This is a follow-up to a post I wrote one year ago, which can be found here
Most of us remember our 30th birthday. No longer young, yet neither old, the third decade is said to be a period of clarity, bringing heightened self-awareness and confidence.
For me, it certainly felt like a transition: finishing up five years of graduate school, I was preparing to embrace change. Yet, I was also preoccupied with another deadline – around 30, we stop building bone.
At 26, I went to see my gynecologist, hoping to change my birth control. Feeling healthy and strong, I expected a routine appointment. Yet, over a series of visits, I discovered that, despite no noticeable loss in energy, strength, or weight, my bone density had been silently decreasing for years. It was severe enough that I had osteopenia, a condition in which the body does not make new bone as quickly as it reabsorbs old bone. Were it to continue, I would certainly develop osteoporosis, an irreversible disease in which bones are brittle and fracture easily.
I was diagnosed with relative energy deficiency in sport (RED-S), a condition where the body does not take in enough energy to meet the demands placed on it. For women, this results in hormonal imbalances that reduce estrogen, a hormone critical for bone health.
The conversations I had with doctors and specialists remain muffled in my memory. But, the numbers are glass, clear and sharp: In parts of my body, I had 81% of normal bone density; I had around four years (until I turned 30) left to build the bone back.
I read a number of personal accounts of men and women diagnosed with RED-S, yet, never found a story of recovered bone density loss. It was easy to feel alone in my journey without a timeline, without benchmarks, and without a roadmap. I had to trust that my body would set itself right, if, mentally, I was on its side.
Startled, having just set foot in a doctor’s office for a check-up required by work, my mind went to humor.
“So, you mean like the weight of a house cat?,” I replied.
“Gain some fat, get a cat” became an inside joke between my coworkers and me, a rallying cry preceding many large dinners as we worked in California’s High Sierra.
That wasn’t the first time I heard such advice. In 2016, I was becoming interested in climbing performance and body composition and got a DXA (dual x-ray absorption) scan, a test that measures amounts of fat, muscle tissue, and bone density. For female athletes, body fat between 14-22% is considered healthy. Bone density is measured in “T-scores”, standard deviations from normal bone density, which is represented as 0. A score between +1 and -1 is considered healthy.
At 5’4’’ and 110 lbs, I clocked in at 15% body fat with a bone density score of -1.1, meaning I had low levels of both. The technician asked if I was having regular periods, an indicator of healthy levels of hormones like estrogen that influence bone density.
When I first noticed the disappearance of my period in 2012, I was under tremendous stress due to a debilitating and complex injury. When I regained my health and my periods were still only infrequent, I transferred the excuse from “stress” to “birth control,” as missing periods are a side effect of the pill.
My dismissal of adverse health indicators and my ability to write off the experience as a joke reveals my attitude toward the issue – I didn’t see it as a problem. I’ve always been naturally thin, a voracious eater and often buzzed with an energy that bordered on hyperactive. I ran and eventually climbed to outlet this energy. In college, I earned the endearing nickname “the vulture” because I would always pick off people’s unfinished plates.
In fact, gaining fat has always been difficult for me, with excess calories manifesting as muscle. The doctor’s declaration that I gain weight sounded like an echo of remarks I’d heard from family, boyfriends and friends. Sometimes it seemed well-intentioned, but it also felt patronizing, debasing and pointless – like they were telling me to just “grow taller.”
As I pursued climbing, I was told anything from “you look great and toned” to “be careful, you are starting to look too muscular for a woman,” as if the purpose of my body wasn’t to enable me to perform, but rather to look a certain way for others. Praised and criticized for my natural physiology, I felt pulled in opposing directions, the result being that I stood still where I was. I became hyper-aware of my appearance as mixed messages swirled like violent eddies in my mind. Perhaps my body, lean and potentially beneficial for climbing, and the stereotypical female body I was told was desirable and attractive, were mutually exclusive.
These competing thoughts were white noise against the background of my drive to climb well. Instead of considering the comments that grew from genuine concern, I developed a chip on my shoulder. I felt energetic, was eating well and was doing what made me happy – why would I change for anyone else?
In 2017 I saw a gynecologist to discuss IUDs, a type of birth control. She took one glance at my medical history, four years of infrequent periods, and ordered another DXA to evaluate my bone density. Since the first scan, I had gained weight, so I assumed the problem was resolved. “This is great comparative data!” I thought. The results arrived quickly.
“Significant osteopenia is noted at the spine and hips; there is currently an increased risk of fracture “
In my spine, my bone density was 86% of normal, 87% in my hips and 81% in my neck. I had early-onset osteopenia, a reduction in bone mass preceding osteoporosis, a severe condition in which bones become brittle and fracture easily. I was 26.
A fear dropped in me swiftly and hard. A once distant threat, some imperceptible sensation I could barely recognize, suddenly brandished itself in irrefutable numbers, grasping me by the shoulders and screaming for attention. I felt cheated; my body was silently crumbling away and it didn’t even warn me – except that it had.
It seemed like an irrevocable and destructive force was moving through me. It was painful to even begin to consider the reality that it was I who let it in.
It’s referred to as the female athlete triad,” my gynecologist told me on my follow-up visit.
The “triad” refers to a syndrome that manifests due to three interrelated conditions. Intense exercise and under-fueling, intentionally or unintentionally, can reduce energy availability to a threshold below that needed to maintain normal menstrual cycles.1 As periods become irregular or absent, levels of estrogen and progesterone, hormones crucial in bone formation, drop. In 2014, the International Olympic Committee coined RED-S (relative energy deficiency in sport)2 to replace the female athlete triad, emphasizing that men are also affected by energy deficiency.
My low bone density and irregular periods were two signs of a third inevitability — I had inadequate nutrition to meet my metabolic needs. My body was stopping basic processes and I felt fine, with enough energy to excel in graduate school, socialize, train, and progress in climbing. My mind felt slippery, ricocheting between my perception of my health and the reality unfurling before me.
Professional rock-climber Mina Leslie-Wujastyk touched upon her experience with RED-S in this excellent piece. While Mina noticed low energy levels yet maintained healthy bone density, I had the opposite presentation. However, we both had a normal BMI, abnormally low estrogen levels, lost our periods, and hadn’t noticed due to hormonal birth control.
The consequences of RED-S are severe. If left untreated or diagnosed too late, a patient is left susceptible to osteoporosis and potential cardiovascular issues related to poor hormonal health. I wasn’t only gambling with my athletic ambitions, but with my long-term health.
Fortunately, since I was still young enough to put down bone, I could reverse the osteopenia.
I was referred to a nutritionist. A vegan for four years due to environmental reasons, I had a restrictive diet. I couldn’t avoid the question — did veganism cause my RED-S?
According to the nutritionist, the answer was probably not. I wasn’t a vegan when my periods first disappeared and I was eating well. I increased my caloric intake and took calcium and vitamin D supplements. Eventually, I decided to eat meat, eggs and some dairy products, though transitioned away from veganism slowly. To increase intake, I had to eat when I wasn’t hungry, behavior which I had always viewed as inadvisable. My weight stayed the same as my body funneled the calories to returning to physiological normalcy, rather than to adding weight.
Changing ingrained habits or opinions is always daunting. As I paid precise attention to what I ate, I realized I was probably not objective about my diet. Though I always felt I had a good relationship with food, obviously something was not right. It took me a long time to admit this to myself.
Changing my eating habits forced me to consider the consequences for climbing.
A climber’s performance is affected by his or her strength to weight ratio. Easier and quicker than increasing strength, weight loss is a popular tactic climbers employ. Though I never tried to cut weight, I, like most, considered it a viable and normal strategy. Now, it felt like a playing card had been taken from my hand. In the context of greater concerns for my health, the strength of this frustration felt out of place and immature.
I briefly went off the pill to monitor my period. However, a month after it returned, I got a hormonal IUD. While the IUD masks my period it is also remarkably beneficial in my life. Choosing between sexual freedom, a basic right that is very important to me, or receiving cues that tell me I am healthy is a rather irritating conflict that I have given much consideration.
To decrease my susceptibility to chronic stress, another major cause of energy deficiency and an insidious tendency of mine, I tried to calm my mind via guided meditation and also socialized more. I was advised to exercise less, a catch-22 since climbing and running have always been a form of therapy for me. I compromised by stopping my habit of cycling everywhere. Otherwise, I did not reduce my exercise and climbed some of my hardest routes in the middle of treatment. However, I did become more regimented in my gym climbing; by making plans ahead of time, I sometimes avoided staying there for hours and using the gym as an emotional outlet.
After two years, I received another scan. My bone density increased; I was at 91% of normal for the spine and hips, yet at 85% for the femoral neck, meaning I still have minor osteopenia in my neck, and, as I near my 30’s, I likely always will.
I had wanted to try an IUD for a year prior to my doctor’s visit, but I put it off due to a busy schedule and lack of health insurance. Had circumstances unfolded differently, I might have walked into the gynecologist’s office in my late twenties, when reversing osteopenia is potentially impossible. While only a frightful hypothetical situation for me, finding out about RED-S too late is likely a reality for many young athletes.
Today, I always consider RED-S when I plan my diet or training. This requires discipline, as my major symptom is a silent one and my birth control effectively removes my ability to monitor my hormonal health. It can be easy to fall into cycles of stress or of believing uncomfortable notions that I am eating “too much.”
So, months after the diagnosis, I printed the initial report and put it in my climbing notebook. That paper can turn the hollow pain I felt on the first day — fearing I made a mistake I couldn’t recover from — into a physical presence I can carry within me.
Sometimes, it is roused when I stress over jobs, climbing or relationships. It reminds me that health is fragile, though easy to ignore in pursuit of other goals, even something as trivial as a climbing grade.
On good days, I realize that what is on the line is often far greater than what I might lose, or, more simply, what I might not achieve.
This article was originally written for Gnarly Nutrition. The post can be found here.
1 Nazem, Taraneh Gharib, and Kathryn E. Ackerman. “The female athlete triad.” Sports Health 4.4 (2012): 302-311.
2 Mountjoy, Margo, et al. “The IOC consensus statement: beyond the female athlete triad—Relative Energy Deficiency in Sport (RED-S).” Br J Sports Med 48.7 (2014): 491-497.