When Ironwoman Carla Papac stopped getting her period, she wore it as a badge of honour.
"The attitude towards it was, 'I don't want my period because it means that I'm an elite athlete'," she told ABC Sport.
"So imagine the effect it has when you're talking to your role models and people who are achieving really good things in their sport and them telling you that they don't have proper menstrual health.
"You are going to take that on board and want to be the same."
Papac was a strong surf ski paddler but wanted to "look" like an ironwoman.
To her, that meant getting "lean", which led to not eating enough.
And what was once her best leg in races turned into her worst.
"I lost all my strength, all my muscle," she said.
"I looked really fit; I had a lot of people telling me that I looked good, which is also damaging because you look fit on the outside.
"But that year, I didn't make any finals of nationals except one, and before that, I used to make every final and be up there in every final too."
It took Papac some time to finally realise the real reasons behind her drop in performance, and it inspired her to educate herself and others.
The cost of striving for perfection
Papac still competes and is now an exercise physiologist who helps run Woman Performance, which provides workshops and education to athletes, coaches, and families about women's health.
She wants sportswomen to understand their periods and the importance of menstrual health — in particular, conditions which can affect them, including amenorrhoea (loss of periods) and Relative Energy Deficiency in Sport (RED-S).
RED-S means energy intake isn't matching energy output – basically, not eating enough for the amount of exercise you're doing.
It's most common in sports where weight/leanness are important, like long-distance running/cycling, aesthetic sports like gymnastics, or where you need to meet a weight category, like boxing and combat sports.
Symptoms include weight loss, disordered eating or eating disorders, menstrual dysfunction, drop in performance, mood changes, and recurrent injuries and illnesses, including stress fractures.
"Losing your period is not healthy," Papac said.
"Especially for people that haven't had that period for a long time, that's when I would be urgently encouraging that person to be making some serious changes in their training and reaching out to qualified nutritionists, talking with their coach about it."
American former distance runner Lauren Fleshman can relate — she had RED-S during her career.
She's the author of Good for A Girl, which details her own experiences in the running world, as well as more broadly exploring women's fight for a place in a sporting system "created by men, for men and boys".
"I think that I had been through my own stage of disordered eating," she told ABC RN's The Drawing Room.
"I had broken bones; I had missed opportunities in pursuit of this idea of looking like the image of excellence, of fighting for every per cent of body fat, just trying to be perfect.
"There was a huge cost. I couldn't even be good because most of the time, I was hurt in this effort to be perfect."
Fleshman realised she needed to listen to her body and forget about any "number on the scale" to be in a position to stay healthy.
"[Eating more] would lower my stress levels enough where I could actually train consistently every day, show up and race at all the big races and not be sidelined," she said.
As Fleshman explores in her book, female athletes have higher rates of menstrual dysfunction, bone loss, and disordered eating, while many think losing their period is a normal outcome of heavy training loads.
"Monitoring menstrual health is the first line of defence against all of this harm. And again, nobody talks about it," she writes.
Puberty is a 'power not a weakness'
Girls drop out of sport at higher numbers than boys and are more likely to experience body image concerns.
Fleshman believes a lot of this comes down to a lack of understanding of girls' and women's bodies.
"Puberty is framed as a career ender for a lot of developing female athletes," she said.
"We're looking at puberty and the changing female body to something softer, like something we need to draw conclusions about now, that it means they can't continue to improve.
"It's just way too premature to be creating these kinds of messages.
"And when we do create those messages then there is something girls can do.
"They can stop eating, they can try to control the development of their body, and that always leads to poor health outcomes in the end."
While boys and men have been shown to experience linear improvement during their formative years as their bodies develop, it's a different story for girls during puberty.
There can be a dip or plateau in performance and loss of coordination as they adjust to the changes, including holding more body fat and fluids, breast growth, and weight fluctuations on a monthly cycle.
American-Greek Olympic runner Alexi Pappas reflects on her own experiences in her book Brave.
"Female athletic programs need to see puberty as a power, not a weakness," she writes.
"Our bodies take time to develop - a word female athletes need to embrace."
Papac believes girls are under too much pressure to perform too soon and do not understand they need to eat more to support their growth.
"I think kids are just getting flogged," she said.
"And that's when you start to see them dropping out. Because they don't have good body confidence; they're seeing a performance decline because they're probably starting to under fuel themselves, trying to stop these changes that are happening to them."
Fleshman added that many coaches and parents looked to sports psychologists, "when there's really nothing wrong between their ears, their bodies are just changing normally.
"There is a big discrepancy in how our female athletes are thriving in sport compared to the male athletes, even when given equal access to play."
NRLW player Tiana Penitani said menstruation was a key factor which could affect girls' participation in sport.
"I think everyone at that teenage level wants to skip out on P.E. when they've got their period or they're feeling super uncomfortable," she told ABC Sport.
"So if we can eliminate that scary factor and take the research and the knowledge and feed it down to that grassroots level, it's gonna have a huge impact on the sport."
Performing while on periods
Awareness and acceptance of menstruation is one factor, but Papac wants athletes to dig deeper to understand how training and nutrition can be adapted through all stages of the cycle.
She acknowledged people with menstrual abnormalities like endometriosis and PCOS would need a different approach, while some athletes may need hormonal contraception to manage their periods.
"You have two phases plus ovulation of your cycle," Papac said.
"And without saying good and bad, there is a more optimal time to be training, which is in the first half of your cycle, and to be doing high-intensity overload.
"In the second phase of your cycle, it's time to maybe bring it back a little bit, maybe prioritise more low-intensity work.
"There are still world records broken in every part of the cycle."
Griffith University's Associate Professor Clare Minahan, a member of the Australian Institute of Sport's Female Performance and Health Initiative's monitoring group, previously told ABC Sport it's important to recognise the wide variations experienced by people who menstruate.
"I would go so far as to say that we don't have a consensus on anything, in terms of how the menstrual cycle affects performance," she said.
Minahan found two-thirds of elite female athletes preparing for the Tokyo Olympic and Paralympic Games reported their menstrual cycle affected their performance.
And more than half of surveyed athletes used hormonal contraception, mainly for birth control, the timing of their periods, and controlling pain or heavy bleeding.
Penitani, who used to be part of the fully professional Australian women's rugby 7s program and now plays semi-professional rugby league, related to trying to manage her periods.
"I spent a lot of my early years as a professional athlete on the pill just so I could skip my period around really important tournaments, and really heavy-loaded weeks as well," she said.
"So that was probably not the right way to go about it."
General knowledge around the menstrual cycle and contraceptives amongst elite athletes is low, and Penitani said it was harder for athletes who do not have access to fully professional sporting systems and support staff.
"Understanding and smashing through that misconception of periods being inhibiting because they're actually not," she said.
"A lot of girls don't even know what their cycle looks if they don't do their own research or understand what impact it has on the body, particularly around sport and training loads.
"So I think education is a really good starting point."
Papac also wants the onus to be shared around with coaches, parents, and support staff.
"We tend to see a lot of eating disorders in elite-level athletes because of the pressure to look a certain way or because of how they think they should be looking and performing," she said.
"People automatically think that athletes are healthy because they're shredded, they're doing amazing things out there.
"But a lot of those athletes aren't actually healthy, and they're not leading a balanced life.
"So if we can provide a little bit more education, a little bit more awareness about making healthy, quality athletes, I think we'll see athletes getting to a higher level and staying in sport as well."
