Top athletes must stop ignoring ‘alarm bell’ of missed periods
Former runner Bobby Clay wants to banish a dangerous mentality after paying the price with her promising career, writes Fiona Tomas
Bobby Clay remembers the tear that slid down her mother’s face in the surgery, trying to process the doctor’s earth-shattering words. She was 20.
“He turned to my mum and said, ‘Your daughter will never have children.’ She didn’t say a word. That’s when I decided to change,” Clay tells Telegraph Women’s Sport.
A successful middle-distance runner, Clay was tipped to be athletics’ next big star. She was fourth in the 1500metres at the 2013 World Youth Championships, crowned European junior champion two years later and made the Great Britain under-20s team when she was just 15. Three years later, she was diagnosed with osteoporosis, a result of years of overtraining and undereating.
That merciless combination meant her body had been deprived of oestrogen, the female sex hormone – crucial for bone density.
Clay first realised something was wrong after fracturing her foot in a swimming pool doing a tumble turn. On another occasion, her shin snapped when she sat down in the gym. Both were clues that she was suffering from Relative Energy Deficiency in Sport (RED-S) Syndrome – formerly known as “the female athlete triad” – which can cause devastating effects due to low energy availability.
In 2019, American middledistance runner Mary Cain became the first high-profile female athlete to speak out about her experience with RED-S.
The condition is not found exclusively in women – Britain’s Olympic champion cyclist Chris Boardman retired in his early 30s due to weak bones and low testosterone.
In women, the condition manifests itself in an early warning sign, the absence of periods, something which Clay says is actually still celebrated in athletics. “I would have been mortified if I had had a period during my teenage years,” she says. “I would have instantly thought, ‘I’m out of shape, I’m not race fit.’ I thought it meant that my body fat would be over a certain percentage. That mentality was the norm.”
Clay was put on hormone replacement therapy – usually used for older women to relieve the symptoms of the menopause – to kick-start her body, wake up its reproductive system and artificially induce her first period.
Clay had never struggled with her physique as an athlete, despite being known as the “chunky one” among her peers and “surrounded” by eating disorders in the sport.
She insists she never had a dysfunctional relationship with food as an athlete, so when she learnt that her osteoporosis was linked with RED-S – commonly seen in athletes who are obsessively restrictive about their food intake – it was a shock.
RED-S is not exclusive to elite endurance athletes, although they are generally at a higher risk due to their increased energy expenditure. A study published last year in the British Medical Journal found that of 112 elite female Australian athletes from eight sports, 80 per cent demonstrated at least one symptom of RED-S.
“You can go through every bodily system and find a reason why underfuelling is a bad idea for performance,” explains Dr Amita Biswas, head of physiology at the English Institute of Sport and co-lead of Smarther, an EIS initiative promoting awareness of female athlete health.
“There is good evidence that your decision-making could be affected, that your adaptation to strength training can be reduced and it can impact your mood and concentration.”
Dr Biswas commonly sees RED-S in athletes transitioning from junior to senior programmes who, like Clay, simply underestimate the amount of energy they need.
However, the normalisation around missing periods is also a major contributing factor.
“It’s common for elite athletes to have irregular cycles, even if they’re fuelling adequately and their body composition is good,” says Dr Biswas. “But missed periods or no periods shouldn’t be considered normal. It’s a really concerning myth.”
The oral contraceptive pill can also mask hormonal problems associated with RED-S. This is because the pill artificially induces a monthly bleed – not a period – at an athlete’s convenience.
“An athlete might think that because they’re having a withdrawal bleed, everything is fine,” says Dr Biswas. “But when you’ve got a female athlete on the pill, you’re effectively putting them into the category where men are, where it’s much harder to realise that there’s a problem.”
After being pressured to change her body composition by a coach, Cain lost so much weight that she lost her periods for three years and broke five bones due to osteoporosis. Clay went public with her battle with the condition after penning a harrowing testimony in Athletics Weekly in 2017, after which she received hundreds of messages from other sufferers. “It makes me
Her shin snapped when she sat down in the gym. It was a clue she was suffering from RED-S
upset thinking about the number of people who had this happen to them,” she says.
As part of her recovery, she came across Train Brave, a campaign founded by Renee Mcgregor, one of the country’s leading sports dietitians, who specialises in eating disorders. The project aims to raise awareness about RED-S and to change the fitness culture of overtraining and under-fuelling.
“I get so many emails from runners who think they need to lose another five kilograms to reach their sub-three-hour marathon PB,” says Mcgregor.
“The number on the scale is never going to determine how fast you run. It’s such an ingrained stigma in endurance sports and definitely one of the biggest fallacies out there.”
Clay, now 23, is already living with the long-term consequences of osteoporosis, which she has
been told is irreversible. With running being too high impact for her body, she took up track cycling at Loughborough University, but ended up fracturing her femur on the bike last spring. “I don’t get these warning signs. Things just go with me.”
Clay is on a mission to raise more awareness and be a voice for those whose sporting dreams have also been crushed.
“I want people to know that you don’t have to be in the grips of an eating disorder to struggle with this problem. You can have a really great relationship with food, but not take note of how much energy you’re spending compared to how much you’re putting in.
“Women have a massive alarm bell with periods – men don’t have that – so they can keep travelling to a point where their body breaks. Women should utilise that alarm bell.”
‘I want people to know that you don’t have to be in the grips of an eating disorder to struggle with this problem’