Talking to your Doctor By Pippa Woolven, Project RED-S Founder
Perhaps the only thing more frustrating than experiencing a RED-S related issue is trying to describe it to your doctor, or anyone else for that matter). Even if you know something’s not quite right, your regular practitioner probably doesn't have the time or resources to explore the underlying reasons why. Despite the fact that RED-S is a worryingly common issue in sport, athletes still represent a small subset of society and many doctors won’t see patients like you too often.
For females, one big red flag for RED-S is a missing or abnormal menstrual cycle. If you’re using a form of hormonal birth control, this can be tricky to identify, since hormonal contraceptives typically work by suppressing the hormones within the natural ovarian cycle.
To complicate matters further, there remains a gap in knowledge surrounding female athlete health (and indeed male athlete heath) matters within general medical practice. Through no fault of their own, some doctors may reassure you that hormonal birth control is a suitable substitute for a natural menstrual cycle. It is not! Even if you aren’t using hormonal birth control and are experiencing menstrual abnormalities, you’re likely to be told this is normal for an ‘athlete like you’. It is not!
As perfectly described in Womancode by Alisa Vitti, using hormonal contraceptives to ‘treat’ a missing or abnormal menstrual cycle, or being told it is fine to experience this, is akin to putting a piece of tape over a big red flashing indicator light on your car dashboard. Instead, we must look under the hood to investigate and address the underlying engine problem.
No matter your age, gender, or situation, there is no better time to become an active participant in understanding your own health. Just knowing there is a strong possibility your menstrual health won't be looked into should help you prepare for ensuring that it is. Similarly, if you’re a male who’s been experiencing low libido and loss of morning erections, it's time to share that too.
Here’s some athlete-to-athlete advice on how to get the most out of an initial appointment.
1. Prepare in advance. It can help to pull together a concise overview of your history, including training hours/intensity, nutrition, and any illnesses or injuries you’ve experienced. You might want to ask for input from your coach, physio, or anyone else who might be able to identify patterns or changes over the recent months/years.
2. Take some information with you. The chances of your doctor having heard of RED-S are slim, so the sooner you can present them with the details, the better. Take a copy of the RED-S clinical assessment tool, or your own version of this example letter, to your appointment. If they aren't willing to read it or learn more, you may want to consider seeking a second opinion from someone who is.
3. Consider going privately. If you are at all able to afford an appointment with a private specialist with knowledge and experience of RED-S, we can recommend options here. For reasons outlined above, receiving support from experts who have seen hundreds of athlete's with RED-S before is likely to be a seriously beneficial investment in your health.
4. Make the most of what you've got. If you aren't able to go privately and your doctor doesn't have the capacity to look into your problem further, ask to be referred to special sports medicine practices. A sports medicine doctor is far more likely to a) know what RED-S is or b) explore it with you further if they don't.
5. Bone health. If you’ve experienced any bone related injuries (e.g. stress fractures), ask for DEXA scan (measuring hip and spine density) to look for signs of low bone density or osteopenia. This is a crucial indicator of RED-S and it is essential to treat it early. While your doctor might seem sceptical as to whether you need one, a scan should be available to anyone considered by their GP to be at risk of developing osteoporosis.
6. Remember you are not 'normal'. Be aware that often athletes don't fit within 'normal' test reference ranges, designed for members of the general population. For example, endurance athletes typically require more than double the iron levels of less active individuals, so even when you’ve been reassured your results are ‘within normal ranges’, it can’t hurt to ask for the actual test results and take it along to a specialist appointment. Also be aware that while your weight may sit within the 'normal' range, RED-S is not restricted to those with a low body weight and can occur in any athlete, of any size, at any time. Deeming someone ‘healthy’ based on their weight can be a harmful practice and lead to delayed investigation for, and identification of, RED-S.
7. Tell the truth. It’s essential to be as honest with both yourself and your doctor about your relationship with food and training as possible. If you are certain you don't display any disordered eating or exercise behaviours (like those described here) then be open to the possibility that you are unintentionally under-fueling. If you’re anxious about eating too much or gaining weight to the detriment of your sports performance, then mention it. If you’re not sure whether you eat enough to sustain your training load or hormone levels, then tell them. And, if you think you might have a full blown eating disorder or exercise addiction then be honest about it.
You should never ever feel ashamed or embarrassed while talking to your doctor. They'll have seen and heard far worse things than whatever you’ll come out with, so this is your opportunity to have a judgement-free conversation with someone who can help. Seize it.
8. Trust your instincts. Chances are, you’re an athlete who would be willing to push through most things if it meant continuing your training. If you’re willing to seek some support, then it helps to come equipped with how best to gain the advice you need whilst avoiding further frustration. Arm yourself with as much understanding of your own health picture as possible and don’t give up if you don’t get everything you need from your first appointment. “You might find that your doctor is a lot more helpful than you’d expected, if you just know what to ask.” - Period Repair Manual by Lara Briden