Nyrene Crowley just wants to bleed again.
It's been more than two years since the professional mixed martial artist last had her menstrual cycle, dealing with functional hypothalamic amenorrhea as a side effect of training at the highest level.
The 32-year-old has been training in combat sports for the best part of the last decade, spending time honing her skills both in New Zealand and abroad. Like with any sport, in order to achieve success at the top level, an athlete has to be willing to put in the work – and Crowley has done exactly that.
However, with limited information on how men and women's bodies react differently to high-intensity training, Crowley overworked her body and experienced amenorrhea – the absence of a menstrual period – from early in her career.
"I was just training like everyone else would train, then all of a sudden in fight camps – maybe two or three weeks before the fight – my menstrual cycle would completely stop and I never really thought anything of it because I knew after the fight it would come back," Crowley recalls.
"The girls at the gym would talk about it all the time, like 'oh, your menstrual cycle is going to stop but it's OK because it will come back.' So, my reaction to it was a little bit blasé, to be honest. There wasn't any information and I didn't feel any need to look further into it because everyone around me was saying that it was normal."
The reality of the situation is Crowley has been dealing with the female athlete triad – now referred to as RED-S (Relative Energy Deficient in Sport) - for the bulk of her career.
At its most basic level, RED-S is caused by the athlete not nourishing their body; not getting enough nutrients to fuel the level of training they are doing. Amenorrhea is just one symptom caused by RED-S, along with disordered eating and osteoporosis – with the issue particularly prevalent with sports in which having to make a certain weight is part of the job.
"Women don't give themselves the calories or fuel for the body to perform, so a lot of things go wrong – your body starts getting damaged from the inside out, then your mind starts to suffer," Crowley says.
"I was overseas possibly in the worst mental state of my life – going through bouts of depression and anxiety; I completely changed as a person. I didn't want to be around people and it was all because I was so completely drained at that point that my body just had nothing to give anymore.
"The sign that everyone notices when your menstrual cycle stops is that sign you need to realise things really need to change. I've been dealing with this for two-and-a-half years, and I'm not in any position where I can stop now, because I have to keep training – it's kind of like the lesser of the two evils.
"I have to keep training because this is the lifestyle that I've chosen, so now I have to focus more on managing it; introducing more parasympathetic activities into my lifestyle - yoga, meditation, mindfulness, breathing – all these things are my way of managing it. But it's terrible when it gets to that point where you just can't get it back; it's devastating."
It's a prevalent issue and one that more and more people have started to speak openly about. Earlier in 2021, world champion Kiwi rower Zoe McBride announced her retirement from the sport at 25, noting her own issues with RED-S as one of the reasons behind her decision, and she has been just one of many to share her experiences.
Athletes like Crowley and McBride aren't alone. A national survey carried out by Whispa (the Healthy Women in Sport: A Performance Advantage project run in conjunction with High Performance Sport NZ) released early in 2021 revealed almost three-quarters of New Zealand's top female athletes feel elite sport is putting them under pressure to look a certain way, potentially damaging their health.
One in four of the Kiwi sportswomen at the top of their game have been diagnosed with a stress fracture at some point in their careers, nearly a quarter have been iron deficient, while a third reported their menstrual cycle was affected by their training volume.
Female athlete performance physiologist Dr Stacy Sims is part of the Whispa project, and says part of the problem for athletes coming forward is the way the high-performance environment works – both in New Zealand and abroad.
"If you're not performing then you're out. One of the big symptomologies of RED-S is the downward side of performance. So, the athlete thinks they're not performing and the mental game within elite performance is if you're not performing, you're not training hard enough, or you're eating too much so it gets into this negative spiral. They're not performing, they get cut and they're pushed out of the system," Sims explains.
"It's not about pushing them out; it's about pulling them back so their performance improves. Because they can't necessarily say 'hey, I've got to step out of the programme right now because I'm sick.' It's the responsibility of those who can identify it to say hey we need to pull you back, keep you in the programme, we can still keep you training but we really need to individualise and tailor what you're doing for your own body to get you healthy so you can keep performing; so, you don't get cut, you don't get pushed out of the programme and you don't lose your contract."
Sims has been researching physiology and how the body of a woman differs from that of a man for much of her academic career, beginning during her undergraduate studies at Purdue University.
The now New Zealand-based Sims was a keen participant in physical testing, such as running on a treadmill, as part of her studies. However, her results were often cast aside. When she began questioning why that was the case, she was told women were anomalies and were not often studied.
"It hasn't really been that well accepted until about four or five years ago to talk about the menstrual cycle or do really sound research around the menstrual cycle," Sims says.
But while there has been little research in the grand scheme of things specifically into the female anatomy in the sporting environment, stereotypes have long been perpetuated around what a female athlete should be; stereotypes that can feed into an athlete's troubles with RED-S, adding mental stress to the physical stress they are putting on their bodies through training and not taking in the required nourishment.
"That's huge," Sims says of stereotyping what an athlete should look like. "It's not only the comments they get on social media about how they look or what they're doing or how they're perceived; it's also the internal idea that the athlete has to look a certain way to be successful in the sport, but society expects them to look a certain way in a dress.
"There's a constant struggle between what's feminine and what's successful in sport and it plays significantly into the mental health of athletes and how they're supposed to look and how that affects their training and nutrition."
While it's is often talked about in relation to female athletes, in 2014 the name RED-S was adopted by the International Olympic Committee as opposed to referring to it as the Female Athlete Triad, as RED-S affects men too.
Like women, if the athlete has insufficient energy intake relative to the demands of their life and their sport it can lead to disordered eating, decreased bone density and osteoporosis, while it can also affect their hormones and lead to low testosterone levels.
"It's very prevalent in both the male and female athlete, and it's not just the elites – it's all the way into the recreational or the weekend warrior," Sims says.
"If you're starting to exhibit symptoms of dead-end fatigue, you're not responding to any of the training, your performance is going backwards, you're putting on body fat even though your nutrition seems to be spot on, and you are having issues sleeping, gastrointestinal distress, cardiac arrhythmia, or having frequent wake-ups in the night – when you put them as individuals, no one thinks it could be RED-S.
"It's looking for two to three of the symptomologies to be like 'hey, that's a red flag for me.'
As it affects the menstrual cycle in women, a reality of RED-S is that it can cause infertility in the athlete. Someone who has lost their menstrual cycle can get it back, however they would have to drastically dial back their training or simply walk away from the sport altogether in order to give their body an opportunity to recover.
For athletes like Crowley, walking away from their chosen sport isn't an option. In professional sports, your career is a fleeting one in the larger scale of things. And if you have worked your whole life to get into a position where you are able to make a living off doing what you love, that is not something anyone would want to give up in a hurry.
Now, there are more resources available to young athletes with the likes of Sims – who works with athletes all over the world – at the forefront of presenting that information in a readily available fashion, and more and more women are talking about it openly both in a professional environment and with their friends at the gym.
While Crowley, now based out of Auckland's City Kickboxing gym, says she feels safe and confident enough to discuss the problem with teammates and coaches alike, if need be, she hopes the possibly of RED-S – particularly how it affects women – is something young athletes are taught about early in their careers and not something they have to go out of their way to learn about as she has.
"I guess the long-term effect of it is I can't have kids," Crowley admits.
"A lot of other women will be dealing with this as well. Until you can regulate your body to a point where it does have that regular cycle again, those things are unattainable. It can come back, but it depends how deep you are into it. I'm quite far in ... basically it means if I am going to get it back, I have to step away from the sport completely for a long time, and I'm not in a position to do that.
"When you start to understand that you're not alone and all of these symptoms you're feeling, there's a reason for it, that started my journey of acceptance and understanding. It helps so much when you can talk about it with other people."