Dr. Emily Kraus, sports medicine physician and director of Stanford's FASTR female athlete research program, addresses the critical gap in sports science that continues to affects all female athletes: from Olympians to college students to everyday women who just want to do their best.

She discusses the physiological differences that lead to unique health challenges and emphasizes the urgent need for tailored research on women.

Learn how to recognize the signs of low energy availability and why understanding women's physiology is crucial for optimizing performance and preventing injuries.

Key Takeaways:

1. Female athletes often experience more severe bone stress injuries due to hormonal sensitivities and under-fueling.
2. Menstrual irregularities, fatigue, and mood changes are critical warning signs of underlying issues like RED-S (Relative Energy Deficiency in Sport).
3. Standard lab values may not be suitable for female athletes; seek comprehensive tests for iron, thyroid, and vitamin D levels — and what numbers you should be looking for.
4. Why building a supportive culture is essential for injury prevention.
5. How to engage in open dialogues about physiological differences to foster a more inclusive athletic environment.

If you found this debut episode of the new Feisty Women's Performance podcast valuable, please leave us a review and share with a woman who needs this information!

Dr. Emily Kraus is a Clinical Assistant Professor at Stanford Children’s Orthopedic and Sports Medicine Center, specializing in Physical Medicine and Rehabilitation. As the director of the Female Athlete Science and Translational Research (FASTR) program, she focuses on closing the gender gap in sports science research, and emphasizing early identification and intervention for female athletes.

Links and Resources:

• Dr. Emily Kraus Profile

• FASTR Program

• FASTR Instagram

FeistyFest Info: https://www.wetravel.com/trips/feistyfest-feisty-media-1943243299#about-this-trip

Courses and Coaching: https://feisty.learnworlds.com/

Women's Mechanic Camp in Tucson: https://www.wetravel.com/trips/women-s-bike-mechanic-camp-tucson-az-feisty-media-24985624#about-this-trip

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Welcome to the feisty Women's Performance podcast where we cut through the noise to bring you science based health over hype.

I'm your host, Dr. Erin Ayala, a licensed sports psychologist, certified mental performance consultant, researcher and endurance athlete passionate about women's health and performance.

Let's get started with today's conversation.

What if everything you've been told about training as a woman is just a hand me down from your brother's playbook?

That's not an exaggeration.

Most sports science research has been conducted on male athletes.

So when your coach says studies show or your training plan promises evidence based protocols, there's a really important and sometimes awkward question worth asking.

Evidence from whom?

And what is this research actually based off of?

Enter Dr. Emily Kraus, Director of Stanford's Faster program, sports medicine physician who's leading the charge to understand how female bodies actually respond to training and injury.

As both a physician and a nine time marathoner herself, she's seen and experienced this research gap from every angle and she's doing something about it.

In our conversation, she unpacks why female athletes get more severe bone injuries, how to spot early warning signs of relative energy deficiency in sport, what lab values actually matter for active women, and the surprising impact that team culture has on injury rates.

Whether you're an athlete, coach or healthcare provider, this episode offers the missing pieces to the women's performance puzzle we've all been trying to solve.

With half of the instructions ready for some answers?

Let's go.

Okay.

Emily Kraus, we are so excited to have you on.

Thank you for joining us today.

Thank you for having me.

And this is such an exciting podcast to be a part of.

Yes, we're stoked to have you.

I mean, we're going to have so many jam packed conversations.

I'm sure we'll have you back regularly.

You've done some really.

I mean, there were a lot of reasons that we wanted to feature you in one of these first few episodes, largely just how much you've moved the needle when it comes to female health and performance for athletes.

Right.

And so I'm curious, at what point in your journey did you start to notice this glaring gap in female specific athletic research?

First off, thank you.

Thanks for having me on.

I definitely have a lot of mentors and just a lot of people that I'm inspired by that have gotten me to where I am.

And a lot of people are doing the work.

And so I think it's just important that we're all moving this needle together.

And I would say as Far as like, experiences, and some that really stick with me was one.

I was a research coordinator back when I was a resident at Stanford in the field of physical medicine and rehab.

And this was part of a study that was led by Dr. Michael Fredrickson and Dr. O'Reillyna Tee.

We were studying bone stress injuries and collegiate runners, both male and female.

And what stood out really strongly for me was how frequently the female athletes were getting injured and sustaining bone stress injuries that were at high risk locations.

So locations like the femoral neck and the sacrum.

And they're in their.

In their twenties or really young age and very talented, very motivated and, and had gotten to where they were.

And I was just so shocked to see the level of injuries that they were getting and how that would completely derail their season completely, sometimes derail multiple seasons just to get back into regular, consistent training.

And so that was one very important moment for me where I noticed these clear differences in just how injuries were developing, why they were developing.

And the other experience that I think really stood out early in my career, when I finished residency, finished my fellowship, was in my own clinical practice and thought that a lot had changed already just based on what I had learned and where.

I mean, some progress had been made in the field.

And, and I noticed that how I had a lot of female athletes who would come into my clinic and they would have menstrual cycle irregularities or complete loss of periods.

So amenorrhea.

And it was oftentimes due to high training volume, not fueling enough.

And sometimes they were on a hormonal contraception or form of hormonal contraception that was masking this menstrual cycle irregularity, or they were placed on this hormonal contraception due to potentially under fueling tendencies.

But.

But were placed on it for irregular cycles.

And then they.

There was no ongoing management of kind of.

Of the why.

Addressing the actual root of the issue of the.

Of the.

Yeah, that makes sense.

Yeah.

And I was like so fired up about it.

I remember, why are we doing this?

Why are.

What is going on?

I. I created this infographic when infographics were very new and, and very.

Just kind of getting off the ground, especially in academics.

And I created this infographic, I tweeted it off into the world.

And this is probably like five years ago, I think I was.

It was around the pandemic, so I had a little bit more time to work on the graphics and graphic design and it went viral.

And it was all about like misconceptions, myths around Hormonal contraception and menstrual cycles.

And I just couldn't believe how, how, how many people didn't know about this, this information.

And so I was very inspired to keep leaning into that and leaning into the education, leaning into more research in this space to just better understand the why and some of those sex specific differences.

I just feel like female athletes have been training in the dark for too many years, too many decades due to a lot of the research focused focusing on male athletes and applying all of.

Those strategies, tools, tips, routines, regimens, everything that comes from the research on male athletes to us assuming that it'll be fine.

So then what are some of the consequences or patterns that you've noticed when we just take kind of the default training model that has been designed from kind of four men and, and the female athletes start using it?

Yeah, I think that some of the consequences, well one, I just feel like we're missing opportunities and these critical, critical insights on, on ways that female athletes can train better and train smarter throughout, throughout their lifespan.

And especially with, with girls and women, we have these different stages of our life where a lot is going on.

Take puberty.

Lots of changes in our bodies, lots of changes in hormonal levels and menstrual cycles are starting.

Our body is changing in a way that can maybe not be welcomed by, by a female athlete.

If there's not research or, and education with, from that research that gets to those athletes, gets to those coaches.

A lot of athletes will try and fight puberty and they'll try to resist it and maybe try and delay their puberty because they don't want to get their menstrual cycle.

They don't want their body to change because maybe they feel like they're performing better in a pre pubertal body state.

And so I think that there's, there's a lot of potential negative impacts and consequences for female athletes, especially during that critical stage of bone building, critical stage of just like body development all like also just as you are an expert in the mental health consequences of trying to navigate body changes without being in an environment that really cultivates and supports that.

So like that's one example of the challenges within the lifespan that we just need to better understand and both do better research in, but also bring that science into, into the community, into the real world.

Yeah, it feels like a lot of it is kind of that we don't know what we don't know.

Like we don't yet know what we're missing out on and how Good.

It could be because we just haven't been there, right?

Totally.

Yeah.

And I mean, just to kind of like also bring.

I mean, I don't want to just say puberty is the only time frame where we need to better understand this information.

I mean, pregnancy and postpartum it another really important time.

Time frame and time stage where I experienced it as a mom of a 15 month old, I.

During pregnancy, I still had challenges navigating.

What, what can I do?

What should I do?

Is there really a heart rate cap?

Right.

Can I, can I keep running?

Can I keep lifting?

And I think that there are potential impacts on not just our bodies, but also the fetus.

And there's value in movement and strength, especially strength TR during those times that if it's better communicated and better researched, we, we can be better off for it.

Right, Right.

There's just so much opportunity.

And then, I mean, let's not get started on perimenopause.

Yeah.

Full market there.

Research calling researchers now.

Yes.

Yes.

Yeah, Yeah, I see.

I mean, having worked with, you know, I work with 14 and older.

Right.

And it's often those developmental kind of life changes and transitions because I have such a focus on health psychology and that, you know, Trent Stellingworth's research and kind of that patience through puberty.

I know Faster has done some work through that has been huge in helping me with coach my athletes and saying like that that plateau is okay, like it's expected.

Right.

And you will catch up.

And you have not reached your peak yet.

Your peak is not when you are a junior in high school.

And so let's focus on strong bone health and fueling and good sleep and all of these really great habits so that you can reach your potential and you're not broken several years from now.

Right.

Easier said than done in a culture that doesn't send us those messages consistently.

No.

And I do feel like it's.

I mean we probably could spend a whole podcast on this, but I feel like it's gotten more challenging for female athletes in their teenage years who are wanting to strive and, and really be at.

Be their best at their respective sports, but also are going through these huge changes for the first time and, and trying to encourage them to be patient when they feel like they need to be pushing and how those can be very contradictory as far as what they feel that they need to be doing, but what they should be doing.

And if there are many people at different levels, including like from your voice, from my voice, from the parents voice, especially the coach's voice because I feel like they'll listen to the coaches the most.

Yeah, I think that's going to give them the, the greatest support and help cultivate that, that pubertal transition so that they can totally thrive through it.

But definitely after it.

It's so hard.

Yeah.

So then if you think about, you know, you've done a lot of the work on bone stress injuries specifically, what are some of the things, is it, you know, training volume under fueling, what are some of the like physiological mechanisms, what's happening to make female athletes so susceptible and are they more vulnerable to them or is it, you know, the health behaviors that make them more vulnerable?

Yeah, yeah.

I mean I, I think that back to that study and the, the project that I was a part of that was I think from start to finish it was at least like eight or eight or nine years because we did a retrospective component where we looked at chart reviews and this is the Healthy runner project with Dr. Frederickson Nativ.

And I was, yeah, just the, the research coordinator.

I was thinking back at this today, being the research coordinator, you're, you're in it, you're in the data, you're recruiting, you're the face of the app like with the athletes and interfacing with them frequently.

And I loved that and I loved, I loved how much I learned about the athletes but also about these different injury patterns and, and more of the why behind it.

And as I mentioned, these female athletes were getting these high risk, high more severe bone stress injuries at these anatomic locations like the sacrum and the femoral neck which are more trabecular rich.

So they have higher amounts of type of bone that is a little more spongy, it's a little more hormonally sensitive and can be more susceptible to perturbations in the hormones.

So if we're thinking about a female athlete in their collegiate years that may be under pressure to be training at training in a way where they're at a higher volume of training that's different than their high school years or maybe they're adjusting their diet due to what's available at their school due to what their teammates are doing, due to what is happening on social media that they're influenced by.

And all of that can drive them into a potentially under fueled state.

And what we're seeing is that a lot of these higher risk bone stress injuries are stemming from these fueling habits and fueling patterns that are either more acute, so that are happening right now, but this could have been happening in their high school years and impacted their bone health in a way where now they're in this injury cycle and all the consequences from that time are now basically coming back to, coming to fruition and coming to fruition and hitting them at the worst possible time.

And so where we see this is related to that, how that low energy availability specifically affects the different hormonal axes and systems that are also related to reproduction and the menstrual cycle.

And so those early signs of menstrual cycle irregularities or even just complete loss of period or even like more underneath the hood and ovulation or an ovulatory cycles are those early signs that something is off.

And, and if we start to intervene earlier and provide a better environment where the athlete is being able to pick up on this and be like, okay, I need to recheck my fueling status, maybe meet with a dietitian or just even talk with my coaches and be like, hey, I, I think that there might be something off within the training and my nutrition that we may just need to rethink, need to investigate.

Yeah.

And so it was really interesting to see all that come together within a study.

And also see as part of this study, there was no nutrition intervention.

And the nutrition intervention was led by dietitians, dietitians that were really working with these athletes for years prior.

So I think that's an important component of this, is that kind of setting that relationship early and building a rapport with these athletes.

So it's a trusted relationship and they know that what they're hearing from that dietitian is coming from a place that is both performance driven, but also health health driven.

And they focused on these points that are really important to just optimize overall fueling and those athletes over time.

We found that those bone stress injury rates decreased in, in the groups that had consistent nutrition education.

And, and so kind of comparing the pre intervention to post, we saw especially the trabecular rich bone stress injuries decrease.

And so those rates went down to the more hormonally sensitive sites.

And so I think that it gives me hope that there are opportunities to, to really make, make change with these athletes as long as you change the environment.

And one other key point to this that I think is really important to, to share is that at the two schools there were a lot of changes.

As as happens in schools there some coach turnover, some coach transition, maybe turnover within the D or other, other staff.

And the, the team that had more turnover actually had less success with some of the decreases in bone stress injury Rates.

So I think it says something about the culture and how the culture will also just really impact behavior.

Yeah.

And if that team captain is maybe not totally bought in to help the importance of fueling and demonstrating those values to her teammates, it's not like it's probably unlikely that the teammates are going to follow suit.

Right.

I think studying that, starting early and really setting some of those important habits within the team and then having those, those dietitians and everyone else be on the same page is super valuable to try and address some of these issues.

It makes sense too, like having the, you know, the turnover.

It's like you need your people, you need your crew.

I often say to the, you know, athletes struggling with injury and comple health concerns, it's like, create your roster.

Like, you know, who are your number one draft picks for sports psychology?

You know, physicians, physical therapists, chiropractors, you name it.

Whoever your people are, you have to have trust in them.

And so if there's a lot of turnover, it's harder to have that.

So that makes on, you know, less success.

I think it's also interesting, I think about too, I could see how the quality of the training changes depending on the team culture.

I see a lot with, it starts to shift in college.

But where can, you know, easy active recovery days are never actually easy active recovery days.

And if the team captain is setting the tone and being like, no, we are chilling, like this is zone one or this is L1, that really sets a precedent where it's not a competition, it's not about like how hard you can go on active recovery.

Oh man.

And I think that there is, there is a dynamic with athletes where they don't feel like they can speak up and they, they don't feel like, I mean, oftentimes they're, they're noticing these physical symptoms or physical signs when they're, when they're running or when they're in those easy recovery days that don't feel easy and they're like, oh man, my heart rate is high.

This is feeling a lot harder than it should.

And instead of maybe backing off or like taking a complete rest day or at least like an easy cross training spin or something, that maybe they're not feeling tempted to, to go with the speed and go with the pace of the rest of the group.

I think that oftentimes they just, they try and take like be easy and, and just go with the flow and then it ends up burning at some point.

And, and I think that having athletes be advocates and also Just really being in tune with their body and understanding what that means, when that happens is so, so important.

What are, so what are some of those kind of early warning signs?

So I have, I have so many questions.

We do a whole nother episode on amenorrhea and menstrual irregularities.

But so you know, menstrual cycle.

So changes in the menstrual cycle, that could be a potential sign that something's going on.

Um, what are some of the others that you encourage athletes to look out for?

Yeah, I think that fatigue is one that comes up a lot and fatigue is hard.

Fatigue can be from so many things.

So I, I feel like I, I like to kind of put the cab like the asterisk that if you have fatigue does not mean you have right relative energy deficiency in sports or you're under fueling.

It can be from poor sleep, it can be from an iron deficiency, it could be from a number of different things.

But I think that that unexplained fatigue.

So maybe your sleep has been optimized and your iron levels have been checked and they're optimal, but there's still this like flatness with training, with workouts and there's just, even despite recovery and despite maybe some time off, you're returning and you're like I still, I still feel terrible, I feel awful.

That's, that's a sign.

And unfortunately that's sometimes not an early sign.

Sometimes that is a little bit later in the game.

But especially for athletes that are on hormonal contraception or that don't have a natural menstrual cycle, I think it's important to understand what some other cues are.

Right.

Sometimes it can be recurrent illnesses, recurrent injuries.

So not just bone stress injuries.

I mean we talk a lot about bone injuries and bone health, but maybe those soft tissue injuries like the, the Achilles tendonitis or tendinopathy that just keeps coming back could also be related to fueling and fueling status and making sure that that's at least within the being checked out and explored more, more thoroughly.

That makes sense.

Irritability, anxiety or just like mood changes that are a little bit unexplained, again can be from a lot of different things.

But I do feel like athletes that are in this under fueled state for a while, they, they both feel flatness in their training, but sometimes they feel this flatness in life.

Yeah.

And they don't even realize it until they're out of it.

And, and that's the hard part because if you ask, sometimes if you ask them if they're feeling more mood changes or irritable, they, they may not acknowledge it because they're just kind of in this more chronic state.

And I'd be curious your.

Your or justify.

Like, I think a lot of times athletes don't want to.

I mean, it kind of goes back to what about not wanting to ruffle feathers or be the problem child, where they'll often assume like, this is just how it is.

Because they don't know what it's like to be really well fueled and well trained and well rested.

Because especially in the world that we live in, student athletes don't have that opportunity for downtime and stress management.

Like it's go, go, go, go, go.

So I think often they're unintentionally, they're justifying it and being like, well, I'm just in a really heavy training block.

Like, they don't realize that it's, it could be different.

Right?

Totally.

I do.

Also, I feel like that the student athlete you highlighted is a really key point because they're, they're juggling a lot.

And, and I think that sometimes they're like, I'm, I'm fueling enough.

Like, I, I eat three meals, I have multiple snacks a day.

But they might be walking around campus, they might be extra stressed from finals, from applications, from like some other life stressor.

And so I think understanding that all of those stressors can demand nutrition and demand energy from the body in a way that is not intuitive and they may not have those appetite cues or hunger cues to fuel more during those states.

So I think that that's a really important point to, to just bring up.

Not to mention just studying, you know, and like that intense focus and being in, you know, just being, having to be locked in and really focusing during finals.

I mean.

Yeah, and often there's more sleep deprivation and so then that sets them up for more injury risks.

Yeah.

Yeah.

What about for athletes?

Cause I can, I can already listen to, I can hear some of my clients being, what about.

So for the female athletes who are on IUDs or other hormonal birth controls, how do they know if there are menstrual irregularities?

Yeah, that's a really great question.

And unfortunately we don't know.

And I think that's part of the, part of the issue.

Unless they have a copper.

Copper iud.

So non, Non hormonal contraception, but other forms.

So if they're taking exogenous hormones, that's going to suppress the endogenous.

So the Inside like naturally circulating or naturally produced hormones in a way that is just, it's how those, those forms of hormonal contraception work.

And so they may completely lose their period.

Yeah.

And that's like a normal part of the hormonal contraception.

But we can't, we can't say that they have amenorrhea.

They just, they're on hormonal contraception.

So if the athletes that do continue to have bleeds that we call them, I like to, we like to call them breakthrough bleeds as opposed to periods because they are more medication induced withdrawal bleeds.

So if an athlete is really concerned talking to a gynecologist about different forms of hormone of contraception, whether it's safe for them to go off hormonal contraception kind of based on their lifestyle and a number of other factors.

So I think like that's, that's a possibility.

But I also think working with a dietitian or there are other biomarkers that we can test like thyroid function and free and total T3 to see if those are low or low normal.

And that can help drive us into maybe this bigger inquiry and some bigger workup with it with a dietitian about whether they might be in some form of low energy availability.

But I get that question a lot and especially with IUD.

Some people have bleeds with IUDs, some people have, have no bleed with IUD'.

And I think that with more research, hopefully we'll understand if there are some other indicators that we can explore.

But right now there isn't like a single perfect biomarker that we can use that, that picks up on this.

It's a lot of clinical reasoning and putting all these pieces together in a way that can be hard for an athlete to navigate.

Which is kind of why finding your team and I need people within, within your circle that you can lean on to, whether it is a sports med doc, whether it's an athletic trainer at your school that can help navigate some of these questions in a way that they can try and get some answers.

And for them to create the healthcare providers and the coaches to create the culture to be able to ask the questions and to introduce those topics without them feeling taboo or too personal.

Just like it's a question, how are you doing in this area?

It's just one more biomarker.

Yeah.

And I think just as a like total side note and tangent, that kind of, that environment is not easy.

Like you can't just like start a season off and like have this like General talk about periods and menstrual cycle and nutrition and low energy availability when an athlete may not be fully ready for it or if it's like completely out of the blue.

And so I think building and a lot of the stuff, the work that we do with Faster and our team talks is we give these pre talk surveys and so we have the athletes fill them out and rank the areas that they want to learn more about.

And of course there are all of those topics but they're in different buckets.

So they're getting it from maybe a lens that is a little more approachable than just like a full on.

We're going to just download everything and share it all at once.

Maybe when a coach doesn't typically do that.

So I think that it can take some time, especially if a coach isn't super comfortable with these areas.

But I think there are especially within Feisty media, they're doing great work to try and provide better education for coaches to just to help them navigate those conversations.

One thing I always say, you know, to my own, my own clients, but you know, coaches, athletes, it applies to all of us, to me, to you, is like in order to get better at difficult conversations, you have to lean into difficult conversations.

You have to have them, right?

And so it's one thing to read about them or to think about it in your head and what you want to say, it's another thing to do it and it's going to be awkward and you might stumble over your words or say something in a way that you didn't mean.

And that's a part of the process.

Just like sport, right?

Like it gets messy, you make mistakes, you reflect on them and you learn from them and then you improve.

And so I think with the difficult conversations it's very similar.

I think it's, it's very loaded because it's so personal and because of the society that we're in.

And then you also add gender dynamics with male coaches who have been told so many things about what not to mention and not to offend anyone at this and that.

Like it's just a whole thing.

Right.

So yeah, it's messy.

And I think, I mean it's like words matter.

And I feel like it's, it is highly likely that you'll say something and you're like, oh, that didn't come out the way that I wanted it to.

But sometimes you just own it.

Yeah.

And you're like, you know, I didn't say I, I want to go back and, and share what I wanted to say or what I was trying to say in this, in this moment.

And I've caught myself so many times and now I feel like I have the confidence to probably even call myself out during, during the moment and say, or even just acknowledge, like, I'm super uncomfortable right now talking about this.

And you can probably pick up on that by how I'm stuttering or other, other body language, just that coming out.

Which honestly is a brilliant strategy.

I've done that.

When I get, you know, voice starts to shake because it's something really emotional and I'm really passionate about something.

I'll just name it.

And saying like, you can hear me getting worked up and this is why this is really important to me.

I don't want to, I don't want to get this wrong.

I don't want to screw this up.

Like, I, you know, I'm really passionate about this issue.

I want it to, I want it to come out in the right way and just that empathy that you then get from the audience and the relatability and being like, okay, like, we need to listen.

So it's a cool dynamic because you.

Care so much that.

Yeah, yeah, yeah.

So then one of the things I'm, I'm curious about is you noted this a little bit.

Is.

And I've, I've also experienced this and I know plenty of athletes who have is especially those with like, injuries, complex or chronic health concerns.

As athletes, I think one of our biggest strengths compared to the non athletic.

I need again, be careful about how I phrase that population is, is our body awareness.

Like we are that proprioceptive awareness, that understanding of how our body is feeling at any given moment, especially for us in endurance sports, because we have plenty of time in our head.

Um, we're good at picking up patterns and little changes.

Sometimes to the point where we spiral and we're like, oh my gosh, this isn't da, da, da, right?

That said, it's not uncommon for a female athlete to go to a primary care physician and say, something's off.

Can we run some labs?

That conversation might take longer than they would like.

So then let's say they get the labs and everything is normal.

But I know there are a lot of conversations in the field right now about normal in general.

Clinical practice may not actually be normal for a female athlete, let alone endurance athlete, who's really putting in the miles, the volume and the training.

So what do you look at in those areas and what should female athletes who are going to their GPs be aware of?

I Realize this is a loaded question.

Totally.

Yeah, I get this question a lot and I feel like whether it's like my patients or our friends, training partners and I think the challenges, a lot of the norms and those normal ranges that we see when we get our lab work and we are trying to interpret what the results say are based on the general population and aren't really athlete focused.

And so the, the lows are probably really low and the highs are really high.

And so what is that optimal range for, for an athlete, especially a female athlete?

And I think that it's also very cool.

There are some different companies out there that are trying to improve upon how, how they can interpret some of this blood work.

So I, I feel like there is definitely some progress here.

But especially when you're trying to get some of this blood work from your primary care provider or a younger female athlete from a pediatrician, it can be like fighting tooth and nail to try and get a full iron iron panel or to get even some of the additional thyroid studies that I like to order.

So I think starting with iron first because I feel like that's one that gets talked about a lot.

Oftentimes an athlete will be feeling fatigued, they want to make sure they want to rule out an iron deficiency and so they go to their primary care provider and ask for, to get their iron checked.

And so oftentimes to get your iron checked at the bare minimum they'll get a ferritin level which is a measure of iron stores.

And that's a good starting point.

Feel like if they get the ferritin back and it's low, that's a good sign.

But what is low?

And, and so we, I use a ferritin level of, of 35 as like my, my benchmark and anything below 35 I start to recommend supplementation or think about more iron rich foods in their diet.

And anything above 35 kind of depends on the level of athlete and how they're feeling.

Sometimes athletes feel a little bit off even when their iron ferritin levels in the 30s.

But if their ferritin is, is above 35 and I'm still suspicious, I often, I mean most of the time I'm ordering all of the iron studies so I'll get like total iron and transferrin and total iron binding capacity and a few others that can help me put these pieces together.

Because the other important point is that ferritin is an, is an acute phase reactant which in med school I feel like we all learned about this.

But when there's a lot of inflammation.

Whether an athlete has a little cold or a big cold or a ton of stress or they did a big workout the day before that ferritin might be elevated and so it will mask a potential iron deficiency.

Okay, so I think that that's kind of a whole other point to be thinking about is if the ferritin level is normal and maybe there are still some other indicators within the iron panel itself, then they may need to, they may want to retest that Ferris level just to help them track it over time.

So iron studies, definitely one that comes up a lot.

Thyroid studies, that's another one that oftentimes if a PCP orders thyroid studies, they may just get a tsh, which is a great lab to test for hypo or hyperthyroidism.

And then with that, sometimes they'll get a reflex free T4 if the TSH is abnormal.

But when I'm looking and screening for low energy availability, I like to get a TSH and free and total T3.

Free or total T3 kind of depends on people's practice style.

But that to me is a better indicator of their metabolic, their overall metabolism and can be a sign of slowing of the metabolism due to low energy availability.

And the other point here is that it doesn't have to be just abnormally low.

And for example, for the, the Reds, Cat 2, which is this cumulative assessment tool or screening tool that's often used in the clinical setting and research setting, they'll use T3 and it can be in the lower quartile.

So even if that normal range is, or that level is normal, if it's in the lowest quartile, that would still raise concern of a possible low energy availability state that's oftentimes overlooked in just a regular blood workup.

And some of the other ones would be vitamin D if it's not extremely deficient, then sometimes an athlete gets this kind of false sense of security.

But I like those vitamin D levels in like the 40s or 50s and that is nanograms per deciliter.

I'll have to double check on the unit there, but I'm just making sure that they understand that we need to be thinking about what is the optimal level for an athlete that's pushing their body potentially going through blood loss every month with their menstrual cycle and, and especially like the stress of endurance training.

I just see iron deficiency being a greater factor and higher prevalence in that in those athletes.

Yeah.

Interesting.

Do you think, I mean, in your experience, how many?

Well, I guess Is it changing?

Are you noticing that more female athletes are coming in with more of this knowledge and information or have you not noticed a lot of differences?

I see a mix.

Sometimes I get really excited because I feel like there is progress and I think it depends a lot of the elite or professional athletes that are coming in, they're tuned in.

Yeah, they, they know the optimal ferritin for, for how they like based on where they feel the best.

And so what I love about that is it's often individualized so people have their own, own range.

And, and I think that, I mean that's where I love for us to get, is to take a more individualized approach that all of us have this baseline information and baseline level of just health that gets us to that point.

Right.

But most of the time we're just trying to get to the, to the baseline and like set a good foundation.

And I would say that the high school athletes that it's a lot more variable based on what, what coaching that they've had exposure to and, and maybe what their pediatrician is, is open to.

Oftentimes if that athlete's working with a dietitian or who's met with a dietitian, they're a lot more well versed on kind of get what levels and what labs need to be tested and, or maybe they got those, those labs done already and then they come to the, the physician or the provider and sometimes just get a more like some follow up labs or some kind of follow up conversation on that.

Sure, sure.

So progress is being made, but I think that we still have a lot of work to do to get the information out more consistently.

Yeah.

I also get really excited when someone starts, you know, start working with a new client and they start dropping all this information and I'm like, oh my gosh, you are in it.

Like, let's nerd out over this together.

Right?

It's, it's cool.

Same thing with other providers, right?

Like, oh, you get it.

Like let's talk.

Yeah, yeah.

What do you think really helpful when you can, can speak the same language on, on a lot of those, those pieces.

Yeah, yeah, yeah.

One, one thing that you've talked about is kind of challenges with coaches who use more traditional approaches are kind of old school, like anecdotal experience.

You know, this is just the old school coaching practices.

When we look at, you know, generational differences, there are definite, definitely differences especially with some of the endurance sports.

So I guess what challenges have you noticed or concerns and what kind of call to modern day Coaches, do you have if you, if you got to kind of influence their training?

Yeah, I think this like this toughness over physiology over these like other kind of natural processes that are happening and, and, or this like this win, win at all costs mindset where you just, you just got to go out there, you gotta, gotta train hard, you gotta train often and, and you just gotta show up and, and do do the workout right.

Is can really have a negative impact on athletes especially at those earlier stages of development.

And a lot of the female athletes that I see and the younger female athletes, they're like, they're pushing their body in a way that I just don't feel like they're quite ready for, whether it's mentally, emotionally or whether their body is, is fully ready for.

And and so trying to course correct that is a lot harder because I think that these coaches, whether it's like volume related intensity and speed related and they're trying to match also these, these athletes that maybe are faster with some of these athletes that are trying to just kind of catch up or find find their rhythm can be, can, can actually really impact their, their season, but also maybe just like their longevity in sport and, and I worry that these athletes could burn out really quickly.

Yeah.

So I think that that toughness mindset should be replaced with kind of just training smarter and training based on an athlete's stage and just being a little bit more strategic with, with when you incorporate the volume, when you incorporate the resistance training.

And so I think that that's probably an area that I feel like could be really improved upon within, within the coaching space.

Yeah Yeah, I see that frankly across multiple sports, but especially endurance.

But you know, I think of you know, swim and dive swimming has that kind of more as better volume approach.

Cross country running for sure.

Track and field.

Right.

And so it's trying to be like it's not always more is better.

So.

Yeah.

And I also would say I have unfortunately heard this a couple of times within the last year or two around some coaches being pretty dismissive about menstrual cycle irregularities or menstrual cycle loss within season where it's just like this rite of passage and, and if you're not training hard enough, if you don't lose your period during, during the season.

And so I think that that really, that that narrative needs to change.

Yeah.

And thankfully there's been a huge shift and there's a lot of progress in that space, but I still hear it on occasion where whether that coach went through it themselves and they're like I lost my period during, during my training and, and it was just part of, part of the process.

What it takes.

Yeah, yeah, yeah, yeah.

Or this, yeah, this badge of honor and this badge of dedication or work ethic or something.

Totally looking ahead.

Or even kind of what you're currently doing, depending on what you're able to share, what emerging research most excites you, either what you're currently up to, things you want to do but need, the bandwidth, funding, research team, etc, all of the above.

Unlimited resources.

I know, I feel like, I mean, especially within this research space, there are so many gaps in the research and we listed many of them.

It can be overwhelming.

And I think that's one of my challenges is trying to stay focused and trying to really start to chip away in these certain areas that are definitely in my wheelhouse.

Definitely things that I'm super passionate about and excited about.

But I'd say the areas that I'm most excited about and hope to be able to really drop into more within my own research revolves around longitudinal monitoring and whether that's menstrual cycle monitoring or biomarker monitoring or training volume and training data or even wearable data.

So like incorporating sleep data and incorporating like HRV and recovery and synthesizing all of that in a way where we can provide better feedback for that female athlete based on her life stage, based on what her training goals are, based on her injury history and what different factors could be contributing.

And I just, I want to see all these different fields come together because it does.

It taps into all these different disciplines in a way that's so cool and can be really just life changing beyond just kind of their sports or athletic career, but really their lifespan and just their longitudinal participation in activity and physical activity.

Yeah.

So I think that's something that just really lights me up is how can we, how can we work together and combine all these variables and help athletes understand and be more in tune with their body and their menstrual cycle, be more in tune with fluctuations within their different phases, but also understand and have more resources to navigate these different life stages.

And so I think like the research, but also continuing that translation effort and getting the information out, working with groups like Feisty Media to continue the podcast interviews and just help disseminate this information too?

Yeah, I feel similar every day.

I'm like, that could be a research study.

I'm like, don't do it, Erin.

I told myself I'm not allowed to start any new research studies until I get my currently Unfinished manuscripts out into the world.

So that's a good goal.

It's so hard.

I know, right?

Just like new shiny objects all the time.

But I think, personally, what I've noticed this will not come as a surprise to you is the dearth of research in mental health and lea in reds.

Like, there are a lot of.

We recognize that there are a lot of mental health concerns, and that is one of the kind of telltale signs on the kind of IOC's Wheel of Lea and reds.

And, um.

And it's often.

I don't want to say it's an afterthought, like, it's always included, but it's.

It's never really understood or broken up or talking about the complexities and the nuances.

So, for example, if someone has a pre.

Pre.

You know, disposition to anxiety or depression, how does that affect things?

Just understanding the pattern.

And are there any psychological warning signs?

Because anecdotally.

Totally are.

Totally.

But it's.

Again, it's the exhaustion, it's the burnout, it's the stress, and then it's like the athlete's response to that can make or break what then happens a few months down the road.

Right.

And so that's what we need more of.

Yeah.

Oh, yeah, I am.

I'm all about that.

I support you in your, like, tapping into any.

Any of those spaces and happy to.

To help in any way I can.

Also, red's recovery and navigating body changes after they are at a nutritionally restored state.

Yes.

And how they.

How they move on and.

And move forward and not have these relapses or.

Or moments of, ooh, like, this isn't what I typically do in this situation and kind of resort back to those other more maladaptive patterns.

Yeah, that's key.

Is that.

Like, that.

I agree that weight restoration, you know, qualitative study and identifying what works well for that would be glorious.

So I've got one.

One final question for you.

Um, then we can open it up and talk about anything else that we haven't addressed that you want to cover.

Um, so I was reading up.

This number may have changed.

You've completed nine marathons and an ultramarathon.

Is that.

Yeah.

Yeah, I need to do more.

Okay.

That's wild.

Because I'm the exact same.

That's an old snap.

That has not changed.

Yeah, I'm at nine marathons, one ultra, and then I've got a lot of, like, other cycling ultras.

Cool.

But, yeah, there's something special about it.

So.

Okay, so and it was while maintaining a really demanding medical career.

I know having done it, this is not easy.

Doing all of the things, let alone I can't imagine.

Also now being a mother to a 15 month old, what is the most ridiculous expert advice or like unsolicited advice about kind of women's training and work life balance and da da da da that you've personally ignored to your benefit?

Yeah, I think the one that, that jumps out to me and was, it's probably the most, most triggering to me was that cross training would make me a worse runner.

And because I, I loved, I loved going out on bike rides with friends and using that as a recovery maybe just if I was feeling a little ache or pain and in the body trying to just nip it and, and go out for a ride instead just to maintain some of that training.

And, and so I, and I didn't listen to that advice and, and I feel like especially my mental and psychological health was, was definitely was saved because of that.

So I would say that was the most extreme.

But I've also heard like lifting during training is going to hurt my performance, especially in like the, the endurance phase.

I feel like that still can come up.

I heard that even recently a coach shared that with a high school runner.

I was just shocked.

I almost like called up the coach in the school right away and was like, we gotta, we gotta talk.

Yes, A lot of like pregnancy myths.

I was, now I was mountain biking three days before I delivered and I was like going up a, like a gravel road, a fire road.

So it wasn't like super technical.

Cause I'm, I'm not super confident on technical terrain anyway.

So I wasn't gonna be more confident with this belly.

I, I, it felt so hard but so good to be, to be riding my bike.

But the amount of questions that, that came up and maybe some of that is also like kind of self induced too where I feel like I'm, I'm going to get those questions but actually the environment is changing and people are getting more supportive of just like women are who are moving and moving during pregnancy.

And so I, I think that there is some, some, those are some of the most, most crazy.

Oh, then also like fasted training.

All the conversations around fasted training in women and girls and women especially just blow my mind.

So I just try and ignore and tell the athletes to ignore if that's something that they get fed on social media or through other, other resources.

Yeah, that's probably mine.

I've heard all of the ones that you mentioned, you know, sans the pregnancy for me, but it's.

Yeah.

The fasted training is what I've personally ignored to my benefit.

And also things of like what you should be eating on long rides or runs and like I eat whatever I want.

Like.

Yeah.

Gas station food is glorious on really long, you know, you name.

Totally.

I think like ground gravel like Coke.

And potato chips on like a hot.

Yeah.

Long ride is some of my favorite snacks.

I still dream about like these McDonald's hash browns at an unbound aid station two years ago.

They were amazing.

So it's.

Yeah, it's great.

Yeah.

Whatever works.

And it's so like, it's so important.

I had an athlete recently that was just.

That had a little bit more of that rigid mindset.

Yeah.

And I was like, what can I do to help?

Along with directing her to a really good psychologist.

Yes, totally.

What can I do right now to.

To help address and bust.

Bust some of these myths that she is.

She's just got in.

Yeah.

Stuck in her head right now.

Yep.

Yeah.

I always experiment.

Right.

Stay curious.

Right.

If they're curious, then we can't leap to all these judgments about what's good and what's bad.

It's like do what works for you.

Yeah.

So anything that we haven't addressed.

I'm sure there are plenty, but that you want.

Want to mention to today's listeners.

Yeah, I mean, I think that.

I think we covered a lot of really important starting like starter topics that hopefully will open up the conversation around kind of like future directions.

I. I would say, I mean, we.

We didn't talk a lot about like pregnancy and postpartum training.

Yes.

And I think that there has been finally some really great research happening and a lot of that's from Dr. Margie Davenport and her group.

So hopefully that's somebody that you can basically.

I mean, I could, I could try to recap everything that they've done, which is a lot.

Yeah.

But follow her Instagram.

Yeah.

For the listener.

She's on the list.

Yeah.

For the listeners.

If you don't, if you don't follow her, we can add her to the show notes.

So you can.

It'll.

It will help your algorithm for sure.

Totally is great.

Yes.

Yeah.

Well, thank you so much.

You did a great job covering all that.

Yeah.

This.

I mean, it's been.

I know how busy you are.

It's a wild time of year, especially starting up with the new year.

So thank you for taking time for this conversation.

I know the listeners have really appreciated it.

Um, Final question for you.

What's the best way for listeners to follow you or get in touch with you?

Yeah, I think that probably like follower Faster Instagram.

It's definitely like the most consistent, reliable of sports science tips for us.

Um, it's Stanford Faster S A S T R. We also have a website, but you can kind of get directed to that where we have infographics and, and if you're a coach, you can download those infographics and share with your, your team.

But yeah, we push out a lot of, lot of content.

We also want feedback of areas that you want to learn more about because we just, we want to make sure this is tailored to the athlete, the coach, the audience, and we help keep closing those gaps.

Yep, it's wonderful.

Thank you so much, Emily.

It has been such a pleasure having you on board.

Thank you for having me.

And congrats on your first podcast.

Thank you.

Thank you.

We've clearly been training in the dark for too long, and Dr. Emily Kraus just handed us a flashlight.

What stands out most of our conversation is how the research gap in women's sports science creates real consequences.

Bone stress injuries in female specific locations to medical systems that don't recognize what normal actually means for active athletic women.

Remember, for those of you who menstruate, your menstrual cycle isn't just a reproductive function.

It's a really important biomarker for your overall health.

And those quote unquote normal lab values, they might not actually be optimal for you and your activity levels.

That team culture you're in matters tremendously for preventing injuries and supporting proper fueling rest and recovery.

This week, pay attention to one signal your body is sending you that you might have previously dismissed.

What might it be trying to tell you?

If this conversation resonated, please share it with another athlete who needs this information.

And be sure to follow Dr. Kraus and the faster program on Instagram.

Those infographics that she noted are no joke.

They are amazing.

Until next time, this is Dr. Erin Ayala reminding you that your body's wisdom deserves to be heard, even if science is still catching up to it.

Until next week, Feisties.

Thanks for tuning in to the Feisty Women's Performance Podcast.

If you enjoyed this episode, please subscribe, review, and share.

This podcast is for informational purposes only and does not establish a therapeutic relationship.

In other words, I'm a licensed psychologist, but not your licensed psychologist.

Always consult your healthcare provider before making important decisions about your health.

Find show notes and resources at Feisty Co. Join us next time as we continue to move the needle in women's health and performance via evidence based conversations.

Until then, keep living your healthiest, feistiest, active life.