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Talking to Your Doctor

Perhaps the only thing more frustrating than RED-S is trying to describe your situation to a doctor (or anyone else for that matter). Even if you know something isn’t right, your regular doctor probably doesn't have the time or resources to help you explore the subtle underlying reasons why. Despite the fact that this is a frighteningly common issue in sport, athletes still represent a small sub-set of society and many doctors won’t see athletes with RED-S very often. This is why we urge you to start becoming an active participant in understanding your own health picture and getting to grips with what to ask and how to explain your situation. Here’s our advice on how.

For all athletes

  1. Prepare for your appointment by pulling together a brief overview of your history, including training load, nutrition and any illnesses or injuries. It can be helpful to ask for input from your coach, physio or anyone else you might work with. Since your appointment is probably only 10 mins, try to keep this concise.
  2. Take some information with you. We would strongly suggest taking a copy of the RED-S clinical assessment tool to your appointment. The chances of your doctor ever having heard of RED-S is slim, so the sooner you can present them with the details, the better. If they're not willing to read it or learn more about research in this area, you may want to consider seeking a second opinion from some who is.
  3. Consider going privately. If you are at all able to afford a private practice, we would highly recommend seeking the medical support from one of the options found here. This is an investment in your health.
  4. Make the most of what you've got. If you aren't able to afford 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 and b) be delve into it 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 assess for signs of low bone density or osteopenia. This is a crucial indicator of RED-S and it is crucial to treat it early. While your doctor might seem skeptical 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': If you’re experiencing prolonged fatigue, hair loss, or any other symptoms of low iron levels, it important to get them tested via blood tests for ferritin. Typically, anything less than 15 ng/mL is deemed as ‘iron deficiency’. However, certain athletes require more than double the iron levels of less active individuals so you might still be deficient at a far higher level. So, we suggest asking your medical practice for the actual test result and keep a record of it yourself. From experience, we'd say you should be aiming for above 30-40 ng/ml.

    Finally, be aware that no matter how many RED-S symptoms you present to your doctor, they are unlikely to understand that the underlying causes of your issue surround an energy deficiency. Ultimately, if your problem is RED-S, then it's caused by under-fuelling for your training load - which may still seem to be a decent quantity of food for anyone else besides you. Your BMI may well sit within the 'normal' range; it may even be above the 'normal' range, yet you can still have RED-S.
  7. Be as honest as possible: The above point feeds into being as honest as possible with yourself and your doctor about your relationship with food. If you are certain you don't display any disordered eating behaviours (like those described here) then discuss the possibility that you're 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 menstrual cycle, 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. We promise, 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 potentially help you. Seize it.

Specifically for females

When it comes to RED-S, one of the biggest red flags surrounds your menstrual health. If you’re on the Contraceptive Pill – this can be tricky to assess. Not only because the Pill works by suppressing your natural hormones, rendering it near impossible to know whether you would get them if you weren't on the Pill, but also because, for some desperately frustrating reason, doctors may well reassure you this is an acceptable substitute. Even if you’re not on the Contraceptive Pill and are experiencing menstrual abnormalities, you’re likely to be told this is normal for an ‘athlete like you’.

We cannot tell you how many doctors reassured us our missing periods were nothing to worry about, or encouraged us to use the Contraceptive Pill when we expressed concern about their absence. Perhaps yet more worrying was that there was no mention of the dangerous and potentially life-long consequences of missing out on these crucial female hormones when it comes to bone, heart, brain and reproductive health. We're not saying this to alarm you – just trying to encourage you to take ownership over your own menstrual health now, whilst medical practices are still catching up with the science.

Just knowing there is a high possibility your menstrual health wont be looked into should help you prepare for ensuring that it is.

We suggest noting down how your menstrual health has been in recent months/years, or how long you’ve been using the Contraceptive Pill. If you’re not on the Pill and are experiencing any menstrual dysfunction, it’s important to rule out any underlying reasons for it.

Explain that as an athlete, you value your menstrual cycle as an important measure of overall health and would like blood tests to assess your levels of:

Oestradiol

Progesterone

Luteinising Hormone (LH)

Follicle Stimulating Hormone (FSH)

Free T3

Thyroid Stimulating Hormone (TSH)

Prolactin

Anti-mullerian hormone (AMH)

Cortisol

DHEA

Testosterone (both free and total testosterone)

These are all important hormones and test results should give you and your doctor an idea of your menstrual health status. Be aware that they may not be able to test them all and there are certain times to test for certain hormones – but your doctor should be able to talk you through this.

NB: If you are on the Contraceptive Pill, then most of these tests would be irrelevant since the Pill works to suppress these hormones. At this point, I would urge you to reconsider your decision to use the Pill. This discussion is way beyond the scope of this post but you can learn more about why it could be potentially detrimental to you here and here.

Bottom line

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 help about your situation, then you need to be 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.