shoulder joint as we age. During the menopausal transition at midlife, muscle mass and power decline and the character of tendons and ligaments changes leading to less stability within the shoulder joint.

When we are in our reproductive years, there is a tremendous opportunity to optimize upper body strength and power to excel in sport and occupation, but also to build this base which will promote vitality and longevity into the later years.

One of my favorite upper body strengthening exercises is the push-up. It requires no equipment, can be done anywhere, and can be modified with numerous variations for any fitness level or limitation.

Anatomy of the Push-Up

The mechanics of executing the push-up require the recruitment of multiple muscle groups including the shoulder joint complex and core muscles of the upper back and mid-section. The complexity of this movement is what makes it an effective exercise for improving upper body strength and shoulder joint stability.

Picture credit: Quora

What to do and what NOT to do

It is critically important to do this exercise correctly, with sound mechanics to reap the most benefit and to avoid injury. I was unknowingly doing push-ups incorrectly for years and my shoulders paid the price! Fortunately, after a lot of time, patience, and hard work, I rehabilitated my shoulders and now they are stronger than ever! Don’t let this happen to you. Check out Push-Ups: 6 Common Mistakes (And How to Get Stronger) from WODprep.

The foundational movement is the strict push-up. However, there is a treasure trove of modifications derived from the strict push-up that provides options for any level of fitness of physical limitation. Below is an excellent video tutorial from the CrossFit archives that breaks down the mechanics of the strict push-up so that you can ensure that you are doing it correctly.

Push-up variations also target different muscle groups within the movement itself. For example, the hand-release push-up targets the muscles that are active at the lowest point of the movement - which is often the weakest point and the first to waiver during fatigue for many people - and that is pushing up from a position where the chest is resting on the floor.

Check out this read from The Professional Coach by CrossFit: A Fresh Take on the Lowley Push-Up. This article is for athletes and coaches alike covering a span of push-up options from beginner to more advanced proficiencies.

The Workouts

First things first: The warm-up. No matter what your age or fitness level, warming up the shoulders before doing push-ups is critically important for peak performance and avoiding injury. Some of my favorite exercises for warming up the shoulders are:

• Crossover Symmetry

• Y raises, T raises, Cuban Press, Scap push-ups

• Banded Bully Series by The Ready State - This is a 3-part series that should be performed after warm-up exercises and before your workout begins. This helps with flexibility and optimizing range of motion.

Make it a habit to warm-up the shoulders for 5-10 minutes before your workout begins. This will go a long way in protecting you from injury and optimizing your performance!

Building Volume. The simplest way to build repetition volume and stamina with push-ups is to do them under time pressure. This simple, 8-minute accessory can be done anywhere, performed with other workouts, and can be progressed over time.

• Select a push-up option that allows you to do 5 repetitions with excellent mechanics but becomes challenging by rep 4.

• Set a timer for every 1 minute on the minute (EMOM) x 8 minutes.

• Perform 5 pushups at the start of the minute. Upon completion, use any time remaining for rest.

• As fatigue sets in, you may need to do short sets of 1 or 2.

• Progression: Perform this exercise twice per week. Each week try to add 1 repetition (Ex- week 1: 5 repetitions per minute. Week 2: 6 repetitions per minute). Once you get to 10 repetitions per minute for all 8 minutes, select a more challenging push-up option and start the cycle again.

Building Volume 2.0. Another way to build repetition volume and stamina is a sequential repetition progression.

• Select a push-up option that allows you to do 5 repetitions with excellent mechanics but becomes challenging by rep 4.

• Set a timer for every 1 minute on the minute (EMOM)

• Perform 1 push-up during minute 1. Then 2 push-ups during minute 2, then 3 push-ups during minute 3, and so on until you cannot perform the round of repetitions in the 1-minute interval.

• Progression: If you can exceed 12 minutes, then select a more challenging push-up option.

Now that you have gained proficiency and stamina with your push-up option, we can add the complimentary movement to pushing, which is pulling!

Push-Pull. Here is another 10-minute accessory that incorporates both pushing and pulling and can be progressed in the same way as the Building Volume workout above.

• Select a push-up and pull-up option where you can perform 5 repetitions with excellent mechanics but becomes challenging by rep 4.

• Set a timer for every 1 minute on the minute for 10 minutes

  • Odd minutes: Perform 5 push-ups

  • Even minutes: Perform 5 pull-ups (if pull-ups are not accessible, substitute the barbell or dumbbell bent-over row.

Push-Pull-Jump. This segment incorporates pushing and pulling but adds cardiovascular fatigue

• Select your push-up and pull-up options, again, selecting options where you can perform 5 repetitions unbroken with excellent form and become challenging by repetition 4.

• Set a timer for 12 minutes and perform each movement sequentially for as many rounds of the three movements as possible (AMRAP 12) in 12 minutes. It is ok to break up sets with short rest intervals to pace yourself and complete the 12 minutes without tapping out:

  • 10 push-ups

  • 10 pull-ups

  • 50 single-under jump rope (or 30 double-under jump rope). If no rope, substitute 7 burpees.

• Your score is the total number of rounds/repetitions performed in the 12 minutes. Log your score and try this workout again in 3-6 months.

Level Up Your Push-Pull. This workout builds on the concept of pushing and pulling, but now incorporates a full-body movement called the Sumo Deadlift High Pull (SDLHP). This awesome workout appeared in the Performance Edge sister publication Athletic Aging and is summarized below:

Beginner

5 rounds for time

• 8 SDLHP - Two hands only/PVC pipe/broomstick

• 8 elevated push-ups

Intermediate

8 rounds for time

• 10 SDLHP (10-35 lb kettlebell, 25-55 lb weighted barbell)

• 12 hand-release/elevated/strict push-ups

Advanced

8 rounds for time

• 10 SDLHP (65# barbell)

• 12 hand-release push-ups

For the full workout warm-up, cool down, description, and movement video tutorials, check out his LINK.

So there you have it! Your guide to taking your upper-body strength to the next level! Good Luck!

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Tactical professionals (Firefighters, police, military, and paramedics, among others) are athletes in their own right. No matter what sport the athlete participates in, there is very specific training for the event (or occupation) and then there is “off-season” training that supports event-specific training.

The Tactical Strength and Conditioning (TSAC) report, Issue # 48 USING COMPLEXES TO HELP IMPROVE TACTICAL JOB PERFORMANCE is an excellent review of the rationale behind using weighted complexes for conditioning and offers some sample workouts.

A “Complex” can be a superset of mulitple repetitions of multiple movements consecutively or it can be stringing together multiple movements in a single repetition (Ex - 1 power clean, 1 push press, 1 front squat = 1 repetition of the complex). The major benefit of training with complexes is that they target multiple muscle groups utilizing pushing and pulling movements together with core strength, stability, and muscle power to move the weight. Much like what a tactical professional may encounter in the field. Building on this concept, we can take training with complexes to another level - CrossFit style!

The Next Level of Tactical Training

The definition of CrossFit is “constantly varied functional movement at high intensity”. There are 10 physical skills that CrossFit training targets: cardiovascular/respiratory endurance, stamina, strength, flexibility, power, speed, coordination, agility, balance, and accuracy. The “constantly varied” component creates versatility in training for any type of physical encounter - training for the “unknown” which is critical for tactical professionals.

Another key element of CrossFit methodology is targeting multiple “energy systems” within a given training session. These metabolic energy systems vary depending on the movement duration and primary source of energy for that movement.

Three Metabolic Energy Systems

There are 3 metabolic pathways that provide energy for every type of human activity:

• Phosphocreatine Pathway: Utilizes creatine phosphate to fuel movements lasting < 10 seconds (ex - a 1 rep maximum deadlift). Does not require oxygen (anaerobic).

• Glycolytic Pathway: Utilizes glucose stored in the muscles (predominantly anaerobic) to fuel moderately powered movements lasting up to several minutes (ex- a 1-2 min high-intensity running interval).

• Oxidative Pathway: Utilizes carbohydrates, fatty acids, and protein to fuel low-powered, longer-duration activities lasting several minutes. Requires oxygen (aerobic). (ex - long endurance run).

Building competency with movements in all three pathways sets the stage for developing the adaptive ability to move among these pathways in short periods of time.

An example of how this applies to action in the field would be a firefighter needing to quickly climb multiple flights of stairs stimulating the glycolytic and oxidative systems and then encountering an unconscious victim who needs to be quickly lifted (utilizing the phosphagen system) and removed from the scene. To successfully execute this occupational task, the professional must physically adapt very quickly to the change in physical stimulus.

We can train this “adaptive skill” of moving among the energy systems in the gym when we are off-duty or in the off-season. Here’s an example of a very simple, highly efficient, 20-minute workout that toggles between the oxidative and phosphagen systems:

AMRAP 20 (As many rounds as possible in 20 minutes). Perform these movements consecutively for as many rounds as you can on a 20-minute clock.

• 800m (1/2 mile) run

• 3 heavy deadlifts (quick singles)

Adding another layer to this, we can substitute a barbell or sandbag complex for the deadlift:

AMRAP 20

• 800m run

• 2 repetitions of this complex: 1 -Barbell or sandbag power clean - 1 - push press overhead - 1 -front squat

The magic of this type of workout is that one can achieve the stimulus of an endurance segment alternating with a strength/power segment with many different exercises. For the cardio segment, you can sub a row, burpees, or ski-erg for the run. For the power segment, you can do 3-5 rope climbs or create other complexes. One of my personal favorites is a CrossFit Benchmark movement called the “Bear Complex”:

• 1 Power Clean

• 1 Front Squat

• 1 Push Press

• 1 Back Squat

• 1 Push Press

  ** For an extra challenge use a sandbag or other irregular object (backpack, other heavy equipment, weighted vest, etc)

For a workout focusing on just muscle power, without the cardio stimulus, let’s omit the cardio segment, but add some time pressure instead! Perform one Bear complex every 2:00 for 12 minutes. Alternatively, alternate one of these complexes with a 400-800m run or row. You get the idea! Mix and match these movements for an array of varied training that will take your fitness to the next level!

How Women Benefit from Training with Complexes

Builds a “base” of functional muscle strength, power, and mass: As females age, there is a dramatic decline in bone mass, muscle strength, and power - particularly after menopause (typically age 50-52). Building this “base” during the younger years will pay huge dividends for the longevity of physical performance - in occupation, athletic pursuit later in life, and general vitality and longevity.

Grip Strength: Training with weighted complexes builds grip strength for both male and female athletes. For females, like general muscle strength, grip strength also declines with age. Again, building a base of strength earlier in life helps to preserve it during later years.

Core Strength/Joint stability: Due to cycling monthly hormones and the hormonal changes of mid-life, joints can become more unstable. These power complexes help to develop core strength and a foundation of stability that stabilizes the joints. This is similar to how the foundation of a house lends stability to the structures that emanate from it.

Bone Health: One of the leading causes of loss of independence and vitality later in life is osteoporosis and fracture. Early in life up to age 32, peak bone mass is developing, which is a major determinant of fracture risk later in life. Once beyond age 32, weight training helps to maintain bone density and thus reduces fracture risk after menopause, when bone mineral density declines significantly.

For the Non-Tactical Athlete

Athletes who are not rescuing victims from burning buildings and chasing bad guys over fences can also benefit from training with weighted complexes! This type of training is an excellent addition to any athlete’s off-season training because these movements are functional and involve the simultaneous recruitment of multiple muscle groups, all of which are foundational elements for any sport.

If you are not an athlete but instead someone who wants to live their best life, training with complexes is a great way to add variety to your resistance training routine for all the benefits noted above! If you are a beginner, dumbbells offer a great introduction to these movements. Optimally, spending some time with a trainer to gain proficiency in these movements is the best option for beginners not accustomed to these movements. Whatever your fitness level, sport, or longevity goal, complexes have their place!

Team! 
This debate is escalating and today's post is an attempt to make sense of it all. As someone who makes a career of straddling the fence between medicine and women's athletic performance, I see the ravages of menstrual cycle dysfunction through every stage of female reproductive life - during her reproductive prime and beyond menopause. 
Enjoy!
-Carla DiGirolamo, MD

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For decades, female athletes have struggled with menstrual cycle dysfunction as a result of imbalances in training, nutrition, and recovery. A common cause of this imbalance is low energy availability (LEA) which when persistent, can lead to relative energy deficiency in sport (RED-S).

LEA and RED-S are seen across many different sports. In one study, the prevalence in gymnasts was 44.8%, soccer players, 33.3%, ballet dancers 22%, volleyball players, 20%, and often >50% in long endurance athletes. When LEA and RED-S persist, women can experience impaired physiological function in areas including metabolic rate, bone health, immunity, protein synthesis, cardiovascular health, and menstrual cycle dysfunction among others. This was previously known as the Female Athlete Triad.

The menstrual cycle is very closely tied to energy availability and the stress response system. This makes sense because the biological purpose of the menstrual cycle is to promote pregnancy, which is highly dependent on energy availability for the mother and fetus. When there is an imbalance in energy availability and expenditure, the menstrual cycle is turned off because it is unfavorable to become pregnant when there is not enough energy to feed the mother and fetus.

When menstrual cycles become irregular or stop completely, there are consequences that include infertility and when prolonged, bone loss and increased risk of fracture. The reason for this is that irregular or loss of menstrual cycles results in decreased cyclic exposure of the tissues (such as the bones) to estrogen. When bones “see” less estrogen, the balance in bone metabolism shifts away from bone building, which negatively impacts bone mineral density. This is especially critical in women < age 30 because this is the period of time when the skeleton is acquiring its peak bone mass - a major factor in a woman’s risk of osteoporosis and fracture as she ages.

Disordered eating and dysfunctional relationships with food are often a component of the LEA and RED-S seen in female athletes from a very early age. Another contributing factor is a lack of high-quality research on how best to fuel female athletes for peak performance. Applying training and fueling principles of male athletes to females has led to overtraining and under-fueling the female athlete and thus the alteration or loss of menstrual cycles - which in some circles is considered “normal” and even more tragically, an achievement.

When a female experiences a change or complete loss of her menstrual cycle, the first step is to identify the cause. It is fairly routine in gynecologic practice to perform examinations and laboratory testing to exclude medical causes of menstrual cycle changes. However, the athlete suffering from LEA or RED-S can be more elusive because test results often do not reveal this energy imbalance. Once medical causes have been excluded, this is often where providers will prescribe OCPs.

But this does a disservice to the athlete - because there is a whole other realm of “root cause” that extends beyond mainstream medicine and that is optimizing fueling, training, and recovery for the female athlete. For this reason, the athlete’s medical providers, trainers, and nutrition experts need to work collaboratively to resolve these imbalances and facilitate the return of regular menstrual cycle patterns. Sadly, this level of collaboration is not the norm.

Fortunately, an increasing amount of high-quality information and research is surfacing to inform coaches and trainers of how best to fuel and train female athletes to optimize performance and preserve menstrual function. When females experience changes in their menstrual cycles, they should inform their doctors and their coaches immediately so that the root cause of the change can be identified and managed.

However, managing the root cause of LEA and RED-S does not always work. As a fertility and menopause specialist, I have seen many retired collegiate and competitive athletes who are no longer subject to the rigors of training and competition but continue to have abnormal or absent menstrual cycles. These women struggle with infertility and in some cases, osteoporosis soon after menopause onset.

In gynecologic practice, it is common to prescribe oral contraceptive pills (OCPs) that contain an estrogen derivative and a progestin to “regulate” irregular menstrual bleeding patterns. There are 2 ways in which OCPs function. First, as a contraceptive, OCPs suppress or disrupt ovulatory function at the level of the pituitary gland, and the chronic progestin exposure thins the uterine lining creating an unfavorable environment for implantation of a conceptus. Second, OCPs create more regular bleeding patterns with the cyclic 3 weeks of exposure to estrogen and progestin, followed by a pill-free week where the absence of these hormones allows the lining of the uterus to shed.

Unpredictable bleeding patterns can be bothersome to women, so creating more predictable bleeding cycles can be favorable. As mentioned previously, long-standing absent or irregular menstrual cycles is a risk factor for developing osteoporosis later in life and can compromise bone health. OCPs have been used to provide regular exposure of estrogen to the bones which is thought to help prevent bone loss.

Although OCPs may generate more predictable bleeding patterns and provide bones with regular exposure to estrogen, they do not address the root cause of the cycle irregularity. This is where mainstream medicine gets tripped up because there is not a clear understanding among most general practitioners of LEA, RED-S, and optimizing female athletic performance.

But let’s not be so quick to demonize the OCP. As I mentioned previously, excluding medical causes and optimizing fueling, training, and recovery does not always normalize the menstrual cycle. Once these efforts have been exhausted, treatment with OCPs is often considered in an effort to mitigate the risk of future bone loss, osteoporosis, and fracture. For the athlete who wishes to pursue pregnancy, there are very effective treatments that help restore ovulation and achieve pregnancy.

The notion that OCP use in younger women can prevent bone loss and reduce fractures is controversial. There are no high-quality randomized controlled trials that definitively argue for or against this in younger women with menstrual cycle dysfunction. However, for young women with hypoestrogenism due to primary ovarian insufficiency or premature menopause, hormone therapy is essential for mitigating the risks of bone loss, dementia, and cardiovascular disease.

Although the physiology of premature ovarian insufficiency is different from hypoestrogenism due to other causes, the study of this population underscores the risk of bone loss and other chronic conditions that can occur with chronic menstrual cycle absence or dysfunction. One could further argue that women with LEA and RED-S are at even greater risk of bone loss than women with POI due to the additional struggle with metabolic imbalances and reduced protein synthesis.

Another treatment that is worth considering is the use of low-dose estradiol patches for bone protection in young female athletes with menstrual dysfunction. There are favorable data from studies of menopausal women showing that ultra-low doses of estradiol can afford significant bone protection. However, these studies may not necessarily be translated to the reproductive-age population. The loss of cyclic estrogen in menopausal women and the loss of cyclic estrogen in young female athletes are two very different physiologic scenarios. Certainly, low-dose estradiol treatment is worth studying in these young female athletes given the scope of the problem in this population.

Summary

Here are the key takeaways for the role of OCPs in young athletes with menstrual cycle dysfunction.

• Prolonged irregularity or absence of menstrual cycles in young women - regardless of cause - is a known risk factor for developing osteoporosis later in life.

• LEA and RED-S are common causes of menstrual cycle dysfunction in female athletes.

• Laboratory evaluation may exclude medical causes but may not reveal energy imbalances of LEA and RED-S. For this reason, collaboration among medical providers, trainers, and nutritionists is paramount for optimal care of the female athlete.

• Effectively managing the root cause of the energy imbalance is critical for preserving the female athlete’s health and achieving optimal physical performance.

• Do not demonize the OCP! Despite best efforts for managing training, nutrition, recovery, and excluding medical causes, restoration of menstrual function may not happen. For these women, it is reasonable to consider OCPs in an effort to provide protection against bone loss, osteoporosis, and fracture given the benefits of hormone therapy seen in the POI population. That being said, randomized controlled trials in young women with refractory menstrual cycle dysfunction have yet to prove benefits for mitigating bone loss and preventing fracture.

• More study is needed on the use of ultra-low-dose estradiol patches for bone protection in young female athletes with menstrual cycle dysfunction.

References

Dave SC and Fisher M: Relative Energy Deficiency in Sport (RED-S). Current Problems in Pediatric and Adolescent Health Care; 2022 vol 52 (8) 101242. doi.org/10.1016/j.cppeds.2022.101242

Mountjoy M et al: 2023 International Olympic Committee’s (IOC) consensus statement on Relative Energy Deficiency in Sport (REDs). Br J Sports Med 2023;57:1073–1097. doi:10.1136/bjsports-2023-106994

COMMITTEE OPINION #634 2015: The American College of Obstetricians and Gynecologists: Menstruation in Girls and Adolescents: Using the Menstrual Cycle as a Vital Sign

COMMITTEE OPINION #698 2017: The American College of Obstetricians and Gynecologists: Hormone Therapy in Primary Ovarian Insufficiency

COMMITTEE OPINION #740 2018: The American College of Obstetricians and Gynecologists: Gynecologic Care for Adolescents and Young Women with Eating Disorders

NAMS Position Statement Management of osteoporosis in postmenopausal women: the 2021 position statement of The North American Menopause Society; Menopause 28(9) 2021. DOI: 10.1097/GME.0000000000001831

Females are an important part of tactical professions such as firefighters, police, paramedics, and military personnel, among others. These professions require an elite level of fitness that answers to the unexpected and can go from “zero to hero” in an instant. No physical task on the job is exactly the same, so these professionals need to train for the unexpected.

Just like athletes who train for their particular sport, tactical professionals train for their occupation. This includes drills that simulate real-life situations, such as carrying a victim from a burning building, jogging or hiking distances wearing 25 pounds of gear, climbing ladders, jumping over fences, and the list goes on. Just as the skill sets required to excel in a particular sport are specific to that sport, the physical skill sets for tactical professionals are specific to their particular occupation. From this arises to conception of “work fitness” and “gym fitness”.

To gain and improve proficiencies in the skills specific to a particular tactical profession, it is important that “gym training” compliments the unique physical demands of tactical occupations. Further, fueling, recovery and injury prevention are just as important as physical training.

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Special Considerations for Female Tactical Professionals

Adequate fueling. This is one of the most important aspects of training for any female who engages in activities requiring a high level of physical performance. Due to the direct hormonal connections between energy availability, the stress response, and the menstrual cycle, a female’s ability to achieve peak physical performance is largely driven by energy balance.

For tactical professionals the workday can be unpredictable, so regular meals may not be an option on some days. Here are some suggestions:

• Food prep - On days off or when you are off-shift, set aside some time to prepare food in bulk for the week. In addition to meals on the go, portable snacks are a great option for those non-stop days when a sit-down meal is not possible

  • High Protein Snacks that are portable

  • Vegan high-protein snacks

• Ensure adequate protein - Muscles need protein to repair and recover after physical intensity. Target protein consumption for high-performing women is 1g of protein per pound of body weight.

• Don’t skimp on the carbs! - Optimal performance requires your “gas tank” to be full. Glycogen (the storage form of carbohydrate) is found within the liver and skeletal muscle and is responsible for the initial burst of intensity when duty calls. Some high-quality carbohydrates include sweet potatoes and other root vegetables, brown rice, steel-cut, and rolled oats, and whole-grain breads (watch out for the added sugar - Dave’s Bread is my personal fav!)

• Nutrient timing. After a training or drill session or a physically intense call, be sure to have an on-the-go snack. Giving your body a little something shortly after exertion will go a long way toward effective recovery - especially if a sit-down meal is not possible.

Training. The mainstay for training for the tactical professional is the drills specific to each occupation. Gym training lends support to the drills to help build a base of general strength, stamina, and particularly muscle power.

• Functional training. Methodologies such as CrossFit were inspired by Navy Seal training and are designed to prepare the athlete for anything they may encounter. The focus of training is proficiency in 10 physical skills and constantly varied functional movement at high intensity. This type of training is well-suited for the unpredictable situations encountered by tactical professionals.

• Utilizing “Complexes” to build strength, stamina and power. Complexes are a series of weighted movements performed consecutively without recovery and target a wide range of complex muscle groups. To learn more about complexes and their role in tactical training, check out this NSCA TSAC report.

• Upper body strengthening accessory. Many women struggle with upper body strength. Try adding this 8-minute accessory sequence onto a training or drill day twice per week.

  • EMOM (every minute on the minute) x 8 minutes

    • Odd minutes - perform 5-10 strict push-ups (depending on ability) - To scale the movement, use an incline (hands on a stable bench or box and progressively, over time, lower the incline angle until you can do them from the floor)

    • Even minutes - perform 3-10 strict pull-ups. If you cannot do strict pull-ups, try these scaled options.

      ** The goal is to complete the repetitions in 30-40 seconds and leave the remaining time in the 1-minute interval for rest. Stay strict with the time domain! This is where the magic is.

Recovery and Injury Prevention. Unlike controlled athletic events and training sessions, the physical demands of the tactical professional do not allow for a thorough warm-up and cool-down. When the situation demands instantaneous intensity, this can increase the risk of injury, making recovery from “just another day at the office” that much more important.

• General tissue care - Foam rolling, mobility work, massage, cold plunges, steam/sauna

• Sleep - Sleep is essential for effective recovery. It is sometimes helpful to track sleep with wearable technology such as a WHOOP! Strap or an Oura ring.

• Joint care - The demands of tactical occupations can put great stress on the shoulders, knees, and hips. It is important to spend time caring for the supporting muscles of these joints to provide stability, mobility, and flexibility and reduce the risk of injury.

  • Shoulders: Strengthening the rotator cuff and scapular complexes lends stability to this joint. My go-to rotator cuff strengthening system is Crossover Symmetry. Exercises such as Y-raises, T-raises, Cuban Presses, scapular push-ups, and scapular pull-ups are also effective.

  • Knees: It is well-known that women are at greater risk for anterior cruciate ligament (ACL) injuries as compared to men. There are many possible reasons for this including body mechanics, anatomical, and muscular differences, but there are steps that can be taken to minimize the risk. Learn more about ACL injuries and prevention from this piece published in the Female Athlete Series from Boston Children’s Hospital.

  • Hips. The hips bear the brunt of many functional movements as they are what articulate the largest muscles and bones of the body in the lower extremities and support the weight of the rest of the body above it. Hip-focus yoga sequences are an excellent way to recover the hip joint and the large muscles surrounding it. Five Parks and Pelaton have excellent hip-focused yoga sequences.

• Mindfulness and meditation. Tactical professions are not only physically challenging but also mentally challenging given the circumstances under which their service is needed. For effective recovery, the stress response needs to return to baseline and from both the mental and physical standpoint. Headspace is an excellent app that teaches mindfulness and meditation in short, doable timeframes and has targeted practices for anxiety, sleep, parenting, and job stress among others.

I’m not a Tactical Professional but I Want to Train Like One

Training for the unexpected utilizing a wide range of modalities and physical skills is something that everyone can benefit from even if they are not tactical professionals. Functional training helps maintain fitness for movements that are part of everyday life which can promote longevity and physical independence even into the 8th, 9th, and 10th decades of life. Functional movements are infinitely scalable with movement options suited for any fitness level or limitation.

CrossFit has a functional fitness workout series emailed to your mailbox daily which includes advanced, intermediate, and beginner options. The sister blog to Performance Edge, Athletic Aging, has a weekly functional fitness workout series with additional modifications for limited equipment availability. There is also a FREE library of these workouts in the Athletic Aging archives. These workouts are a great start for anyone who is not a tactical professional but wants to train like one!

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Welcome to the September edition of Performance Edge! This month we are doing things a little differently with a podcast!

Today’s episode was inspired by a session I attended at the Female Athlete Conference in Boston, Massachusetts, where a panel of elite and professional female athletes shared their struggles when their identities as athletes conflicted with their roles as new mothers after giving birth to their first child. This hit home for me personally, as I remember struggling with my own identity as a partner physician in a multi-million dollar medical practice when I had my son 17 years ago.

Whether you are a competitive athlete or high-level professional who has dedicated your life to your sport or career, there may have been times when the very core of your identity clashed with other life roles. In Episode 1 of the Performance Edge Podcast, Erika Snyder discusses her struggles and triumphs while navigating the identity clashes that she encountered throughout her life as a professional athlete, entrepreneur, through the loss of her father, and as a new mother.

Erika is a former professional CrossFit competitor who competed at the CrossFit games with her team in 2011. She and her husband, Sam, own CrossFit One Nation in Needham, Massachusetts. Erika also works as a Health Coach for Wild Health. She is an Executive Leadership Coach for women in the health and fitness industry and she is also a mom to her beautiful son, Max, who turns 1 year old today! Connect with Erika @erika_snyder_ and @fullroe

I hope you enjoy today’s episode!

Housekeeping…

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Historically, studies investigating athletic performance have focused mostly on male athletes. Knowledge from these studies has been applied to female athletes, but unfortunately, what is good for the gander is not always good for the goose!

Females are different. As Dr. Stacy Sims and others have said so accurately, “Women are not small men”. Our physiology is vastly different from males and thus our nutrition requirements, response to training, and recovery - you name it - require different approaches from what is effective for our male counterparts.

One of the key differences between females and males is the monthly menstrual cycle. We have spent a lot of time in Performance Edge learning about the menstrual cycle, what happens when the cycle changes, and how female hormonal physiology serves as a driver of performance. But how do we use this information to gain that edge in athletic performance?

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Menstrual Cycle Phases - Some Physiology

The menstrual cycle can be divided into 3 phases:

Follicular phase: The follicular phase begins on the first day of heavy menstrual flow (Day 1) and ends at the time of ovulation, midway through the cycle (~Day 12-18). During this time, the pituitary gland is signaling the ovary, via follicle stimulating hormone (FSH), to begin the maturation of an egg for ovulation. As the egg develops, there is a concomitant rise in estrogen production by the ovary.

• Training implications: During this time the rise in estrogen favors an anabolic (growth) environment for skeletal muscle, increased capacity for glycogen storage, and less dependence on fatty acid utilization and oxidative pathways resulting in less fatigue. Bursts of high-intensity and heavy lifts may be favored during this time.

Ovulation: Marked by the surge in luteinizing hormone (LH) production by the pituitary gland which signals the ovary to release the mature egg for pick-up by the fallopian tube (~36 hours).

Luteal phase: Begins after ovulation and extends to the start of the next menstruation. During this time, the rise in estrogen and progesterone production by the ovary prepares the uterine lining for implantation and pregnancy.

• Training implications: Although estrogen levels remain elevated following ovulation, Progesterone is now the dominant hormone of the luteal phase. Following ovulation, there is a rise in basal body temperature which can result in a subjective feeling of increased exertion. Progesterone is a more catabolic (breakdown) hormone and antagonizes the effects of estrogen on glycogen storage and metabolism in skeletal muscle and may increase dependence on fatty acid utilization and oxidative pathways. The progesterone dominance of the luteal phase may also blunt protein synthesis in the skeletal muscle impacting muscle repair and recovery. Increased attention to protein intake and recovery activities may be favored along with more low-intensity, endurance activities.

Does Training with the Menstrual Cycle Improve Athletic Performance?

This is a very hot topic with much debate surrounding it. The underlying basis that complicates this question is the high level of variability among each individual’s menstrual cycle pattern and experiences surrounding her cycle. This high level of variability makes the study of populations difficult because to see statistically significant differences in the setting of high variability, large study populations are needed to achieve statistical power to demonstrate these differences if they exist. Unfortunately, the current research in this area is of low to moderate quality and thus cannot definitively conclude - for or against - any benefit of synchronizing training with the menstrual cycle.

What is interesting is that according to experts presenting at the Female Athlete Conference in Boston, MA this year, 60% of athletes surveyed in a recent study report that they subjectively believe that their menstrual cycles impact their training and performance.

Although the aforementioned studies do not show evidence of a benefit of cycle-synchronized training, Dr. Stacy Sims, a leading expert in exercise physiology and nutrition science refutes these studies in her blog post Cutting Through the Confusion of Cycle-Synced Training.

Training with Awareness of Your Menstrual Cycles

Although the debate over whether there is a benefit to cycle-synchronized training continues, one thing that the experts can agree on is that an athlete’s awareness of her menstrual cycle is greatly beneficial for the following reasons:

• Every female’s cycle and the experience surrounding her cycle is as unique to her as her fingerprint.

• Changes to her usual pattern of menstruation may signal an underlying physiologic issue that could be negatively impacting her performance and/or overall health.

• More than 60% of athletes surveyed in a recent study report that they subjectively feel that their menstrual cycle impacts their training and performance.

Even though population data does not support a recommendation for cycle-synchronized training, the fact that many athletes perceive an impact of their cycle on their performance cannot go unnoticed. Perhaps this is the reason why the debate continues.

Despite no clear consensus on this issue, cycle-synchronized training is another tool in the training “toolbox” for athletes to consider on an individualized basis. For some great resources on how to synchronize training with your menstrual cycle, check out this blog post from Dr. Stacy Sims Nail a PR at Every Phase of Your Menstrual cycle, and this great Podcast appearance with WHOOP! Dr. Stacy Sims Answers Members’ Questions on Training and Menstruation

A Word about Hormonal Contraception

A significant number of female athletes use hormonal contraception. As such, questions have arisen about the potential effects of hormonal contraception on training and performance.

This is a complicated subject because females use hormonal contraception for other reasons than to prevent pregnancy. Some females have painful, heavy menstrual cycles that can leave them on the couch for days. Other females experience irregular menstrual cycles and use hormonal contraception to make uterine bleeding more predictable. Irregular cycles can be anxiety-provoking due to an unexpected bleed during an athletic event. Others may have irregular cycles despite all efforts to optimize energy availability and use estrogen and progestin contraception to help prevent bone loss.

So to make a statement about whether hormonal contraception has an impact on athletic performance, one must consider the underlying reason for using hormonal contraception. If an athlete has heavy painful menses that leave her on the couch for days, it is likely that her performance improves while taking hormonal contraception. For females with otherwise normal cycles who are using hormonal contraception strictly for the prevention of pregnancy, there appear to be some trends regarding the impact on athletic performance.

According to a summary of some recent studies, combined estrogen/progestin hormonal contraceptive pills can blunt gains in muscle size and strength, increase cortisol levels, decrease VO2 max, and increase oxidative stress. Estrogen/Progestin contraception is also associated with an increased risk of thromboembolism (deep venous blood clots). Although rare, these blood clots can lead to life-threatening pulmonary emboli (blood clots in the lungs). But to lend some additional perspective, pregnancy has a risk of thromboembolism that is far greater than the risks associated with hormonal contraception.

Progestin-only contraceptive methods tended to have less of a detrimental impact on performance when compared to estrogen/progestin methods according to some studies. These methods include the “mini-pill” or subdermal implants. Lastly, the progesterone intrauterine device (IUD) (Mirena, Liletta, Skyla, Kylena) affords superior contraception with minimal systemic exposure to synthetic hormones. The copper IUD is also a very effective method that contains no synthetic hormones. Caution must be used with some types of progestin-only contraception due to the risk of bone density loss with extended use.

Another consideration when using hormonal contraception is that bleeding patterns are not a result of ovulation as occurs with the natural menstrual cycle. These therapies add predictability and control over uterine bleeding by suppressing the natural patterns of the hormonal cycle, which can be favorable for the reasons noted above. However, low energy availability (LEA) remains a very common problem among female athletes affecting their performance and overall health, and menstrual cycle changes are a strong correlate that can signal LEA and relative energy deficiency in sport (RED-S). When using hormonal contraception, the menstrual cycle is no longer available as a barometer of energy status and can potentially mask this problem unless close attention is being paid to other indicators of LEA and RED-S.

Data are mixed and many would argue, and rightfully so, that there is not enough evidence to advise athletes against the use hormonal contraception for the sake of optimizing athletic performance. Reproductive freedom remains paramount to the well-being and quality of life for any female athlete and should be prioritized in any decision making surrounding contraceptive methods.

In Summary…

• Female athletes can benefit from awareness of their menstrual cycles.

• The current studies investigating the potential benefits of menstrual cycle-syncrhonized training are insufficient to definitively recommend for or against this practice.

• Despite the lack of evidence for performance benefits on a population basis, cycle-synchronized training is a tool that is available for athletic training on an individualized basis.

• A significant number of female athletes use hormonal contraception for many different reasons.

• There is not enough evidence to recommend against the use of hormonal contraception for concerns over athletic performance, however, some trends in the literature warrant some attention.

• Hormonal contraceptive methods can mask natural menstrual cycle patterns and thus mask a key indicator of LEA and RED-S.

• Reproductive freedom and quality of life of the female athlete should be prioritized in the decision-making surrounding the selection of contraceptive methods.

My Friends! 
Very often I come across random nuggets of knowledge that I find helpful for my every-day life as a fitness professional, physician, mom, athlete - whatever hat I might be wearing at any given moment! Here are just a few from my collection that I wanted to share with you!
I hope you find them helpful too! 
Enjoy!
-Carla

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Let’s Talk Food!

Fueling your training for your sport or high-performance profession is paramount for optimizing overall health and performance. Women are classically very sensitive to energy deficiency states as evidenced by the high incidence of menstrual cycle irregularities, stress fractures, and low energy availability (LEA) in the female athlete population.

So when we fuel our training we need sources that are packed with protein, healthy fats, high-quality carbohydrates, a wide variety of fresh fruits and vegetables, as well as appropriate supplementation. Below are some links to two of my favorite recipes that help you give your body what it needs to train and perform.

Rainbow Thai Peanut Chicken Wraps from Ambitious Kitchen

Believe it or not, the magic in this recipe is in the rainbow slaw and less the chicken! I wanted to share this because a forgotten player in the fueling equation is our gut microbiome. Fresh fruits and veggies are key to a healthy gut which is key to making the most of the food we eat to support our best performance. This awesome summer recipe can be made vegetarian or vegan pretty easily by substituting tofu or other plant protein for chicken.

Slow-cooker Turkey Chili from Two Peas and their Pod

This one is a great fall/winter dish with its comfort food flare. What I love about it is the diversity of nutrients with high-quality plant-based protein as well as lean poultry (which can be omitted if you are vegan or vegetarian) and it is chock full of veggies! You can make a big batch in the slow cooker and have leftovers for the week!

Performance

If you are a high-performing female in any profession or sport, you undoubtedly have your “medicine cabinet” of supplements. Some are new, some are old and some are just sitting on the back of the shelf collecting dust, pushed aside by the newest in supplement “fads” and promises to help you leap tall buildings. It’s an information abyss that can be confusing. Check out this article by Selene Yeager, Pro off-road cyclist, and former All-American Iron Man Triathlete who cuts through the fluff and reviews which supplements have particular benefits for female athletes: 5 Sports Supplements Female Athletes

Proper recovery from training, sport, or profession is critical for improving fitness and ensuring readiness for the next physical encounter or event. But many times, due to time constraints or just the lack of desire, this important part of training can be left behind. Check out this great article from Kineon “Hiit Recovery tools to get you back in the box” for some great tips and tools for how to best recover from your high-intensity training.

One of the greatest challenges that female athletes face across all age groups is low energy availability (LEA) and Relative Energy Deficiency of Sport (RED-S). There are many drivers that lead to these conditions including limited research surrounding how to fuel female athletes as compared to males and the pressures of sports with weight class or aesthetic requirements just to name a few. Further complicating this problem is the prevalence of disordered eating in the female athlete population. This is an excellent article published in Morning Chalk Up from the point of view of a coach on how to approach athletes struggling with these issues. Coaching Athletes with Eating Disorders and Body Dysmorphia

Training

Whether you are a seasoned athlete, firefighter, paramedic, police officer, or member of a military special forces division, the skills, and fitness required to excel are founded in the movements we do every day - also known as “functional movements”.

CrossFit methodology combines various functional movements to achieve different stimuli or fitness effects. Below are three CrossFit “benchmark” workouts to supplement your training and track over time as a way to measure your level of functional fitness”.

“Nancy” - Running and overhead squats test your ability to adapt between strength and endurance energy systems and target shoulder and hip mobility and stabilization.

“Karen” - This workout is a test of mental and physical grit utilizing the “wall ball shot”.

“Fran” - A CrossFit “original” known for its soul-crushing capacity in under 10 minutes with two simple movements - the pull-up and the barbell thruster.

So far in Performance Edge, we have learned a lot about female physiology! In earlier posts we have discussed the menstrual cycle, what it means when the menstrual cycle changes as well as the important role that the stress response plays in our physiologic balance and as the driver of physical performance.

Today we are putting it all together to better understand the Female Athlete Triad - a constellation of physiologic processes that occurs as a result of a sustained imbalance among fueling, recovery, and training.

The Female Athlete Triad was originally defined in an American College of Sports Medicine position statement published in 1972. It describes a condition in physically active young women that includes low energy availability (LEA), menstrual cycle dysfunction, and low bone mineral density (BMD). When the caloric amount and/or types of macro and micronutrients do not adequately fuel an athlete’s physical expenditure, this is referred to as low energy availability (LEA). When LEA is sustained, there are significant, detrimental physiologic changes that occur and are referred to as relative energy deficiency in sport or RED-S.

Today we are going to review the details of this triad of physical findings, how to identify them, and things you can do to keep your body in balance and at peak performance.

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The Triad

1 -Low Energy Availability (LEA)

The imbalance between fueling and physical expenditure comes in many forms and is not as simple as just “calories in and calories out”. Nutrients are just as important as energy. Below are some examples of how fueling imbalance can happen:

• Inadequate caloric intake - Although this is not the whole story, it plays an important role. The nutrients we consume are the “potential energy” the body uses to carry out its functions. A 9V battery cannot power your Tesla.

• Imbalance of macronutrients - The Human body requires carbohydrates, proteins, and fats to function optimally.

  • Carbohydrates are the main source of energy or “battery juice” for cells to function. When carbohydrate is insufficient, the body starts breaking down proteins, most notably muscle tissue, to obtain the energy it needs to function.

  • Proteins provide the “building blocks” for muscle, bone, and other bodily tissues. If protein is insufficient, tissues cannot repair properly. Muscle, bone, tendons, and ligaments suffer creating inflammation that further limits the ability of the body to repair and prepare for the next physical task.

  • Fats serve as the structural component of cellular membranes of every cell of the body and serve as long-term storage of potential energy. When fats are insufficient, cellular integrity suffers resulting in skin rashes, hair loss, and potentially immune system dysfunction.

• Nutrient timing - The body needs fuel when it needs it! There is a “baseline” need at rest to perform “routine” bodily functions and an acute need when a physical task is upon us. To satisfy both needs, a consistent, continuous supply of nutrients is needed for optimal function, with extra nutrition surrounding physical tasks.

  • One large meal during the day - Our professions and life, in general, can make it difficult to eat multiple times throughout the day. This creates a situation where the body dials down metabolic processes during the hours without food to conserve energy. Even when caloric and macronutrient volumes and ratios are appropriate, when consumed only once during the day, the body has not had access to those nutrients during the times when it needed them. So the body thinks that it is starving even when total caloric and macronutrient intake in that one meal was appropriate.

  • Insufficient fuel surrounding training - Training sessions for athletes, high-performing service processions and the military can be prolonged and intense, and thus have special nutritional considerations and fueling needs. Again, the body needs fuel when it needs it. Depending on the type of training and duration, proteins, carbohydrates, and fats are needed prior to, often during, and after training. It is critical for the body to have access to the nutrients it needs to fuel these intense sessions and recover from them thereafter.

  • A word about fasting for active women - Don’t do it. Plain and simple. Dr. Stacy Sims nails this one in her blog post “Yes! You are an athlete. No! You shouldn’t practice Intermittent Fasting”. Intermittent fasting can be beneficial in the sedentary population for the management of obesity and metabolic disease. But the evidence suggests no significant benefit for women who consistently train and can potentially be harmful. This is because female hormonal physiology has built within it multiple endocrine pathways that sense energy availability throughout the body with safeguards to protect it as a top priority.

    When energy needs are not met, it’s like a “five-alarm fire”. Muscle is sacrificed, menstrual cycles are suppressed, thyroid function dials down, the “fight-or flight” response is activated and cortisol levels rise. Performance and procreation take a back seat to the favor of restoring energy balance.

2 -Menstrual Dysfunction

This second element of the Female Athlete Triad is a direct result of the first. As we reviewed in “What does it mean when the menstrual cycle changes”, the menstrual cycle is a “vital sign” that reflects physiologic balance in a woman’s body. LEA and RED-S often lead to menstrual cycle changes because of sustained physiologic imbalances that result from inadequate fueling and chronic activation of the stress response pathway. This critical pathway is evolutionarily programmed to suppress reproductive function when the capacity for physical adaption (required for pregnancy, a triathlon, or other physical performance tasks) is suboptimal.

3 - Low Bone Mineral Density

This third element of the Female Athlete Triad is a direct result of the first and second elements, however, multiple endocrine pathways contribute to the balance of bone formation and resorption.

• Menstrual cycle suppression - Bone mineral density is directly related to circulating estrogen, as estrogen is a bone-building hormone. When menstrual cycles are regular, there is cyclic production of estrogen by the ovary that regulates ovulation. When menstrual cycles are suppressed or absent, the cyclic production of estrogen is also absent leading to a shift in the balance away from bone formation.

• Metabolic impact of LEA - As mentioned above, the female body sounds the alarm when energy availability is insufficient, impacting multiple endocrine pathways. Menstrual cycle suppression is one of these pathways, however, there are other metabolic pathways impacted by LEA.

  • The hormones Ghrelin and Leptin and Peptide YY (PYY) are secreted in the gastrointestinal tract in response to fat mass and energy availability. They regulate feeding behavior to achieve energy balance.

  • Oxytocin is a bone-building hormone that modulates metabolic rate as well as appetite. Night-time oxytocin levels tend to be lower in states of high energy expenditure. Lower levels of oxytocin in athletes whose menstrual cycles are absent have been associated with abnormal bone microarchitecture in non-weight-bearing bones such as the radius (forearm).

  • Insulin is a bone-building hormone that is responsible for the uptake of glucose in the peripheral tissues. Elite athletes with absent menstrual cycles have lower serum insulin concentrations compared to normally cycling athletes.

Building bone density is critically important in younger women, particularly those under the age of 30. Bone formation during these young adult years will determine peak bone mass. If the development of peak bone mass is compromised, this becomes a leading risk factor for developing osteoporosis and debilitating bone fractures later in life.

Tips for Avoiding the Female Athlete Triad

• Track your menstrual cycle! Now, this does not mean you need to obsess over it like a food log - simply be aware of the interval of time between your cycles from the first day of one to the first day of the next. Consistency is most important +/- 3-4 days. Most women have menstrual cycle intervals of 28-32 days.

If you are missing menstrual cycles on more than one occasion in a 6 month period or notice more than 7 days of variation in cycle interval for 3 periods or more, contact your health provider for an evaluation.

For more information on the things that cause menstrual cycle irregularity, check out this previous post “What does it mean when the menstrual cycle changes?”.

• Fractures. If you experience a fracture, contact your healthcare provider and discuss whether a bone density scan is appropriate. Even if you are pre-menopausal, special scaling (the Z-score) is used to determine if osteopenia or osteoporosis is apparent. The sooner this issue is identified, the more effective any interventions will be to slow bone loss or even rebuild lost bone density.

• Seek the help of a sports nutritionist. Whether you are an elite or avid recreational athlete, food “relationships” can be complicated. Obsessing about “macros” and “clean eating” can be counter-productive psychologically, but a lack of awareness of the amount and types of fuel needed to perform is equally harmful. Finding that balance is critical and can be achieved with help from coaches and sports nutrition experts.

• Communicate with your coaches and trainers. Just like it is important to keep your coach/trainer in the loop about physical injuries, it is equally important to inform them when your menstrual cycles have changed. It’s not the easiest topic to discuss, but your menstrual cycle is your most critical cue to your physical response to training and achieving your peak performance. If your periods disappear, your trainers and coaches need to know, and if they tell you “This is normal”, you need to get a new trainer/coach.

A Word About Body Image

One of the most common themes I have seen in my patients and clients is the significant impact of body image on eating and training behavior, which speaks directly to the energy balance we have been discussing.

Sadly, the societal definitions of and the pressure to attain the “ideal female body” are often in direct conflict with what the female body needs for optimal health and performance. These “ideals” are one-size-fits-all, no matter what your age, morphologic body type, sport, or profession. Women’s performance and health are anything but that.

Now, I’m not saying we shouldn’t want to look good. Taking pride in one’s appearance is a virtue. My beef is when these set “standards” jeopardize health and performance. Six-pack abs do not work for all athletes. Thighs that don’t touch in the middle don’t work for all athletes. D-sized breasts do not work for all athletes - my running is slow enough without them! My favorite one that plagues my generation is that “muscles are masculine” - which is the last thing any menopausal woman needs to hear as she loses muscle and bone mass by the day due to her changing hormones.

What has further complicated the issue is the lack of research that tells us how to achieve optimal energy balance in female athletes. For decades, the principles for training and fueling men have been applied to women for lack of meaningful research that applies specifically to women’s performance. Thankfully, this is changing and more and more attention is being paid to the physiologic differences between men’s and women’s physical performance and fueling requirements.

Although there is much work to be done, we have every reason to be optimistic as we see that the tide is changing with the more we learn about women’s unique physiology. So the key to success is keeping these complicated dynamics in perspective and prioritizing your health and well-being front and center, without compromise.

References

The female athlete triad: review of current literature. Curr Opin Endocrinol Diabetes Obes 2022 Feb 1;29(1):44-51

The Female Athlete Triad. Weiss Kelly, AK et al.; Pediatrics 2016 Aug;138(2):e20160922.

American College of Sports Medicine position stand. The Female Athlete Triad. Otis, CL et al.; Med Sci Sports Exerc. 1997;29(5):i-ix

Note: For the purposes of this article, the terms “Woman”, “Women” and “Female” refer to individuals who possess two X chromosomes.

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What Nature Intended

When we think about the physiologic processes that drive performance in females, we need to look no further than Mother Nature.

The first post of this publication “What is Women’s Performance Endocrinology” discusses the female “superpower” of physical adaptation. Pregnancy is the best example of this because the changes to the cardiorespiratory, skeletal, and immune systems in response to pregnancy are profound.

Further demonstrating the power of Nature’s “blueprint” for female physical adaptation is the fact that successful pregnancies are experienced by individuals across the entire spectrum of health. From poor to excellent health, uneventful, successful pregnancies are achieved the vast majority of the time. If you are Mother Nature, this foundational “blueprint” of physical adaptation makes sense because the ability to carry pregnancies successfully, predicates the continuation of the Human race.

Intimately tied to this powerful blueprint of procreation is the ability to protect it. Enter the stress response. Mother Nature was clever in her design because the stress response is directly linked to the menstrual cycle and thus acts as the “control panel” for conception and other physiological processes important for survival.

Whether we choose to bear children or not, this profound capacity for adaption and survival is engrained within us by design. If we harness these advantages in our lives as athletes, fire fighters, police, CEOs, and executives, among many other high-performing occupations, we can be unstoppable in our chosen professions and in our everyday lives.

Let’s begin with gaining an understanding of how this eloquent system works.

What is the “Stress Response”

The hormonal pathways involved in the stress response are complex. Here we will focus on the highlights that will give us a basic understanding of this response and how it impacts female physiology.

This first video, “Stress Response - Part 1” is a 7-minute excerpt from my course “Menopause Health and Fitness Specialist” where the stress response (for all ages) is introduced.

Pertinent points from this video are below:

• The “Fight or flight” response represents the activation of critical hormonal pathways in response to a physical or psychological threat.

• Three pathways interact during the “Fight or flight” response:

  • HPA axis - hypothalamus (an area of the brain responsible for many important regulatory processes), and hormones from the pituitary and adrenal glands

  • HPG axis - hypothalamus / pituitary gland and female reproductive hormones (menstrual cycle pathway)

  • Immune system

• During the “Fight or flight” response, the HPA axis and immune systems are activated. Activation of the HPA axis SUPPRESSES the HPG (menstrual cycle) axis.

HPA activation and HPG suppression is the reason why menstrual cycles can become irregular during times of stress, or disappear completely with chronic or ongoing over-training and under-fueling.

Returning the Activated Stress Response to Baseline

Once the stress response has effectively resolved the “threat” a branch of the nervous system called the parasympathetic nervous system (PNS) is in charge of bringing the system back to equilibrium. This 2:50 video, PNS Activation, reviews the basics of this very important regulator of the stress response and summarizes the entire process of SNS activation, PNS activation, and recovery.

Pertinent points from the video are below:

1 - The PNS is also known as the “rest and digest” response and is modulated by the vagus nerve.

2- The purpose of the PNS is to deactivate the “fight or flight” response and return the stress response system to equilibrium or baseline “balance”.

3 - Heart rate variability (HRV) is a reflection of the level of recovery of the stress response system and the ability of the system to respond to the next “threat”. When HRV is low, the stress response system has not fully recovered and, therefore, is less able to respond effectively to the next encounter (threat, physical task, athletic event, etc.).

NOTE: HRV is best interpreted relative to the individual’s normal range - not compared to a population average. Some of the most highly conditioned athletes have HRV levels lower than the population average. The most useful interpretation of your HRV is comparing readings along your personal HRV range of variation.

Special Attention to Recovery

Returning the activated stress response to baseline is important for optimal performance. Once the stress or threat is effectively dealt with, the HPA returns to baseline, and reproductive and digestive functions resume.

Women in high-performing professions spend a lot of time in HPA activation due to the nature of their occupation and the required training for it. For this reason, greater attention needs to be paid to mental and physical recovery. This becomes even more important as women enter the mid-life transition, most typically in their 40s due to the “wear and tear” effects of age as well as hormonal and physiological changes. For more information on this hot topic, check out this post in Athletic Aging: Stop Demonizing Cortisol!

This 3rd video “Stress Response Part 2” is a 2:46 excerpt from my course that discusses the importance of returning the activated stress response to baseline and some recovery strategies for high-performing women of all ages.

Pertinent points are below:

• Stress-management strategies:

  • Take a “stress inventory”

  • Fuel your training appropriately - Low energy availability (LEA) is a very common culprit for menstrual cycle loss or irregularity in high-performing women.

  • Sleep hygiene

  • Mobility work, tissue care, active recovery days

  • Mindfulness, meditation, and breathwork

• Activation of the stress response is essential for improving fitness and performance. Return of the response to baseline is essential for recovery and readiness for continued gains in performance with the next training day, event, or occupational task.

• The hormonal changes of mid-life create an additional barrier for returning the stress response to baseline. This does NOT mean avoiding fitness for fear of activating the stress response -it means better managing the stress response with greater attention to recovery strategies.

Putting it all Together

Optimizing physical performance starts with self-awareness. I’m a big fan of “taking inventory” of your health and wellness and using that as a starting point. Here is an example of a “Stress Inventory”:

• Am I fueling my daily training/activity appropriately? Fueling imbalance is a leading culprit triggering ongoing activation of the stress response.

• How much time do I spend on recovery activities? (ie tissue care, massage/bodywork, foam rolling, yoga/meditation)

• Am I taking enough time to warm up and cool down appropriately?

• Am I getting enough sleep? This is huge.

• What are my biggest life stressors outside of training? (Keeping a journal of the conditions under which you experience the greatest stress can be helpful!)

• What are my current “stress-reduction” strategies? Be honest!

• Consider wearable technology that helps to monitor recovery (ex - WHOOP! and Oura ring are great). For my personal journey with “wearables” check out Athletic Aging: My Journey with Wearable Technology

Once you have your arms around this for yourself, seriously consider a Coach - even if just for 4-6 weeks to put you in touch with the resources you need to get yourself on track. There are so many great resources available! Tapping into them will be the best investment any high-performing woman can make - and you deserve it!

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Team! 
Happy April!  Last month we learned about the normal menstrual cycle and why being tuned in to your cycle matters. This month we will take a look at what it means when menstrual cycles changes. Feel free to leave comments, ask questions and by all means, message me if something isn't clear. We're all learning together!
Enjoy!
-Carla 

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The human endocrine system is a complex network of “hormonal conversations” between various organ systems of the body that promote everyday functioning as well as responding to changes within the body and the environment.

Because reproduction is critical for the survival of the species, the menstrual cycle is front and center in these hormonal conversations. When the body or the external environment changes in an unfavorable way, the endocrine system protects the female from becoming pregnant during unfavorable conditions that could harm the mother or her offspring.

The physiologic changes and adaptations of pregnancy are profound, as we learned in my first post, “What is Women’s Performance Endocrinology?”. So when the endocrine system detects conditions that could limit the ability to physically adapt to the conditions of pregnancy (thus potentially putting the mother and offspring in danger) the endocrine system “turns off” the menstrual cycle until conditions become more favorable.

The endocrine system “sees” physical performance in sport or occupation in a similar way to pregnancy. If conditions are not optimal for physical performance (ie physical stress and adaptations of pregnancy), the menstrual cycle will turn off, until conditions are more favorable for optimal physical performance.

This eloquent, evolutionarily conserved mechanism provides us with a tool that signals when the body is primed for performance versus when a physical or environmental stressor is keeping us from performing at our best.

Causes of abnormal or absent menstrual cycles

The list of circumstances where menstrual cycles may become irregular is long and beyond the scope of this post. However, below, is a list of the most common reasons why a woman’s menstrual cycle may become irregular or absent.

Hormonal abnormalities

• Thyroid dysfunction: Hypo-thyroidism (under-production of thyroid hormone by the thyroid gland), Hyper-thyroidism (over-production of thyroid hormone by the thyroid gland)

• PCOS (Polycystic Ovarian Syndrome): A condition that results in absent or irregular menstrual cycles due to an imbalance of the production of androgens (male hormones) by the ovaries and adrenal glands.

• Hyperprolactinemia: Over-production of the hormone Prolactin by the pituitary gland can cause irregular menstrual cycles.

Energy imbalance - Low Energy Availability (LEA)

• Overtraining / Underfueling - This is, by far, the most common issue that I see in my clients of all ages and of all fitness levels. The body’s energy expenditure does not match the body’s perception of the availability of fuel. This goes beyond calories in/calories out - other equally important variables include nutrient timing and availability of macronutrients (carbohydrates, protein, and fat) during training, recovery, and times of high stress.

• Disordered eating - Mental health disorders and dysfunctional relationships with food that exist on a spectrum of mild to severe. Examples include anorexia and bulimia.

Psychological stress

• Exists on a spectrum of mild to severe: Life stress, grief, loss, divorce, dysfunctional interpersonal relationships, and a geographical move, among other causes.

Medical treatment

• Chemotherapy/radiation for cancer treatment or medical treatment of other conditions.

• Surgical or medical treatment involving the ovaries, uterus, and pituitary gland.

• Contraception

Head injury or malignancy

• As we learned previously, the pituitary gland drives the hormonal “messaging” of the menstrual cycle. Processes that disrupt the function of the pituitary gland, such as head injury or tumor/malignancy, can cause menstrual cycle irregularity.

Pregnancy

• If you are of reproductive age (age 12-45) and you miss your period, the FIRST thing you need to do is take a pregnancy test!

Perimenopause / Menopause

• The transition to menopause (perimenopause) typically begins in the mid-40s and concludes with menopause, on average, by age 52 in the US. During perimenopause, menstrual cycles become irregular and less frequent until cycling stops. One year beyond the final menstrual cycle is when menopause is achieved.

• This transition can occur much earlier in some women who have medical conditions or other unknown factors that lead to this transition occurring at a younger age. Premature menopause is defined as achieving menopause before the age of 40.

If you are experiencing irregular menstrual cycles, it is important to connect with your healthcare provider AND your coaches, trainers and nutritionists. As you can see from the long list of circumstances above, the causes of abnormal menstrual cycles span multiple disciplines including medical, physical performance, nutrition, and wellness. A multi-disciplinary approach is required to address the complexity of the factors impacting female reproductive physiology.

Bringing it Back to Evolution

As I just mentioned, the most common situations I see as an endocrinologist specializing in female performance (this includes athletes, police, military, paramedics, firefighters, CEOs, and executives among others) is the impact of low energy availability (LEA) and psychological stress on the menstrual cycle, performance, and overall physiology.

LEA and psychological stress illustrate the interplay between the endocrine pathways of the “fight or flight” (a.k.a the sympathetic nervous system (SNS)) response, the menstrual cycle, and overall female physiology. These interactions are part of a powerful endocrine force that is highly conserved through evolution that promotes survival from reproductive age through menopause and beyond.

Next month we will improve our understanding of this powerful endocrine interplay so that we can harness this system to our performance advantage through every stage of reproductive life. Stay tuned!

Note: For the purposes of this article, the terms “Woman”, “Mother” and “Female” refer to individuals who possess two X chromosomes.

Housekeeping….

I had the privilege of being a guest on two amazing podcast episodes that dropped this past week. Enjoy!

Inside Sports Nutrition Podcast: Hormones and Female Physiology with Dr. Carla DiGirolamo - Ep. #69 – Dina Griffin/Bob Seebohar

Fit Womens Weekly Podcast: Should Workouts Change As You Get Older? Dr. Carla DiGirolamo Breaks It All Down - Kindal Boyle

My Friends!
Welcome to Performance Edge! This post begins the first in a series of posts that will help you get to know our unique female physiology! We will then build on this knowledge and learn how to train, fuel and live taking full advantage of the amazing gifts nature has given us! 
Enjoy!
-Carla DiGirolamo, MD 

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As we begin our journey together, we will first lay the groundwork for understanding our unique female physiology, what it means when problems arise, and how we can best train and fuel WITH our bodies and not against them!

Historically, what we know about training and fueling athletes comes from studies of male athletes. But as Dr. Stacy Sims so eloquently states, “Women are not small men…”… and the reason we are “not small men” is because our physiology is driven by our monthly hormone cycles.

There are many hormones involved in the menstrual cycle as we will soon discuss. However, the main player is Estrogen. Cellular receptors are the “antennae” that live on the surface of cells and bind with the hormone and transmit a functional signal to the cells and tissues.

Estrogen receptors are present in nearly every tissue of the body - which suggests that cycling estrogen impacts nearly every bodily system. When women enter the menopause transition, estrogen levels decline. During this transition and ultimately when menstrual cycles cease, there are dramatic changes to mood, muscles, bones, tendons, ligaments blood vessels among other tissues, further underscoring the central role that estrogen and the menstrual cycle play in a female’s collective physical existence.

Now that we know how important the menstrual cycle is, let’s begin to understand it! The 8-minute video below gives a basic overview of the hormone players involved in the menstrual cycle and how they work together throughout our reproductive lives to affect our physical performance and overall health.

**Short on time? View just the slides HERE. If you wish to see the written narration, click on “notes” in the lower right corner of the slide presentation screen.

Why this matters and what you will see in later posts:

• The menstrual cycle is a “vital sign” that tells us when our bodies are primed to perform or when something may be wrong that requires further evaluation.

• The female body’s response to training and the ability to recover changes during the phases of the menstrual cycle.

• Understanding your own menstrual cycle will help you optimize your training by taking advantage of the changes occurring throughout the cycle.

**Next month we will discuss what is happening when menstrual cycles become abnormal or lost completely. Stay tuned!

My Friends!

I am so excited to begin this new journey in my career where I have the opportunity to bring two of my life’s passions together on my continued mission to help women thrive!

As a physician, I have dedicated my career to Women’s Health. For the last 17 years, I have practiced as a Reproductive Endocrinologist managing hormonal issues from menstrual cycle disorders to infertility to menopausal care. Since age 7, my “free” time has been spent in the fitness world, which has expanded from being a recreational athlete to a fitness professional.

Today, the area of female athletic performance has emerged as a field of its own! There is a greater appreciation of the physiologic differences between male and female athletes, and those differences are rooted in the unique female hormonal physiologic paradigm. It is from this realization that this new area of hormonal health known as Women’s Performance Endocrinology (WPE) was born!

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Female Capacity for Adaptation

Genetic females are uniquely suited for physical adaptation. The best example of this is pregnancy!

During what is typically a 9-month period of time, a female’s cardiac output (the volume of blood pumped by the heart in a given time period) increases by 50%! Their blood volume expands and the resistance of their blood vessels decreases to support circulation to the developing fetus.

Their chest size increases to accommodate the upward movement of the diaphragm as the baby increases in size so that lung capacity is preserved.

The immune system undergoes dramatic changes to protect the baby from autoimmune attack, while still maintaining the protection of the mother against outside infection.

Once the baby is born, the cardiovascular system needs to adapt to accommodate the increased blood volume in a matter of just hours, so as not to overload the heart into failure.

The vast majority of the time these adaptations happen seamlessly along the entire spectrum of good and poor health.

What is Fitness?

Fitness can be defined in many different ways depending on what sport or other activities one engages in. But the common thread of achieving excellence is through training and practice, both of which require physiologic and nervous system adaptation.

Adaptation to training is a process by which the body contends with a physical stimulus, recovers from that stimulus, and is stronger, fitter, and more efficient as a result. The response to training and the recovery from it is mainly driven by two neuroendocrine pathways: the Sympathetic Nervous System (SNS) or the “Fight or Flight” response and recovery is driven by the Parasympathetic Nervous System (PNS) or the “Rest and Digest” response.

Because these pathways are involved in the survival of the species, they are highly conserved and thus very powerful. When we, as females, train as athletes or for our profession, these pathways know no difference between the physical training/circumstance and the bear in the woods. So the goal is to harness these primal neuroendocrine pathways that are responsible for our survival and apply them to our training, competitive events, and our high-performance professions.

The focus of WPE is just that! The cutting-edge in women’s performance has emerged through the realization that women are different from men in so many aspects of training, performance, metabolism, and recovery. Attention has now turned to the unique facets of female physiology in the pursuit of optimal female performance.

It is high time that advances in female performance catch up to that of their male counterparts. Coincidently, it is also time for the field of endocrinology to merge its wealth of knowledge with the advances in female performance optimization. With this synergy, we not only can take female physical performance to new levels, but we can also preserve their long-term health and vitality.

So join me and subscribe to Performance Edge where my goal is to give every high-performing female of any age the resources they need to reach their physical potential and lead their healthiest life.

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For additional cool stuff, check out my website, the “big sister” blog of Performance Edge - Athletic Aging, Instagram @Dr_Carla_D, Facebook, and Linked in.

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