Lightweight Rower with Performance Decline and Menstrual Loss
A 19-year-old female lightweight rower training at the Institute reports a 4% drop in 2,000 m ergometer score over six weeks, persistent fatigue, recurrent calf strains and five months without menstruation. She is 1.70 m and 58 kg (BMI 17.8). Fasting ferritin is 12 µg/L, haemoglobin 118 g/L, and resting heart rate has risen from 52 to 61 bpm. She trains 11 sessions and 18 hours per week, has cut carbohydrate portions to 'make lightweight' and says she feels guilty after eating. The head coach proposes adding a 15% training-volume block before the qualification regatta in 10 weeks, arguing that 'talent will cope'. The athlete asks the nutritionist not to tell the coach about her eating concerns because she fears deselection. The doctor is on leave for two weeks.
1. What are the immediate clinical and safeguarding priorities, and what should not happen?
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Immediate priorities:
- Medical review cannot wait two weeks. Arrange cover or refer to a sports physician. The combination of five months’ amenorrhoea, BMI 17.8, low ferritin, fatigue, recurrent injury and performance decline raises concern about low energy availability and relative energy deficiency in sport (RED-S). This is a clinical suspicion, not a diagnosis to be made by the nutritionist alone.
- Nutrition assessment: Review energy availability, carbohydrate intake around training and eating behaviour. Her guilt after eating and carbohydrate restriction need sensitive exploration for disordered eating.
- Psychology support: Offer a psychologist experienced in athlete eating concerns; do not frame this as mental weakness.
- Training load: Do not add 15% volume. Reduce or hold load pending medical advice. Increased volume in a low-energy state increases injury, illness and endocrine risk.
- Iron: Ferritin 12 µg/L is low, but iron treatment should follow medical assessment, including whether inflammation or other causes are present. Do not self-prescribe high-dose iron.
What should not happen: No weight-loss target, no 'make weight' deadline, no promise of absolute confidentiality, and no public discussion of her menstrual or eating history.
2. How should the team handle the athlete’s request that the coach not be told about her eating concerns?
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Starting point: Confidentiality is the default, but it is not absolute. The team should explain, in advance, that clinical detail will be shared only on a need-to-know basis and that safety overrides secrecy.
Reasoning:
- The coach does not need the full eating-disorder assessment to coach safely; the coach needs a medical restriction and a training-load instruction.
- The athlete should be involved in the conversation. Ask what she is willing for the coach to know and agree a script. This preserves trust and reduces the risk that she disengages.
- Share the minimum necessary: a documented restriction such as 'no additional volume; modified sessions until medical review'. Do not disclose menstrual status, food rules or psychological content.
- If she refuses any sharing and the risk is high, escalate to the safeguarding lead and sports physician. Duty of care to a young athlete can override her preference, but she should be told what will be shared and why.
- Document the decision and the rationale.
Conclusion: Do not promise silence. Use a controlled, athlete-involved disclosure of restrictions, not a full clinical briefing.
3. Outline a 10-week training and monitoring plan before the qualification regatta.
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Weeks 1–2: Medical and dietitian review; temporary reduction of training volume by 20–30%; establish regular fuelling, including carbohydrate before and after key sessions; sleep and recovery plan; psychologist contact. No weight-loss goal.
Weeks 3–4: If medically stable, gradual return to rowing volume while maintaining energy intake. Strength work twice weekly to support bone and tendon health. Monitor morning heart rate, sleep, mood, calf symptoms and menstrual status.
Weeks 5–6: Re-test ergometer only if the athlete is symptomatically better and medically cleared. Review ferritin and haemoglobin as advised. Begin race-specific work but avoid sudden volume spikes.
Weeks 7–8: Progress load by no more than about 10% per week, with a recovery week if markers worsen. Continue dietitian and psychology support. Educate the coach on RED-S and on why weight-based commentary is harmful.
Weeks 9–10: Taper. Participation in the qualification regatta should be conditional on medical clearance and stable markers, not on making weight. Have a written plan for what happens if symptoms recur.
Monitoring: Weekly multidisciplinary meeting; red flags include further weight loss, missed periods continuing, resting heart rate rising, worsening fatigue or dietary restriction. Performance is a late indicator, so do not wait for another 4% decline.