World Mental Health Day - PMDD

 

Today is World Mental Health Day. A day "to raise awareness of mental health issues around the world and to mobilize efforts in support of mental health."

According to the World Health Orginzation, stigma and discrimination continue to be a barrier to social inclusion and access to the right care. We can all play a part by talking about mental illnesses without stigma, learning more about the conditions that affect millions of people very year, improving the affordability and quality of mental health care and raising awareness about which mental health interventions work.
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It was the winter of 2014. A few months prior we moved from Jacksonville, FL to Greenville, SC This was my first "real" winter after spending over 10 years in warm and sunny Florida. My dad had recently passed away after a 10-month battle with stage IV cancer. 

Throughout this time, I noticed that around the start of my menstrual cycle (in the 1-2 weeks prior), I did not feel or act like myself. I was becoming easily irritated and anxious. So many unexpected and uncontrolled heightened emotions started to negatively impact my life. There were times I felt suicidal, times when I would panic and other times when I was angry and irritable. I was hypersensitive to everything. I had trouble concentrating.

And then it was like a light switched off. A few days after my menstrual cycle started, the darkness cleared and I became more like myself - happy, optimistic, patient, positive. Month after month, I felt like I only had two weeks of living normally. The emotional symptoms were so distressing that it was severly impacting my daily life. And once my period started, it was a huge relief - I finally had my life back. 

I talked with my sport doctor and he diagnosed me with PMDD (premenstrual dysphoric disorder) - a much more severe form of premenstrual syndrome (PMS). 

Women like myself who have PMDD are sensitive to the normal fluctuations of estrogen and progesterone during the luteal phase of the menstrual cycle, which triggers the debilitating mood symptoms.

I'm extremely thankful to my doctor for not blaming my symptoms on my "raging hormones." He gave me a diagnosis so I could then explore treatment options. When I talked to my GYN, she suggested that an antidepressant may help. I was hesitant. I felt like an antidepressant was the easy way out and I could treat this on my own with lifestyle changes. I tried tweaking my diet, working with a counselor and changing my exercise routine. Nothing was helping. Almost two years after being diagnosed with PMDD, I decided I would try an antidepressant (SSRI). 

After a few months, I found it easier to function each month. My symptoms were less severe and I could better manage my emotions. I could better recognize my triggers and I learned how to better cope with my symptoms. 

For a while, I felt embarassed that I needed medication to feel normal. But overtime, I realized that taking one small pill, once a day, was my lifeline. The antidepressant wasn't turning my into a different person - it was helping to maintain my normal personality and quality of life. 

Every month I pick up two medications from the Walmart pharmacy. Phenobarbital for Campy to prevent his seizures and Sertraline for my mental health. I always joke with Karel that I am picking up our "happy brain" pills. 

Campy needs a pill to control the abnormal activity in his brain and I need a pill abnoral response to normal hormonal changes.

Demonizing medication as a treatment option for mental health does a real disservice to those in need of it. Mental health is equally as important as physical health. Illness is illness. Mental health is health. 

The female athlete and her hormones

Sadly, sport, science and exercise are still dominated by men. For example, women are grossly understudied when it comes to research on exercise physiology and sport performance. A big part of this is due to menstrual cycles. When a female has monthly hormone cycles, there are two phases to consider when it comes to exercise physiology and performance. Although it's well-documented that menstrual disturbances (ex. amenorrhea) can result from chronic energy imbalance (either increased energy expenditure or insufficient caloric intake), most research on performance, nutrition and exercise is done on men - with no menstrual cycles to plan for or fuss over.

So where does this leave female athletes who have to train and race with fluctuating hormones? How many coaches talk to their female athletes about their period and how to manage training and racing during this time of the month? What about the uncomfortable symptoms that female athletes experience before and during their cycle, like bloating, low energy, mood changes and cramping?

Thankfully, there are a few loud voices in the research setting that are letting scientists (and the public) know that you can't study men and then downsize the info to fit women. Among this chatter is the way we look at and talk about menstruation. So what about those of us who have a normal monthly cycle and have to train and race with fluctuating hormones?

As a female athlete, I'm impacted by my monthly cycle on, well a monthly basis. My changing hormones affect me for ~2 weeks of every month. I've gotten my period on race morning, the evening of a race, the day after a race, the day before a race, a week before a race and two weeks after a race. I suffer from a range of physical and mental symptoms every.single.month. As you can image, being a female athlete is not easy - especially when my performance and body is impacted by my hormones on a monthly basis. I'm not one to make excuses but I can honestly say that I perform a whole lot better when I'm in the low hormone phase of my cycle. With this comes an understanding of my body and how my hormones impact my physiology and performance. I'm proud that I have a healthy body that menstruates regularly but I sometimes think that life would be a lot easier as an athlete if my hormones were stable throughout the month.

Although there are tips and strategies to help minimize the effects of fluctuating hormones, I believe that the first step is knowing why things are happening and that you are not alone in the monthly battle (or acceptance) with your hormones.

To continue the conversation and to break down the stigma associated with the impacts of a female athlete and menstruation, here are a few things to consider as it relates to hormones:

GI ISSUES - Have you ever noticed that your stomach feels a bit off around your cycle? When the uterus shed excess lining/tissue due to fluctuations in hormone levels, the rise and fall of estrogen, progesterone and prostaglandins cause changes in the muscles of the GI tract. Digestive issues are very common - like gas, diarrhea, loose stools, constipation and bloating. Progesterone is contributed to constipation whereas estrogen tends to increase GI motility, causing diarrhea or loose stools. This is something to consider when training or racing as your GI system may not be working at its best.
Personal note: In the week before my cycle and the first day or two of my cycle, I typically have to stop to go the bathroom during run workouts, which is something that normally doesn't happen to me when my hormones are low. I've learned to accept this and make sure I plan my running routes accordingly. I've also learned that some foods don't sit well in my belly before my period so I avoid them and find a temporary replacement option. 

THERMAL CONTROL - Once again, fluctuations in estrogen and progesterone can affect the regulation of fluid balance. An increase in progesterone in the luteal (high hormone) phase can cause an increase in both skin and core temperatures. This can also alter the temperature when sweating begins in a hot environment. Thus depending on the weather, some women are at an increased risk of a heat illness and dehydration during the luteal phase, specifically during prolonged exercise in hot conditions. This can also cause early exhaustion or fatigue due to the strain on the cardio system. This is something to consider when training and racing in the heat.
Personal note: I feel my body temp increase before my cycle. This often affects my sleep. I also have to use more water to cool my body during training and I find that respiration is higher (and so is HR) in the days before my cycle. I increase my sodium by pre-loading before my workouts/races during this time and also make an extra effort to stay up on hydration.

ACHES AND PAINS - Your muscles, tendons and ligaments have receptors for estrogen so it makes sense that during the menstrual cycle, the structure and function of these tissues may change and you may also experience more muscle and joint pain and stiffness. If you have ever noticed that you experience more niggles, aches and pains around your monthly cycle, it could be due to an increase in estrogen causing your tendons and ligaments to loosen. This can cause instability in certain joints, like the pelvis and knee. Be mindful of how and where you train/race throughout your menstrual cycle as tissue instability may lead to injury.
Personal note: This is something that affects me every month - my SI joint gets out of whack so I make sure to see a massage therapist and I also use KT tape on my back. I find that I get more "twisted" with my hips/back so I have to keep up with certain mobility exercises. I also know that I don't recover as well from intense sessions before and during my cycle so I stay diligent with some type of protein recovery drink during this time. I also communicate with my coach so that I don't do too many intense run or bike trainer sessions during that time of the month. I also stay up on my Mg12 cream to help with my muscles. 

MOOD CHANGES - It's true that females will "act differently" before and during the high hormone phase of the month. Connected to the rise and fall of hormones (specifically estrogen), these peaks and valleys of hormones can cause mood swings. Making things worse, stressful situations can make PMS even worse. It's very normal to experience symptoms like being oversensitive, crying more easily, getting angry, feeling sad or feeling more anxious or depressed.
Personal note: I have found that communication is key. I let Karel know that my menstrual cycle is likely coming soon so he knows that if I say something that may be out of character for me, he knows it's not me talking but my hormones. I also get more tired easily so I may not be acting like myself. I also find that I do better with social and outdoor workouts during this time as I happier when I am with other people or outside. I try to avoid social media as this can make me feel anxious and sad at times. 

SLEEPING ISSUES - Although you may be tired from life/training, menstrual cycle insomnia is a real thing. When estrogen is kicked up a notch, sleep disturbances are common. You may feel more drowsy and exhausted and you may notice that your sleep is more restless. You may even feel like you need a daily nap. Coupled with a raise in body temperature and feeling restless, REM sleep may be compromised.
Personal note: I'm a great sleeper for ~2 weeks of every month. I make sure to let my coach know when I'm not sleeping well as this is likely more to do with my hormones than training stress but it still impacts my recovery. There are some nutritional strategies to apply here (ex. Tart Cherry juice) but I feel the most important thing is to try to keep your room environment suitable to sleeping - with no electronic or light distractions and to avoid going to bed with a brain that is filled with running thoughts and emotions.

BLOATING - This is where I feel most female athletes struggle - with body image during PMS. A drop in progesterone can cause period bloating, which can be uncomfortable and can also negatively affect your self-image or confidence. Although you may feel like you've gained weight/fat and you may notice that your stomach is protruding, this is all due to the body retaining more water and salt due to changes in progesterone and estrogen. It's important to pay attention to your thoughts during this time as low self-esteem, poor body image and body dysmorphia can trigger disordered eating habits such as restriction and overexercise. Or you may feel too uncomfortable to exercise. Logically, it's important to know that nothing about your physical self has changed and that exercise can do wonderful things for your mind and body.
Personal note: Although this is when most of us females will feel most uncomfortable in our own skin, it's very important not to make radical changes in your diet or exercise regime. Restricting food will only lead to compromised health and performance. Accept what's going on with your hormones and make sure not to let your thoughts impact your actions. I find that wearing looser clothes and not spending energy on how I "feel" helps me get through this time of the month. Plus, I remind myself how awesome I feel when my cycle is over and when I'm in the low hormone phase, I call that my superwoman phase where I feel like I can take on the world and I can crush my workouts. I also try to schedule more work projects, writing and daily to-do's during my low hormone phase as I am much more productive. During the high hormone phase, I give myself permission to put a few less things on my daily plate. 

Menstruation and body image

I consider myself an expert on menstruation.......as it relates to my body. I've had a regular (naturally produced) menstrual cycle for over 13 years. Each month, my menstrual cycle is a reminder of my healthy body and mind. Even in peak Ironman training, I still have a normal cycle. However, this doesn't mean that it's a fun time of the month. For almost two weeks out of every month, I suffer - mentally and physically. As a fellow female athlete, can you relate?

For females, menstruation is a normal monthly occurrence for a good 30-35 years of life. For female athletes, training and racing can be positively and negatively affected by your cycle - every female is different. An excellent read on this topic is ROAR by Dr. Stacy Sims. Although menstruation is often shunned by the media, it is gaining more attention by athletes, researchers and coaches. However, a topic that is not heavily discussed is the way your body image changes during your period.

Menstruation causes many physical and mental changes, specifically during the luteal phase (the second half of your cycle phase). Research shows that anxiety and negative body-image related thoughts are highest during this phase. In other words, females are more unsatisfied with how they look (appearance and body image) in this high hormone phase, often perceiving the body to be larger than it really is and feeling less attractive than normal. Despite research showing that body size remains the same, there's a strong association between body dissatisfaction and the menstrual cycle.

As I've discussed in previous posts, body image is a tough topic for athletes for its influenced by many factors. With so many mixed messages about what's the "ideal" image, how attractive or comfortable you feel about your body can be a constant work in progress. Emotionally, it can be tough to deal with all these messages, especially when there are dramatic changes in your hormones in the 10-14 days before your cycle. For this reason, it's important that female athletes become aware of the physiological changes that occur in the body throughout the menstrual cycle. The more self-awareness you have, the easier it is to take care of your body - especially when your hormones are making you feel miserable about the way that you look.

Here are a few side effects of menstruation that may affect your body image.

• Constipation
• Loose stools
• Bloating
• Diarrhea 
• Swollen or tender breasts
• Night sweats
• Gassy
• Lethargy
• Feeling tired
• Mood swings
• Depression
• Appetite changes
• Food cravings
• Trouble concentrating 

Body image and restrictive eating/dieting often coincide. For when you are dissatisfied with your appearance, you may conclude that losing weight will make you feel better about yourself and your body image. Self-esteem, anxiety and depression can also be problems of being dissatisfied with your body image. For many, to help combat uncomfortable physical and psychological feelings, next comes restrictive eating, overexercising and patterns of disordered eating.

By recognizing that these issues (above) are normal, my hope is that you will avoid extreme dietary changes in attempt to try to change the way that you look and feel and instead, have more compassion for your body during this time of the month.

I can attest that it's no fun to deal with the side effects of menstruation...month after month after month. Especially when trying to train consistently - often in tight/revealing clothing. That is why I feel it's very important to recognize how your feelings about your body change in the week (or days) before you start your menstrual cycle and to remind yourself that what you are experiencing is due to a change of hormones - because you are healthy. If you find yourself being more critical of your body during this time of the month, often noticing more physical changes with your body, use this time to become more in-tune with your body so that you can give it what it needs, what it matters the most.