With conversations now underway, the next step to take action in the prevention and treatment of undereating, menstrual dysfunction and osteoporosis in female athletes.

Conversations about female reproductive health in sport have definitely started – that’s for sure. Athletes, coaches and governing bodies are getting involved in raising awareness of the risks of under eating, eating disorders and prolonged amenorrhoea.

What has become apparent is that it’s not just the occasional athlete who suffers the short and long-term effects of prolonged amenorrhoea on bone health; numerous athletic careers are being hijacked by repeated stress fractures.

But we need more than just conversations and awareness. The message is definitely getting out, but it’s not necessarily getting through.

Earlier this year, body shaming was again a feature of BBC athletics commentary; inappropriate race kit continues to make more than the occasional appearance; and, if social media is anything to go by, additional ‘punishment’ miles were yet again on the menu following Christmas indulgences.

If we are to truly get on top of the issues at hand, and break the cycle of energy deficit, amenorrhoea and bone injury, we absolutely need a cultural change. The solutions are both complex and difficult to implement. There is certainly no quick fix.

What follows are some ideas on where change can be implemented to improve prevention, diagnosis and treatment.

Remove barriers in the diagnosis and treatment of eating disorders

Imagine having severe insulin and blood sugar issues, but being told that you will only be diagnosed with diabetes once your foot needs to be amputated.

Imagine having coronary heart disease, but being told that you can only be treated once you’ve had your first heart attack.

Imagine suffering debilitating depression and anxiety and being told you don’t have an issue unless you’ve made at least one serious attempt on your life.

Now imagine having such a dysfunctional relationship with food, your body and your emotions, that you have essentially stopped eating. That you no longer feel hungry. That you have become obsessed with calories and ensuring that energy output is always higher than energy intake.

That even a single slice of bread means a punishing extra hour on the cross trainer. That you’ve got so used to lying about how much you’re eating (or not eating) that you don’t even notice you’re lying anymore.

That you’ve become skeletally thin, but keep thinking that you need to lose more weight. And then imagine being told that your BMI needs to fall even further for you to receive the medical attention you need.

Eating disorders are complex mental illnesses – albeit ones which are compounded by the physiological and biochemical effects of starvation – requiring psychological treatment, and not simply solved by a visit to the nutritionist.

With denial a major feature of anorexia in particular, each and every individual who seeks help for their eating disorder, must be treated with urgency, irrespective of whether or not their current weight places them in the ‘severe’ category, or whether or not their weight loss has been drastic enough to tick all boxes for diagnosis.

Diagnosis of anorexia, in the past, depended on weight loss leading to body weight at least 15% below that expected. That has changed in recent years, and there is no set weight listed in the most recent DSM criteria for anorexia, though BMI is still often used to classify severity.

Extreme weight loss should be considered a consequence rather than a cause or characteristic feature of the illness. A mental illness shouldn’t depend on a physical outcome for treatment to begin, particularly when early intervention greatly improves the prognosis. An individual should never be told that they need to be thinner or weigh less in order to receive treatment.

Not all athletes at risk of menstrual dysfunction or bone loss have an eating disorder. And those with an eating disorder are not the only ones that require help. But until eating disorders are treated with some level of urgency – and until we stop justifying disordered eating as a normal feature of endurance running – we have very little hope of treatment in other cases.

Downgrade the role of cross training

Your life is an imbalance… you’re not eating enough… your endocrine system is under so much pressure that your periods have stopped… your bones are breaking down… your body has had enough… you’ve just been diagnosed with yet another stress fracture.

Why then is your first thought to start twice-a-day, soul-destroying, time-consuming cross training in an attempt to maintain fitness, and then to adjust your eating patterns to ensure you don’t put on a single ounce of ‘unwanted’ weight during your injury ‘layoff’.

Listening to your body? If you can’t hear its desperate screams for help, how are you ever going to learn to answer its subtle warning whispers?

Anna Boniface is one athlete who has shared her story about amenorrhoea, overtraining, under fuelling and the resulting stress fracture. Now she is progressing with her comeback and recently wrote specifically about cross-training saying: “retrospectively, I should have taken this initial period not training completely. My body was screaming for some R & R. Continuing to plough away, I was still in that energy deficit, stalling my recovery.”

This is not to say that cross training doesn’t have its place.

In fact, it could play a much bigger role than it does in adding variety and reducing impact in the regular training programme. It is vital in the return to training after injury, and, in some cases, it can allow individuals to overcome a badly timed injury and keep dreams on target.

It can allow athletes to keep their head ‘in the game’ during times of injury, and some level of maintenance is good. But, as Katie Kirk, among other athletes, has recently discovered, it’s not the be all and end all!

In fact, you may later come to resent all that extra time you’re spending in the pool and on the cross trainer. And this can leave you more likely to throw in the towel altogether the next time you get injured.

Perhaps it’s not just your bones that need a rest – your mind may benefit from some downtime too. Use your injury time to do the things that you never have time to do. And if you get some space away from running and gain a little bit of weight along the way, then maybe that’s a good thing. Listen to your body!

Ensure that there is a structured referral process

Even if you’re really clued up on the causes and consequences of undereating and menstrual dysfunction. Even if you can spot and raise issues, and even if you have an open relationship with your athletes.

You can still feel desperately hopeless when faced with an athlete who reports that they have not yet started their periods or are having real issues with food and body image.

That is not your fault. I did a PhD on the subject, know pretty much all I ever want to know about the endocrinology of the female reproductive cycle and the biochemistry of the bone remodelling process. And even I’m still not sure what the next steps are when faced with an athlete suffering from some or all the elements of the Female Athlete Triad/RED-S. We are all hopelessly unsure what to do. That, above all else, needs to change.

The issues leading to our communal sense of hopelessness are multifactorial. The logical next step with primary amenorrhoea, for example, is to send the athlete in question to see their GP where underlying issues can be ruled out.

But in many cases, the doctor will then say that there is nothing physically wrong; that the lack of periods is due to their training load, and that amenorrhoea is ‘normal’ for athletes.

Common, it may well be, but healthy it definitely is not. Worst case scenario, the athlete is sent away and told not to worry about it.

The best case scenario is they are prescribed the pill – a bit like sticking a small plaster on a 6-inch laceration – told to consider calcium supplements, and possibly sent for a DEXA scan.

In this situation, and especially if it’s a whole body scan, the results may be normal, not just because the issue hasn’t got that far yet, but because whole body scans can mask underlying issues in trabecular bone (the spongy bone where the real problems lie).

Addressing the cause

Treatment needs to start addressing the causes, not just deal with the consequences. Whether or not low body mass is considered an inevitable feature of the endurance athletes, the energy imbalance should be addressed. Menstrual function should be restored. And every effort should be made to increase bone mineral density to normal age-matched levels. But all this takes time. Time which an athlete doesn’t ever believe they have. But the alternative is far bleaker.

When an athlete seeks medical help, they shouldn’t accept a quick, sticky-plaster, solution. They shouldn’t be told that what they are going through is a normal consequence of sports participation.

They may well have to fight for the support they need. And in many cases, the medical support required may lie outside of the public health service. Their fight would be immeasurably easier if a list of suitable practitioners was available, and not just of NGB sports medics which a select number of high-performance athletes have access too. But also other practitioners – dietitians, nutritionists, psychologists and counsellors – who will help in their return to help.

Education and research have improved greatly in recent years, and a lot more is known about treatment than a decade or two ago. It’s time now to put the final jigsaw pieces in place.

RELATED: Broken dreams: why we need to break the cycle

Make Long Term Athlete Development something more than a romantic ideal

We talk about Long Term Athlete Development. We know what it is, we understand the importance of it, and we like the idea of it in theory.

In practice, however, we continue to push athletes too young, entertain their ideas of trying to qualify for every international championship going, and cut the end of season break short to get ready for the next major championship, which is only ever a few weeks away.

We’ve become obsessed with endurance, without any consideration for age appropriateness, and uncovering the next child star. We behave like the next big competition is the only one left in the life of young athletes, and we are so desperate for success that we attach the same glory to underage medals as we do to senior success.

Then we place clearly unhealthy young athletes on the front covers of our athletics magazines, where the image a lot of their aspiring peers see, is that in order to win, you need to be thin too.

That’s not to say that we shouldn’t encourage competition at a junior level, that we don’t get excited about junior records, nor that we discourage aspiration. But underage success should never come at the expense of developing the skills and capacity for success later in life, or, more importantly, at the expense of future health.

Junior competition should ultimately be a stepping stone along the way, not a destination in itself. It should be about getting an athlete to the best possible position to train at a senior level, without draining them of their physical and psychological reserves. Athletes should be gliding into senior competition, ready to up the ante, not reaching 20 already drained of their physical and psychological reserves.

There’s no doubt but that Olympic champions are constantly pushing the limits of human health and performance. But in most cases, they are fully grown adults who have a sound training base, built over a long period of time.

Their health matters too, of course, but there’s a big difference in pushing the limits for a few years in your twenties and depriving a teenager of reaching peak maturation.

In many ways applying long-term athlete development requires guts.

It definitely won’t make you popular in the short term. But taking a long-term approach will, absolutely, help prevent many of the health issues faced by young endurance athletes. It’s time to start putting ideology into practice.

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