Eat. Sweat. Play

by Anna Kessel

  For Kelly Sotherton, the former British heptathlete, the link between periods and injury was always apparent. ‘If I had an injury it was often because it was the week before my period and that’s why it happened,’ she tells me. ‘I always felt sluggish . . . so we changed my training to be three weeks on and one week off, the rest week would be the week prior to the period because that’s when your body’s getting ready to have a period and that would always be when I’d get a niggle. That helped a lot towards preventing injury.’ Kelly made sure that her coach and the medical team were kept up to date with her periods, though she concedes that not everyone is able to be so open on a subject that many people still see as a taboo. ‘I’m a very open person,’ says Kelly. ‘I wasn’t afraid of saying to my coach: this is happening, I’m on my period, I’m a bit sluggish. You have to tell your coach everything or they can’t help you. I really had to ensure that my coach knew what was going on. As soon as September came around I’d start planning for next year’s championships and changing my periods so they wouldn’t clash with the major competitions. I’d plan really far ahead because I wasn’t a big fan of continuing to take the pill and missing a period that way, for months, which some girls do. But I’d start manipulating them using the pill and so my two key dates were always Gotzis [the world heptathlon competition] and the Championships and I’d work backwards from there to find out when my periods would be and then change them.’

  What Marilyn and Kelly discovered, through trial and error, is that periods cause most havoc to an athlete’s body in the week leading up to bleeding. Dr Charlotte Cowie, Clinical Director at St George’s Park, has worked with every kind of athlete from Olympians to Premier League footballers and has seen the impact periods can have on sportswomen. But she tells me that she feels hesitant to speak about it because for most women the benefits of exercising before and during a period far outweigh any negative side effects. ‘I do agree it’s a real step forward being able to talk about this stuff, but we’ve got to put it into context: statistically women who don’t exercise regularly are much more likely to have symptoms of menstrual pain than women who do exercise regularly and my worry would be that a big discussion around [the negative effects] would make women think it’s not OK or it’s difficult to train when they’re menstruating. When actually it’s just so important for women to exercise. There are some studies in relation to injury rates and women who are menstruating, though . . . it seems there are points in the menstrual cycle where you are more prone to injury.’

  Charlotte says some of the more common problems she sees are practical ones, things that might affect any woman – not just athletes. She talks about training facilities where the toilets cater for men only and yet women have to change their sanitary protection there. For young girls, only just coming into puberty, this can create an extra barrier to them doing sport and exercise. ‘For young athletes, just remembering to have the appropriate sanitary protection is important so they’re not worrying about it and are prepared so they don’t have that fear they’ll suddenly be caught competing and there’s nothing they can do about it.’ For elite athletes of any age, the drugs tester visits feel particularly intrusive when they are on their period. Drugs testers are expected to ‘watch where the wee comes from’, as Kelly puts it, to ensure that urine samples are genuine. But for a woman on her period this can feel humiliating. There might be blood in the urine, or a visible tampon thread, or a full sanitary pad in your underwear. Thank goodness, then, that the testers are at least female. Tanni Grey-Thompson remembers a time in her career, in the 1980s and 1990s, when she occasionally had to provide samples in front of male doctors.

  Treating the common symptoms of menstruation, such as period pain, can usually be achieved with normal painkillers. But while many women prefer to use alternative remedies such as evening primrose oil, these can be problematic for elite athletes who need every medication they take to be batch tested in order to prevent doping test complications. ‘In terms of hormonal manipulation it’s an individual thing, if girls are very young and they’re not sexually active yet it’s a big step for them to start taking the pill. Whereas if someone’s in a relationship and they need a method of contraception anyway then they can more appropriately consider going on the pill,’ says Charlotte.

  Each sport has its own challenges – Olympic athletes have just one tiny window every four years to perform, compared to footballers who compete the year round, or tennis players who need to peak at least four times a year for the Grand Slams. ‘If you’re in a weight-regulated sport like weightlifting or taekwondo you don’t want to be dealing with water retention ahead of a major competition,’ says Charlotte, ‘so there’s individual solutions for individual athletes. There’s only a tiny percentage of athletes who have terrible symptoms. That’s why I feel so sorry for Heather Watson, because not only is it very hard to talk about, but because it’s not that common she may not have had other female tennis players to talk to about it. Having looked after the whole England women’s football squad, there were a few players who took anti-inflammatories but only one athlete who really struggled with severe performance-limiting pain. So it’s not nothing, but it’s certainly not the majority.’ Indeed, Charlotte, who previously worked at the Lawn Tennis Association, believes that tennis players have it hardest, being on the road for most of the year, searching for sanitary protection in different countries around the world, and not having the same doctor throughout the season, as medics are assigned to specific tournaments rather than to athletes. It’s an opinion shared by Judy Murray, former captain of the British Fed Cup team which includes Heather. ‘Because the women’s tour is so dominated by men, especially if your coach is a single guy, the whole thing with periods becomes a very difficult thing to explain because it’s not something a man will ever experience himself,’ Judy tells me. ‘So if they’re not close to someone who has to deal with that every month – a wife, girlfriend, partner – many of them won’t get it. But it’s a fact of life that significantly affects performance at certain times of a player’s cycle so we need to make sure they do understand the ins and outs of that and we shouldn’t be afraid of talking about it.’

  Then, quite unexpectedly, Charlotte reveals something that stops me in my tracks. Research around periods and injuries, she says, has only been taking place in the last decade. I am so stunned I ask her to repeat this fact. ‘Yes, well, most of the studies that we go on in sport are nearly always on male subjects and so we make assumptions about female athletes in relation to research being done on males.’ But how can this be? How can male bodies be so casually substituted for female bodies? Charlotte matter-of-factly explains that there are fewer elite sportswomen than sportsmen, and fewer women exercising than men, which makes recruitment for research trials more challenging. And then there’s the money factor. ‘Generally speaking male sports are better funded so there’s more financial support to do research on male athletes than female athletes.’ But there must be so much we don’t know about the female body then, I ask? ‘Very much so, yes,’ says Charlotte.

  This is a bombshell. Men’s bodies being substituted for female bodies in sports research is about as unscientific as you can get. A few weeks later I go to see the campaigner and journalist Caroline Criado-Perez, best known for protesting against the Bank of England’s decision to remove Elizabeth Fry from the £5 note, leaving no female presence on English banknotes. Caroline’s protest captured the public’s imagination because what was a relatively small detail in our currency snowballed into a national campaign. Soon politicians were up in arms and both Caroline and the MP Stella Creasy received rape and death threats for their audacity in speaking out.

  When we meet, Caroline tells me she is writing a column about this exact issue in science. ‘It’s the kind of sexism I find most interesting, when the male is the default,’ she explains. She tells me about crash test dummies that were based on male bodies for decades, until someone realized they’d better find out the
impact on pregnant women’s bodies. ‘It’s the same thing with drugs; the FDA [the US Food and Drug Administration] have had to cut the dosage of sleeping pills for women in half because women’s bodies metabolize the active ingredients much quicker. They only just realized this in 2013.’ But Caroline hasn’t finished yet. ‘And then there’s the women who were being misdiagnosed when they presented with heart attacks because they had different symptoms from men and lots of doctors had been only trained in male symptoms, so they’d send them off home thinking they had stomach or indigestion problems. Of course no doctor wants to misdiagnose a woman, but it’s happening because of the way the female body is seen as the male body with some boobs tacked on. Female medicine is just about female troubles, rather than seeing our whole body as different.

  ‘The most astonishing thing was the rationale behind not testing on women which was that the female body is too hormonal. That’s very interesting to me on a number of bases. If a test cannot account for the bodies of 50 per cent of the population, surely there’s something wrong with the test, not the bodies. But the male body also fluctuates hormonally, so the science is incorrect. So it doesn’t make sense in any way. I find it so fascinating that even scientists who are interested in fact are basing their decisions on incorrect methods.’

  We sit there in silence for a moment digesting this thought: how can science be so unscientific? In the weeks that follow I come across dozens more examples. There’s the alcohol test for the controversial female Viagra pill, which used twenty-three men and just two women for one of its trials despite the fact that women have a lower tolerance of alcohol than men. And the article I read in US publication the Atlantic about a woman who went to the ER in severe pain and waited nine hours to get a diagnosis while medical staff told her to calm down, stop crying and wait her turn. It turned out she had ovarian torsion and was hours away from death. The article says that women’s symptoms are routinely played down in the US medical system compared to those of male patients. In the US, ‘men wait an average of 49 minutes before receiving an analgesic for acute abdominal pain. Women wait an average of 65 minutes for the same thing.’18

  What is clear is that women need answers, they need guidance. They need the science, and they need it right now. Marilyn is thirty-one at the time I am writing this book. This is probably the last major championship cycle of her career. She’s already missed out on so much expertise. It’s so unjust. ‘It’s not that female athletes are looking for an excuse,’ she says, ‘but not having awareness of your movement [in your menstrual cycle] is dangerous. It’s simple things like wearing compression leggings or a sacroiliac belt to keep my hip movement in check. If there are things out there that can help me I want to have the knowledge and not just find out using trial and error, which it’s been like – I mean it’s literally been me on the Internet googling stuff.’ I can’t help but think this is mad. Can you picture Wayne Rooney or Usain Bolt sitting at their laptops desperately googling solutions to their medical problems? It just wouldn’t happen.

  I need to speak to an expert. As it happens a consultant gynaecologist for the International Olympic Committee is giving a speech to the British Association of Sport and Exercise Medicine, titled ‘To Bleed or not to Bleed? That is the Question!’ Mr Michael Dooley appears to be the leading expert in this country on sport and menstruation.

  Over the next four months I speak to Michael every few weeks. I have never met anyone so passionate, or who speaks with such fervour, about the health of the female body. He’s worked with some of Britain’s most famous sportswomen – from Paula Radcliffe to Mary King – both of whom have written about the support he has given them through their pregnancies. He wants to tell the world about periods, infertility, pregnancy, the menopause, the benefits of exercise and the health of a woman. Despite spending years devoting his professional career to this subject, I quickly discover over the course of our conversations that there remain a lot of unanswered questions in this area. ‘Sadly there are no answers to a lot of your questions because we don’t have all the evidence,’ he says. ‘That’s what I’m trying to do, more research. I’m probably one of the only gynaecologists in England looking at elite and recreational athletes because it is such an important area to be addressed.’

  But why isn’t there more research, I ask, exasperated. ‘Because we’re quite a conservative lot, the medical community, only recently are we realizing the importance of exercise and sport,’ he says. ‘In my lifetime we’ve had a huge cultural shift around attitudes to women and exercise – from only 11 per cent of the athletes competing at the 1960 Olympics being female, to 42 per cent at London 2012. Therefore we have moved very quickly socially, but we haven’t taken it on medically, and we’re only beginning to realize the benefits of being active. Even culturally, though, I still don’t think that we’re encouraging women to compete or take part in exercise at any level.’ Michael says a lack of investment in research is a big part of the problem, and he is working towards setting up the first ever NHS sports gynaecology clinic to extend his work in the private sector.

  ‘There’s no doubt that premenstrual syndrome can be greatly improved by doing exercise, ditto endometriosis and pelvic pain – and we’re not talking about the elite here, everyone can benefit – and there’s no doubt fertility can be improved by losing weight because too much body fat affects your hormones. So an educational programme isn’t too difficult but we also need more data on what the problems are – I’ve got quite a huge database now from athletes coming to me with their problems. Five years ago I was saying to people with low body fat that being on the pill is fine. Now there is evidence that this may not be the case and that the combined oral contraceptive may not be as beneficial for bone protection as we thought. The newer contraceptive pills, which contain natural oestrogen, may be better.’

  Michael’s specialist area is elite athletes, but his message that this issue affects all women – not just sporty ones – is important. At school, and as a young woman, I remember the terrible pain that many of my friends went through prior to and during menstruation. They were in and out of the doctor’s surgery, being put on different drugs to control the symptoms. I was lucky never to suffer in that way; it looked excruciating. During that time they were never given advice to exercise – right at the point in their lives when they most needed to engage with physical activity, and when they were most at risk of being lost to sport and exercise forever. Instead all the talk was of hot-water bottles and curling up in bed, enduring the cramps. Imagine if they had been told that exercise would alleviate their pain? Why don’t we convey these messages in schools? Why don’t we educate young women – whether they’re walking into a GP’s surgery, or reading a magazine?

  Out of the blue, Michael asks me if I’ve read The Diary of Anne Frank. Yes, I say, confused as to what the Nazi occupation has to do with periods. ‘Well,’ he says, ‘that’s well worth reading because she talks a lot about periods. She says: I don’t like them but they’re my inner secret – and that’s very important because that’s so true. When someone comes along and tells me “I’ve got regular periods,” instantly I know what’s going on with someone’s hormones.’ The point that Michael is making is that women – all women – need to be able to talk about their periods because they tell us so much. Rather than shying away from them as some sort of taboo, we should be positively embracing them, grateful for everything they can tell us about our own bodies. ‘We’ve got to educate women about their own reproductive health. The number of talks I give to women, highly intelligent, high-powered women, who don’t understand their own body, they didn’t understand that after menopause they didn’t need contraception, they didn’t understand the risks of the menopause. Women don’t know what happens during ovulation, or during PMS, there’s a huge lack of understanding, even very basic things which if they did understand could really help to prevent lots of problems.’

  What about sex, I say? How does sex impact on a woman’s at
hletic performance? Is it like what they say about men? That sex and orgasms weaken the testosterone and therefore abstinence is the best approach for athletes? Michael says he doesn’t know. He hasn’t come across any research about women, sport and sex.

  It’s not just Michael. Everyone I ask, from medics to athletes, tells me the same thing. And, crucially, most say they’ve never thought about it before. And so I find myself stumbling into the next information black hole.

  Some years ago I was asked to write an article about sex and sport for Observer Sport Monthly. There was the usual hype at the time around the Beijing 2008 Olympic Games and how many crates of condoms would be made available to horny athletes whose libido had been boosted by intense athletic competition. Was it all an irresistible urban myth? Or was there any truth in it? A British sprinter, who requested to remain anonymous, spilled the beans and described corridors full of girls queuing for a night of passion with male athletes after competition. But, interestingly, he also talked about his female teammates. ‘Some of the girls say they can’t compete unless they’ve had sex the night before an event. One girl told me she feels lighter on her feet after sex and has a greater sense of well-being.’19