Veronica Ewers said nothing, despite all the signs, despite the blood test results staring back at her, telling her the hormones in her body were barely present. Because the results came with an all-too-familiar indifference from her doctor.
“Based on this person being an elite athlete, they don’t have their period and that’s fine,” the 31-year-old American cyclist says, reciting her 2022 medical report to The Athletic with a somber half-smile. “So I didn’t flag it.”
The results should have been Ewers’ crisis point. Instead, she continued to believe that “when a woman loses her period, she’s at peak fitness.”
That is how she operated when playing soccer at Willamette University, a small liberal arts college in Salem, Oregon. She shrugged off signs then, too, leading to wan performances, her body toiling to keep up with demands. Eventually, Ewers was benched.
For nearly a decade after, as Ewers became entrenched in the cycling community and joined the professional peloton, she seemed healthy enough to compete. She finished ninth overall in the 2022 Tour de France Femmes. While some around her expressed concern over her eating and exercise habits, no discussion was had around the ongoing absence of her period, she says.
It took a broken collarbone in 2023, ending her season, before the consequences finally manifested. After being medically cleared to exercise again, she fractured her heel while running and had her bone density levels checked. She was tipping into osteoporosis.
This time, rationalizing the medical results was impossible.
Ewers knows her story is not unique. Swapping stories of similar experiences has become a bonding exercise for many female athletes across the world, she says.
Ewers before the start of the Liège-Bastogne-Liège cycling race. (Luc Classen / Getty)
According to a survey conducted by The Female Athlete Health Report from Project RED-S and Kyniska Advocacy in 2023, 36 percent of female athletes ignored missed periods, thinking it was normal or, in some cases, beneficial for their athletic endeavors.
The survey, which focused on responses from 769 athletes in the United Kingdom assigned female sex at birth, with questions concerning their menstrual cycle and body image, also found that 30 percent of respondents had been told by a medical professional that period abnormalities, including absences, were “normal” given their activity level.
“Elite sport first, period later.” Kerry McGawley, a professor and senior sports physiologist at the performance optimization company Orreco, recalls the pithy mantra recited to her by a professional Swedish cross-country skier more than a decade ago.
“It was shocking hearing that for the first time,” she says. “But the amount of times I’ve heard it since? That’s more worrying. Athletes coming up to me, one by one. They’re not having any period. Another is told if she’s getting her period, she isn’t training enough or hard enough. Nobody is taking care of that for them. Nobody is caring at all.”
The origins of the misconception that elite sports might require missed periods are multifaceted, according to researchers whom The Athletic spoke to for this piece. There’s the historic lack of scientific research into, and education around, menstrual health and its influence on sporting success; bygone or unrealistic ideals of elite sporting physiques; a dearth of education among coaches and athletes; and the historic taboo of discussing sexual health openly.
Also at play is the culture of sport itself, an arena of ultimate corporeal sacrifice — and a multi-billion-dollar enterprise.
The repercussions for athletes, researchers say, can include long-term health implications — and the curtailing of some careers, like Ewers’, altogether.
There is hope, however, for a more informed future, a greater understanding of how knowledge of the menstrual cycle can be an elite athlete’s “superpower.”
Temporarily losing a period for a short amount of time, quantified as one to three months, according to researchers, is not considered an immediate cause for alarm.
However, long-term absence of an athlete’s period can often indicate wider complications, such as disordered eating, being under too much stress, or operating within the RED-S framework (Relative Energy Deficiency in Sport) — meaning an athlete’s energy intake is insufficient to support the demands of their body.
The consequences can be manifold, including negatively impacting bone health, fertility, metabolism, iron levels, rate of recovery, sleep, career longevity, and emotional well-being.
Secondary amenorrhea (when you don’t have your period for more than three cycles) or primary amenorrhea (the complete absence of a period in a female of reproductive age) can compromise a young woman’s physical maturation due to the lack of regular growth hormones. Some women may consequently not reach peak bone health, which typically occurs around the age of 30, potentially increasing their risk of osteoporosis later in life.
The normalization of losing a period has impacted athletes across the sporting gamut for decades. Athletes in endurance sports such as cycling, running, skiing and swimming, aesthetic sports such as synchronized swimming or gymnastics, and weight-bearing sports, such as rock climbing or rowing, are particularly vulnerable due to the arithmetic of lighter often equaling faster or more nimble performances, say researchers.
Psychological and physical symptoms of a period — from cramps, fatigue, cravings, bloating, and mood swings, to fears of bleeding through white shorts — have helped portray the period not as a critical bodily function worth understanding and harnessing, but as an inconvenient, painful, even shameful hindrance to success.
Underfueling, excessive weight loss, and contraception, such as birth control pills, have been used as tactics to manipulate or even avoid periods during intense seasons of training or competitions, according to practitioners and athletes spoken to for this piece.
Indeed, the initial loss of a regular period can often be followed by an addictive uptick in performance.
“Before things started going wrong, losing iron, losing energy, finding myself fatigued, everything was pointing in a positive direction,” said Pippa Woolven, founder of Project RED-S — an organization that works to increase awareness and prevention and support athletes in their recovery.
Woolven represented Britain at the 2018 European Cross Country Championships and was part of the women’s silver medal-winning team. Coaches and peers praised Woolven for her physique and work rate, she says, reinforcing the idea that the absence of her period symbolized something positive.
“That’s the sad reality of the mathematical equation and the physics behind it,” Woolven says. “If you’re looking for a shortcut to success, then weight loss or restriction is the answer.”
Demi Vollering prepares for the fourth stage of the 2025 Women’s Tour de France. (Julian de Rosa / Getty)
This summer’s Tour de France Femmes brought concerns over shortcuts into the spotlight. After finishing second, the 2023 Tour champion Demi Vollering stood in front of the media, fielding questions not about her performance, but rather about weight — specifically: Had she lost enough, given her runners-up finish to Pauline Ferrand-Prévot in the Tour?
Vollering, who is 5ft 8in, describes herself as a “heavier rider” compared to Ferrand-Prévot, who is 5ft 4in. The 28-year-old turned the script: Why was jeopardizing one’s health still expected in the pursuit of victory?
“Sport is all about being in perfect balance,” the FDJ-Suez cyclist tells The Athletic. “That’s what we should show the world, to the young girls watching us. We all have different bodies. You need to understand yours, find your limits and accept them.
“I don’t want to be good for only two years, so I need to take care of my body as best as I can. Because if you don’t, there will be a limit where your body says, ‘That’s it. I’m done with all the years of you tearing me down.’”
In the wake of Vollering’s comments, the Cyclists’ Alliance — the representative body for professional cyclists — this year renewed its calls from 2024 for the sport’s world governing body, the Union Cycliste Internationale (UCI), to introduce mandatory screening for RED-S and bone mineral density for women and men. In a statement to The Athletic, the UCI said it took the issue of RED-S “very seriously” and was finalizing risk-assessment questionnaires and screening tools that could help team doctors.
Vollering’s comments did not occur in a vacuum. Against a backdrop of tales similar to Ewers’, sports stars such as American rugby player Ilona Maher are advocating for body positivity in sports, while federations and sporting bodies are being called on to act.
“Before we’re athletes, we’re women,” says 24-year-old French cyclist, and Ewers’ EF Education-Oatly teammate, Cédrine Kerbaol.
“We’re not trying to control what women can and can’t do with their bodies. We want to make sure that young athletes, men and women, are aware of the potential consequences.”
The United States women’s national team (USWNT) famously integrated menstrual cycle tracking into performance strategies ahead of its 2019 World Cup triumph, under the guidance of high-performance coach Dawn Scott and Dr. Georgie Bruinvels (Orreco’s Female Athlete Lead and the developer of period tracking app FitrWoman).
A year later, Chelsea became the first soccer club to tailor training to players’ menstrual cycles, spearheaded by current USWNT head coach Emma Hayes and Bruinvels.
Tracking apps and programs have now become staples for teams in the WNBA and NWSL, as well as top international sporting federations. The International Federation of Sport Climbing (IFSC) introduced RED-S and other health screening requirements last year, the first of their kind.
However, insufficient education and expensive screening techniques mean many sporting organizations and teams still rely on training, recovery regimens and monitoring programs modeled after, and designed for, the male body, says McGawley.
That’s the result of a historic lack of women in research spaces, both executing the studies and being studied, she says. Science often pursues a path of “least resistance,” she says. “Accounting for hormonal fluctuations was not that path.”
Dawn Scott (left) and Georgie Bruinvels (far right, pictured with USWNT head coach Emma Hayes) incorporated menstrual cycle understanding into performance coaching for the USWNT (Meg Oliphant / Getty, Brad Smith / Getty)
While a PhD student at University College London in 2015, Bruinvels asked for blood samples for her research into iron metabolism in endurance athletes. She was handed blood samples from only men.
“I asked, where are the females?” she recalled. “Why aren’t we recruiting females?”
Weeks later, Bruinvels stood among a crowd at the 2015 London Marathon, asking runners about their periods. “And literally, excuse the pun, the floodgates opened,” she says. “Everyone was asking questions. I spoke to over a thousand people in four days. I realized people don’t understand anything about their body.”
Bruinvels also discovered a familiar layer of embarrassment quietly coating those conversations. “My biggest ‘why’ for what I do now really was I was so ashamed to have a period,” she says.
That shame has deep, ancient roots. Where some early civilizations portrayed menstruation as a powerful, god-like phenomenon (some ancient Egyptian texts suggest that menstrual blood was used in potions or healing rituals), many considered menstruation with awe and fear, leading to the ostracization of those menstruating from regular society.
Centuries later, despite sanitary napkins existing before television was invented, advertisements of such items were banned from TV until 1972 in the United States.
The Venus of Laussel, a statue from Bordeaux Museum’s collection, estimated to be around 20,000 years old, holds a curved horn or cornucopia that has 13 notches. This may symbolize the number of moons or menstrual cycles in one year. (CM Dixon / Getty Images)
It took another 13 years before “Friends” actress Courteney Cox uttered the word “period” in an American television commercial. Actress Anna Chlumsky’s infamous “I’m hemorrhaging!” line in the 1991 film “My Girl” captured the modern perception of menstruation as a terrifying tableau.
But a woman’s period represents its own kind of “vital sign,” says Bruinvels, and in the case of elite sport, can be a margin-mover.
“I always say, the period is an additional biomarker that’s free that males don’t have,” says Bruinvels.
The rhythms of the menstrual cycle often reflect balance in other bodily systems and functions. Periods are the result of a coordinated conversation between the brain and the ovaries, with the adrenal glands, thyroid and gut all involved at points. Missed or irregular periods can be the first tell-tale sign of disrupted signaling along these pathways.
According to some studies, the follicular phase — which brings an increase in hormones — is often referred to as the “feeling on fire” or “superpower” phase: recovery can seem to happen quickly and energy levels feel supercharged.
Meanwhile, the luteal phase — occurring at the end of the cycle with higher levels of the hormone progesterone — is considered ideal for rest and recovery.
This ongoing fluctuation is crucial.
According to research conducted by McGawley, high-level amenorrhoeic runners missed more days of training, recorded more injuries, and experienced drops in performance rankings.
Further research, specifically long-term studies following athletes throughout competitive seasons, is needed to prove the perceived “superpower” nature of the menstrual cycle, says McGawley. But athletes’ perceptions of how they feel during any particular phase of their cycle — gleaned from surveys, interviews, focus groups and other qualitative studies — should not be dismissed or trivialized if no numerical data yet exists to support their claims, she says.
“It matters what this particular Olympic champion feels she can and can’t do month after month, even if the physiological metric doesn’t necessarily show it,” says McGawley.
Understanding the physiology of one’s body — why heavy bleeding occurs, how certain symptoms can be assuaged (from anti-inflammatory smoothies to opening a window while sleeping to help regulate increases in body temperature), what “regular” means to you — is what McGawley considers the “superpower” of the menstrual cycle.
“The period itself is not the superpower,” she says. “It’s understanding how to confront it, to have that power to make decisions and adapt to empower yourself during that time.”
McGawley notes that missed periods among elite endurance athletes competing at a high level, or what she refers to as “periodization,” is, to some degree, normal, particularly before a big race when stress or physical load is greater. The human body is an intricate and intelligent set of fight or flight responses. When the body feels it is under stress — whether physical or emotional — it will turn off non-essential systems.
According to Renee McGregor, elite sports dietician and best-selling author of “Fuel for Thought”, 21 percent body fat is considered a minimum threshold for maintaining regular menstrual cycles and ovulation in women. Elite athletes, though, are often outliers, transcending physiological norms, meaning many can and do perform at lower body fat percentages and remain healthy.
“However, I think we have a role in identifying when that is true and when that is not,” McGregor says. “We need to consider an individual’s genetic physique, their history, their phenotype.
“Many athletes I’ve worked with, specifically from Afro-Caribbean backgrounds, have been asked to fit a Caucasian physique. That’s not possible. We can get them to a point where their body is optimal, but I refuse to push them beyond that.
“But it’s still controversial. Should we be asking female athletes to be a particular body composition in order to perform?”
A year from now, Vollering, Ewers and Kerbaol do not want to be speaking about periods.
But right now, their social media inboxes overflow as much with gratitude from strangers for speaking out as calls for help from concerned parents and athletes at various levels.
“The reason we’re talking about it now is because there’s proof of the consequences, but it’s becoming worse,” says Kerbaol. “We need to act.”
That action needs to be multifarious. The various researchers The Athletic spoke to point to a glaring dearth of research into menstrual cycles and optimal hormone levels of different ethnicities. The natural occurrence of myriad hormone irregularities in female athletes, such as Differences of Sex Development (DSD), Polycystic Ovary Syndrome (PCOS) and endometriosis presents issues for accurate screening.
Demi Vollering (second from left) and Cédrine Kerbaol (far right) compete during the fourth stage of the 2025 Tour de France Femmes. (Szymon Gruchalski / Getty)
Most researchers and athletes The Athletic spoke to supported forms of screening and intervention rooted in holistic athlete support from a young age, emphasizing longevity over short-term gains and educating, with the aim of prevention rather than a cure.
“It’s a whole cultural movement that needs to change,” says McGregor.
“We can’t just thrash athletes until their bodies’ metabolism is down-regulated. It’s also about athletes understanding from a young age that they’re at risk and getting support.
“It’s about coaches listening to the wider team and appreciating that maybe we need to take five years to get this athlete where they need to be rather than push them to the brink now.”
Bruinvels also emphasizes a duty of care belonging to stakeholders and investors entering women’s sport. She points to American businesswoman and entrepreneur Michele Kang’s $25 million investment in U.S. Soccer in April this year, integrating the Kynisca Innovation Hub into the Soccer Forward Foundation, and actively investing in female health sciences as an example of positive investment.
“A lot of people want a piece of the pie of women’s sport. But I don’t think necessarily people are backing that up with, ‘OK, we want to support you,'” she says. “That’s where there are some gaps that need to be closed.”
Ewers still does not have her period back, but her hormone levels have improved significantly. Recent bone density scans indicate she is now in the osteopenia (low density) realm.
“Sport is also a business,” she says. “We’re all replaceable. There can be a lack of patience when it comes to getting better because it’s so unknown. ‘When is she going to be able to perform better? When is she going to start adapting to training?’ I don’t know the answer. No one does. A hormonal and metabolic injury is not visible. You can look at blood tests all you want, but that won’t tell you how long recovery will take.”
In February, she returned to the professional peloton after more than a year away. “Mentally, I’ve climbed out of the hole,” she says.
But without more research and education, the danger of tumbling back in remains.
“I really want to win the Tour de France,” says Ewers. “Everybody does. There are ways to have performance gains. But there is a risk.
“So the question becomes, if there are no rules or regulations, how do we stop young athletes from doing that in a way that risks them falling into those really deep holes?”
