Stanford Doctor: Why Female Athletes Break Bones More Often (And the Fueling Fix)

Added: 2026-05-19

[00:00:04]Hi everyone. Welcome to Proof of Practice and it's exciting because we have finally gotten together. Today we're going to be talking about bone health. I'm here with Abby Smith Ryan and Amber Taylor. I'm Gabby Reese and our guest today is Dr. Emily Krauss.

[00:00:19]Thank you so much for joining us. She is a doctor of research Samford faster program and we're going to be talking about the importance not only for young athletes but also opportunities to avoid fragility fractures and things like that as we age. So whether you're a teenager, a parent of an athlete or somebody who's just interested in staying healthy and strong forever, this is a conversation that will support you. So Emily, welcome to the show.

[00:00:48]>> Thank you so much for having me.

[00:00:50]>> So let's get right into it. Emily, talk to us about what you're doing at Faster up at Stanford.

[00:00:54]>> Yeah, so um a little background. I'm a sports medicine physician and researcher at Stanford and direct the Faster program, which stands for female athlete science and translational research. And so I split my time between seeing athletes and treating injuries as well as trying to optimize their performance.

[00:01:11]And then our faster program is is funded by the WAI Human Performance Alliance and we're all about trying to close the gender gap in sport science. And we do that through doing good research and also by translating the science.

[00:01:25]>> I just have to ask really quickly, are we seeing more sort of bone injuries, fractures, things like that in young athletes than before?

[00:01:34]Is it because more girls are participating? They practicing longer, they're competing more often, or are there actually actually changes? You know, like in our world, testosterone has dropped and other things. So, are are we seeing any correlations or any differences? Yeah, I mean I think we can approach it from a couple of different angles. One, I think that we're talking about it more and and so through that we are detecting more bone stress injuries and having conversations about it.

[00:02:00]Female athletes are at higher risk of bone stress injuries and that includes stress reactions as well as stress fractures. So those are overuse bone injuries and that's a season ender. So whether they're a gymnast with a a stress fracture of their spine or a runner with a stress fracture of the the tibia, they're out for probably they're in season and there are a lot of important risk factors and indications of what that could mean overall with their body.

[00:02:26]>> I'm going to jump in Emily. So from a research perspective when we talk about female athletes are at greater risk, can you tell us why? So I'm thinking about like what is the data that we have yet where are the gaps and why do we see it more in female athletes? So a lot of these female athletes um unfortunately it's a lot about nutrition and these athletes are trying to fuel their bodies but either through social pressures or just through training high high amounts of volume or through high volume training they are not fueling enough and over time that can cause hormonal suppression specifically around reproductive hormones and that can suppress a specific hormone estrogen among others.

[00:03:08]which is super important for bone health. And over time, that can cause low bone density and increased risk for bone stress injuries. And so we call that the female athlete triad. In addition to the female athlete triad, there's also a condition called REDS, which is an expansion of the female athlete triad to encompass a number of other health and performance consequences.

[00:03:28]Yeah, I remember you've talked a little bit about reds before and in a lot of research. Can we talk more about what reds means? Like we were talking before starting recording, I remember when I was running track and cross country, it was a status symbol to be 90 lbs and have no period and then come later to learn that that can really hurt you. But can you talk more about what reds is and what it means?

[00:03:50]>> Absolutely. So red stands for relative energy deficiency in sport and as I mentioned it expands on the triad. So the the underpinning or underlying theme is this low energy availability. And so that might mean underfueling or training high amounts of volume, but not fueling enough to support your body for the amount of exercise the body is doing or just to support daily life. And that can cause a number of health and performance consequences in addition to impaired bone health, menstrual cycle dysfunction, can also suppress immune function, cardiovascular function, can affect sleep and performance. So, as a followup from what you said too, so nutrition and training seem to be the biggest causes and it sounds like women, females are they're a little bit more sensitive to that. So, how do you like I think most of these women are trying to do the right thing. What do you tell them from a clinical perspective and maybe put on your clinical hat and your mom hat and and what do we tell our female athletes whether they're young or midlife? like how how do you know if you're eating enough to prevent some of these downstream effects?

[00:04:57]>> I think that it's helpful to get resources. So, we often are working with sports dieticians and they can help calculate low energy availability and what that athletes fueling needs are. I will also say with young athletes, it is a critical time to fuel your body well to support your bones. Adolescence is critical bone building time to achieve peak bone mass. And that's in your late teens and early 20s specifically is when we see the best bone gains. And if that doesn't happen, these athletes can be at a a lower overall bone density for life.

[00:05:35]>> So I sorry, I'm going to ask I'm thinking about myself, young Abby, and I don't know if you knew this, but I had nine stress fractures.

[00:05:42]>> I did not know this. all in my left leg as a collegiate distance runner. And so I think back of I wasn't um trying to restrict food. I just couldn't eat enough to keep up with what I was doing.

[00:05:54]Um and it was almost like, you know, type A like let's go all in. And so I didn't know anything about relative energy deficiency. Like what would you tell someone in that perspective? I think so many people are trying to do the right thing. And you mentioned resources, but any practical takeaways or like >> intangible feelings or signs and symptoms before we lose our period or pain, anything that you could give us that you you look out for?

[00:06:19]>> I touched on it a little bit, but we talked about menstrual cycle dysfunction and this like losing the period being a big indicator of a fueling mismatch, but there are a lot of other signs that can also be indicators. They're a little less specific. So, it could be fatigue, could be recurrent illnesses, could be just performance plateau.

[00:06:40]They're just not performing at the level that they think they should, and the fatigue isn't recoverable. So, they take a rest day, they take some time off, and they're still not able to get to that recovery that they would expect. So, those are some other signs. We also see some changes in just um some hormones and some hormonal suppression, but that's what we're seeing clinically and it's it's harder to detect and we don't have the the wearable technology at the place where we can find those earlier biometric indicators. Did you ever like I remember thinking back of GI distress like I had massive GI pain and of course you don't want to eat more. Is that a a sign and symptom or is it just me?

[00:07:21]>> Yes. Yes, it is. I would say so with the relative energy deficiency in sport conceptual models there's a health figure and then there's a performance figure and then with the health figure there are all these different spokes and one of the spokes is to the GI system so GI distress could be constipation could be bloated and it can be really non-specific and so what we're seeing clinically is that these athletes are often siloed and seeing different specialists so they might see their endocrinologist they might see a GI specialist, maybe even a hematologist for anemia. And so it's really hard. And so they think that they have all these problems. And then when we put the pieces together, we're seeing that low energy availability is a is a common theme.

[00:08:06]>> When I think of it like a sport like volleyball, you can you there's a lot more range. You can get away with things. You can play with a little more weight and mass. When you're talking about gymnastics specifically or long distance running, it's it's the amount of hours or the amount of miles. So, if you have an athlete that comes in and goes, "Hey, I have to also keep a certain weight for running or even kind of physique appearance in in gymnastics or ice skating or something like that cuz we're beat over the head about protein. So, maybe they're trying to get their protein, but where are we seeing a lot of the gaps that not only in the athletes, but even kind of the general population that is contributing to this?" Yeah, I think there's a common misconception, one that leaner is always faster, especially for our young athletes. We need to we need to work that out of them. We need to really work with them to say you need to work with your body and you need to fuel your body for your sport. And that means fueling enough always. And so we sometimes we see athletes who they skip breakfast because they go straight to their their morning practice. And and there's then this common theme that fasted training is okay, but it's not okay for female athletes because it can start to suppress some really important hormones that can impact their their performance and start to slow down their metabolism.

[00:09:27]I'll also say that there's some research that talks about carbohydrate intake and making sure that those athletes are consuming enough carbohydrates at every meal, every snack, and ensuring that they're hitting those macronutrient goals is is really critical. And and I try and shift away from talking about overall body composition, especially in the young developing athlete, because they need to be getting their period and getting their period consistently. And if we're not seeing that, I am concerned that they're not developing to the to the degree and to the level that they could be um due to not feeling enough.

[00:10:04]>> What about healthy fats? Is that something that's a really important for bone health? And because I know with your hormones, there's a real correlation which obviously would impact estrogen and other things. So, is it hard to encourage people? It's such a funny word because fat has really been demonized and we know, okay, how important it is, but yet a lot of people, women, and a lot of athletes kind of try to avoid it.

[00:10:32]>> I see fat phobia, carb phobia, sugar phobia, all of that in in my clinic. And so I'm I'm trying to get these athletes to have a healthy relationship with all food, with the fats, with with carbohydrate, with protein, and and hitting those important goals. And and I'm not a dietitian, so I can't get super specific with each meal and each snack. But for my female, for my young female athletes, I'm saying consume three meals, two to three snacks a day.

[00:10:58]And that means finding those breaks, figuring out a time to pack the snacks and work it in. And then as far as hormonal health, we want to def we want to make sure that they're consuming enough of those fats to optimize those important hormones and make sure that all those hormones have the important factors for um optimal levels, too.

[00:11:17]>> What about supplements? I have I mean, it's so funny cuz for me, I feel like you're not doing the basics. I feel like supplements is like putting it into a dumpster fire.

[00:11:25]>> It's expensive pee.

[00:11:26]>> Yeah. But but there could be certain things that maybe give you a little bit of extra support if you are trying to do all the right things. Are there things that you guys are seeing in your in the lab when you're working with athletes that there are certain things that bridge the gap nicely?

[00:11:41]>> Yeah, both both clinically and with research, we are seeing value in intentional supplementation.

[00:11:48]So I first encourage food food first. So finding those micronutrients, those vitamins and minerals in your food, especially dairy products, if they can consume, dairy products, depending on on the type of food that they're consuming, just eating all the colors of the rainbow in their on their plate. But especially female athletes, we see iron deficiency can be pretty common. And so a lot, especially a lot of my endurance athletes, they're they're running low.

[00:12:15]And so feritin is a measure of iron stores. And so we're often encouraging those athletes to be supplementing with iron. Um and it's and it's about timing timing with a lot of these supplements.

[00:12:24]There's an optimal time to take them.

[00:12:26]And so there's a lot of education that's happening both clinically and even just within um our our faster program and how we communicate this so they're optimizing their levels both in their diet as well as within supplements.

[00:12:37]>> I have so many questions, but I'm going to I'm going to ask one. Um I think one of the key things about iron uh obviously that can cause some GI distress. I'm just curious if you have >> really on the GI distress.

[00:12:48]>> Well, you know, if you're always running to the bathroom, um, but I mean, what would you tell people? A lot of people say always supplement with iron if you're an active female yet you want clinical blood measures like what do you start with and is there a baseline? And I've even heard some interesting data around you should supplement with three weeks on, one week off. Um, any insight like what would you tell tell the listeners? I try to keep it simple because I think if we over complement over complicate our protocols and just supplementation strategies, it's not going to happen. And I worry that athletes are going to forget, especially very overscheduled athletes. I will say that I'm a fan of testing levels first, so that way you have a bit more of a precise idea of how much you should be taking.

[00:13:34]>> And would you test feritin? I would test feritin with additional other iron studies because fun fact iron um feritin specifically can be elevated in states of inflammation. So if an athletees sick of course or even after a hard workout they can have elevated feritin levels that may confuse the the picture. So I usually recommend some additional iron studies and in in addition to that um for GI related concerns there are different forms of iron that are a little easier on the gut and so usually I recommend iron biscinate over ferraulfate and the challenge is often times when we're in the clinical setting um if you're prescribing a form of iron it's usually in the ferrra sulfate form and so I'm I'm having to work with the parent and the athlete to find the optimal supplement for and the supplement optimal supplemental timing throughout the day.

[00:14:25]>> Okay. I'm dying to like write down what amount. What would you start with without knowing like kind of knowing an active young female they have a well-rounded diet? Like what would be a starting point?

[00:14:36]>> Usually the the starting point is 100 milligrams of elemental iron is is kind of the go-to. Now, I will say that I have super absorbers and people that can absorb iron really well and some people who can't. And I would love for any of the the researchers out there to help better understand and there are researchers out there that are doing ironbased research and supplementation based research. And I think I find it fascinating. So in a couple of years, maybe even next year, I might have a different recommendation for you regarding supplementation.

[00:15:07]>> Interesting. People digest it differently or people take in different kinds of iron differently, too.

[00:15:12]>> I just learned this that you have microbes in your gut that will steal the iron also. Like there's all these things of why we have low iron or >> I didn't know that.

[00:15:21]>> Yeah. And I even heard Did you ever hear this that foot striking athletes, right?

[00:15:25]>> Yeah. Like they call it foot strike hemolyis.

[00:15:27]>> Yeah.

[00:15:27]>> Wait, what is it? Keep going.

[00:15:29]>> This is you. Do you take iron?

[00:15:31]>> No, not anymore. I used to It tastes disgusting.

[00:15:34]>> Yeah. Well, if you have a foot, you explain it.

[00:15:36]>> Yeah. For the for the runners. And there are a lot of contributors to iron deficiency, especially in female athletes. If they're they're menstruating, if they're having a period, they're bleeding. And so that's one one possible contributor. I will say inflammation from training. So if your gut is just not absorbing as optimally, that's going to impact iron absorption.

[00:15:54]And then there's a foot strike hemolyis for the runners where when they're striking and their foot striking, it's um breaking red blood cells and breaking breaking cells.

[00:16:02]>> Aren't all runners foot strikers?

[00:16:04]>> Yes. Because I run on my feet. You got on your feet. Right. Right. But it's it's preferentially in affecting you more than say a a swimmer or someone who's not doing impact.

[00:16:15]>> Interesting.

[00:16:16]>> Like even volleyball and basketball cuz you're striking your foot when you jump every time. It's a pretty pretty rigorous strike.

[00:16:22]>> Yeah.

[00:16:22]>> And so this can impact your iron.

[00:16:24]>> Yeah.

[00:16:25]>> I just heard something on jumping and bones too. So maybe away from iron.

[00:16:29]Let's talk about that.

[00:16:29]>> Is it accurate that jumping is good for your bones? Is better for your bones than running? Is that >> Yeah, because you have seven times your body weight with each step.

[00:16:39]>> So for any age is down that seven times.

[00:16:42]>> Yeah, there is.

[00:16:43]>> I know. I actually I need to look up if it's actually truly seven times. But but Gabby is on the right track. Yes. With jumping over running is going to have higher impact. But I'll also say if you're going to just jump out of the blue and start getting into this plyometric training, you're going to put your yourself at risk for bone stress injuries and these overuse injuries. So you got to ease into it. But I think I'm a big fan of multidirectional movements, different sports, um, participating in both strength training as well as impact training, whether that's running or plyometric.

[00:17:16]>> I'm going to stay kind of on jumping, but on the different ages because you talked about all the injuries. I bet we all had all kinds of different stress fractures and injuries. If you got tons of injuries when you were younger or in your pre-teens or teens and then you become a permenopausal woman and you want to keep your bones healthy, what do you do? Like how do you make up for all of the sins of your past of foot striking and not enough >> being sedentary for that matter >> or being seditary?

[00:17:42]>> Yeah. I mean I think that we kind of talked about these like this critical time during adolescence to build bone and you got like >> say you messed that all up. you messed that all up through maybe some fueling errors. And a lot of this is unintentional. So I'm not saying not blaming anyone, but you down the road now you are in your penmenopausal years.

[00:18:02]You're going to experience an estrogen decline that's going into late permenopause into postmenopause. And so with that, there's also a decline in bone mass. And so we worry about fragility fractures at that time. And so what do you do about it? It's not like you just have to like sit there and put yourself in a little bubble, but you can I went I recommend continuing to move, getting into resistance exercise and resistance training, finding what works for you. There are some studies that are really showing the what we call osteiogenic or bone building potential of different types of exercise. But I think first and foremost, you just need to keep moving and move in a way that you're going to stay motivated to do.

[00:18:40]>> And so she's saying that it's we're not doomed. your sins of the sins of the past are there, but there's data that shows that you can increase bone um especially through midlife, which and I don't know how many midlife athletes you see, but I have a follow-up question to that.

[00:18:55]>> So, we're talking about reds in young girls who are having periods. What we're looking at too, and I'd love your clinical perspective, is that transition from um premenopause to perry, especially with late pregnancies and very active women um on this bridge of a lot of women are experiencing pmenopausal symptoms, but we really think it's probably symptoms of reds.

[00:19:19]Have you seen that frequency? So, at like 35, 38, they're experiencing relative energy deficiency syndrome, but they think it's pmenopause. I think it gets really complicated. One, there's not a lot of science or research for reds in the pmenopausal athlete.

[00:19:37]Two, there are a lot of other causes of hormonal disruption during that time.

[00:19:41]Um, I'm I I'm I'm just going to put it out there. I'm 40 and I have a one and a half.

[00:19:47]>> I have a one and a halfyear-old and so I I was a late >> You you have reds right now.

[00:19:53]>> It's like, you know, >> I mean I Yes. Yes. when you're burning the candle from both ends >> and you think it's normal >> and you think it's normal and I think that a lot of athletes and they're trying to train and they're trying to do the things they're trying to follow all the the recommendations many of which we're recommending but but there's a point where you just you got to fuel more and you got to find the time to fuel and find what works works for you and and so I I think that one we do need more more science in that space but I also think that there's more that we can do to communicate hey don't follow that new social media craze for this focus on thinness because right now we need to we need to to build your bones. We need to keep you healthy and and optimize your hormonal state too.

[00:20:36]>> So I just want one follow-up question for that. So you have this I know I know okay >> just just say I have another question.

[00:20:44]>> When you it's it goes back to Gabby's initial question of that's a life stage where women want to optimize body composition. Optimize is not the right word. They want body composition to be better than it is or at least to maintain it. What would you tell a woman in that that's 40 active juggling all the things and you tell her just to eat more that that's a little hard to chew on, no pun intended. Um, what would be a takeaway or like maybe from a a physician perspective and an active woman perspective, what what would you say? I think I would reframe it that you need to fuel your life. And whether that is chasing your toddler around or that's going out for a run or a hike or doing your your class, CrossFit or whatever.

[00:21:31]Um, whatever you like to do, you need to you need to fuel that. And and I think even as the the 20-year-old athlete, they're fueling your their their bodies for their training. And we're still we're still training. We're training for life in a way that we want to continue to to move in a way that we want to move in in our 50s and 60s and 70s as opposed to being worried about breaking our bones. And so I think fueling for life, fueling for optimal bone health and just reframing it from fueling to change your body composition to a way that you you may not want to. Um I think that's that's the wrong way to look at it. And if we can have more women going that direction as opposed to focusing on leanness and a certain phys aesthetic physique, I think we'll all be better off for it. And and I hope I I think that we can get there.

[00:22:17]>> I hope so.

[00:22:18]>> You do?

[00:22:19]>> I do. I do.

[00:22:20]>> I think we're in this way. It's so it's such a unusually it's so ingrained in us. Um, and now it's even worse because we see ourselves a million times more than like for example when I was a kid or or a young adult even there was no phone. And now that everybody unfortunately is seeing images of themselves every single day. So it's so interesting. You have to really almost fight it. Like there's something inside that you have to sort of decide, hey, I want to feel I want to have vitality, life force, energy. I want to be mobile and independent forever. Um, and sort of all these ideas. And it's so interesting to see if we can if we can at least in moments, you know, kind of believe that shift versus, you know, how do I look? I think that that's a really hard thing for us all to get past. One thing on that and this is a and it's gonna it's about you Gabby, but that I found that I do is every and this is super weird and nerdy so I'll overshare here because we're in a safe space. Every quarter I go through everyone I follow on Instagram and I unfollow everything that makes me feel bad and then I'll only follow people like you. Actually, I follow both of you as well. No, I follow you cuz your life is so it's inspirational and it's happy and it's still sport, but it's healthy and well, but all of the ones that are men and women, super skinny and only the supposed to, they kind of terrify me and make me feel bad about myself, so I just unfollow them every quarter.

[00:23:51]>> Well, it speaks to environment, who you surround yourself with versus, you know, are you around people that want to be thin all the time versus strong and powerful. So going back to parents of these athletes um or young people in general, I think you know so so much growth and expansion and important parts of our foundational health happen when we're young. Even though of course the body is regenerative and if we have late practices and we don't start until, you know, we're in our 30s, there's so many opportunities there. Maybe we can just outline how a parent can support the athlete because also the parent can do it for themselves >> and even bringing that to sort of their even their their general doctor like what we can be looking for >> just to make sure that we're helping them stay on top of it.

[00:24:36]>> I think it's such a great question. It's like what can what can we do? What conversations can we have? And and I think for parents, normalizing conversations around the period is one.

[00:24:48]Um encouraging good fueling practices and good nutrition practices that starts in the home, but and then making sure that the pantry is stocked with all of those important macro and micronutrients. But then also in the clinical setting and especially as a sports medicine physician, we need to also ask those questions. Even if it's an athlete coming in with an ankle sprain or or something that seems unrelated, we should still be asking that athlete, are you having regular periods? When was your last period? How old were you when you had your first period? All that can play play a role into their recovery, into their current state of of health and and performance.

[00:25:26]And then I we haven't really talked about hormonal contraception, but a lot of these athletes, they're they're not having periods because they're on hormonal contraception. And sometimes they're placed on hormonal contraception because of Mr. irregular periods which can be related to under fueling and those questions weren't being asked when they were placed on the hormonal contraception. So I also think it's important for the parents and the clinician to understand why why were you placed on those or do you know and is this the optimal form for you and is this the right time to to be exploring that?

[00:25:58]>> Yeah. Because what you're saying is that a lot of that those contraceptions are hard on you. I mean, there I I I know unwanted pregnancies and stuff, but a lot of times you see they're using oral contraception as a as like a one a gunshot spray that it's like, oh, well, this will just kind of take care of that, >> right? I think that they're um they can be prescribed in in ways that might not be the best first approach, like first slime. And and for for some athletes um they they do want it to manage their periods or um control their periods in a way, but I would also say we need to make sure that that athlete is fueling enough. And when an athletes on hormonal contraception, it is masking their regular hormonal production in a way that they may not know if they're having a a regular menstrual cycle or not.

[00:26:45]>> I have to ask just because people have sons as well. I YOU QUESTION THAT.

[00:26:51]>> I'm sorry. I thought you wanted to talk more about GI issues. I don't know. I uh I'm just curious. Are we seeing are young male athletes or, you know, middle-aged men are are they is there something they're navigating or because they have testosterone and other hormones, they don't they don't have to face this quite as much?

[00:27:12]>> Yeah, I do see male athletes in my clinic and so I I feel qualified to answer that question as well. And I do see these male athletes who are suffering from reds. Uh we don't they don't have the indicator of a period of course, but they do have uh testosterone suppression. And as a clinician, I'll get that those those numbers and get those labs as a helps explain to them what's happening in their body through under fueling through high volumes of training. And I think that can have impacts um well beyond their understanding both for bone health, but also just overall reproductive health and definitely performance. And so usually when I see these athletes, they're coming in with a with an injury, with a a bone stress injury. And we've got to unpack the layers of how did you get here? How can we start to shift you in the right direction to fuel more? And and it can be a long journey. But um to your point, uh hormonal levels is is helpful in that in that case.

[00:28:05]>> Actually getting your hormones checked.

[00:28:08]It's it's so interesting because you wouldn't you know you wouldn't think it quite as much with men but really the conversation about reorient reorienting around not only the right kind of food but maybe more of it. So I feel like coaches would be really helpful in this process too because if it became a culture kind of of the team it would make that process a lot easier. Um but I also think everyone's overtraining.

[00:28:35]I see that and I see a degree of overtraining.

[00:28:38]>> You didn't say it. I said it. But I I do see that I feel that young athletes they are in one sport all year round.

[00:28:45]Repetitive motion over and over. I think culturally we've moved into a place where >> everyone is just >> got to win training. So so much training.

[00:28:56]>> Yeah. Yeah. And I think it it's it goes back to culture and what is what is the environment that we're living in right now and what is the priority and and I think that it's gone away especially in the younger athlete from free play and letting those athletes go outside and play pickup games and which is still very important for for bone health development, socialization and it gets into very structured play and that structured play is year round and and so with that those athletes are doing sometimes repetitive movements um depending on the sport um swimming and even with with running, but it also can lead to burnout. And we're we're trying to not to get doom and gloom, but we're trying to keep athletes in sport. And and so I I grew up in a small town in Nebraska and so played all the different sports. And I and I think it did protect me from some of the the overuse injuries that I definitely would have developed if I would have just been running or just doing tennis.

[00:29:48]>> So moved to Nebraska, jump around a lot.

[00:29:52]>> Jump around. Maybe maybe we can take go back to estrogen a little bit because I I feel like we talked you mentioned it but the importance now you're seeing in research of estrogen the connection of it. So especially for a middle-aged person, the importance estrogen has also on bone health.

[00:30:08]>> Yeah, estrogen is good for bone. It helps build bone and it helps prevent bone breakdown. And whether that's the naturally circulating estrogen that we get um throughout the phases of the menstrual cycle or um in a form of like transdermal estrogen and there is an indication um in certain athletes uh even in young athletes where I I recommended prescribed transermal estrogen with cyclic progesterone for low bone density in those athletes that are having a hard time normalizing their menstrual cycle. It's not a band-aid, but it's a a supplement or something to help with their um recovery of of bone density in that critical time. And I would say similarly in the permenopausal timing, I think really thinking about hormonal treatments and what can be valuable for that individual is and having those conversations early with your clinicians is is really important.

[00:30:58]>> So on that note, I think it's interesting. One, I think you're one of the first clinicians that have said that out loud, which is great. That's why you're here. It is great.

[00:31:06]>> Um, but then also thinking about as a clinician, you use the evidence that exists, but then also practical experience. So, putting on my research hat, can you tell me where you see the biggest gaps are or what is the research that would really help inform you as a clinician as you're kind of prescribing these things across the lifespan?

[00:31:28]>> Yeah, I think we need earlier indicators and earlier detectors. And I I touched on this earlier with with wearable data, but I I see so much opportunity with using wearables to detect maybe earlier signs of low energy availability or that overtrained underfueled state and and we're we're not there yet. I'd love um with even within our faster team, we are exploring different types of wearable data and how we could implement that in an effective way and design that design that well. So that's one one idea. Just to follow up, when you are seeing like things that make you excited, when I think about wearables, I think about the ones we're using in the lab, the the aura, the Whoop, the hormone trackers, like are there ones that really come to your mind as like this is what's really going to be helpful?

[00:32:13]>> Yeah. I mean, I think first of all, they need to wear it.

[00:32:15]>> Yeah. A wearable that will be used and really natural within just the the daily life. um one that is going to pick up on hormonebased changes and whether that's a proxy through um different biometrics um through HRV or through sleep changes or body temperature. But I think that if we can start to crack the code and get the right algorithm to get that earlier sign that instead of just says you're you're overtrained and you're stressed and whatever else is communicated on your phone, but gives you some tips and say, "Hey, are you feeling enough? are you you've trained 20 days in a row, maybe you need to take some some time off and then an athlete understands the why behind that to implement some of those changes.

[00:32:57]>> I think the why is super critical cuz with so many I love wearables. I love online social showing off sport, but it trains you to want to do it every day so that you can beat your previous day or your previous year or maybe that's just me, maybe unhealthy. Yeah, mine too. I'm like, you. I'm doing a marathon.

[00:33:18]Too bad, >> right? I mean, what if the wearable could say you are 10 steps away from a bone stress injury or I mean that's a very >> Wouldn't that be nice?

[00:33:27]>> Please do that study. That would be very helpful to know. What is that? So, this is like a real householder question.

[00:33:34]What does that look like? like from one step step to the next. If somebody was, let's say, two months of training out from a stress fracture, besides the fueling, is there anything sort of even more proactive that they could do to pull back from that from that situation and avoid it, >> right? I mean, besides fueling or or rest or modifying training, I mean, I think that there's sleep is so huge and so I'm making sure those athletes are getting enough sleep and especially my my young athletes, they're not getting enough sleep and they're stressed and and it always it worries me if there's a sleep issue that early and they're trying to to continue to train through it. So, I think that's like control the controllables. how can you control your sleep, your um fueling your recovery, making sure that you're really taking time off your feet. And maybe there are some other interventions that we could start to explore with research and um different therapies. And I I won't get too deep into the weeds because it's it's way too early, but I think that there probably are some interventions that we could explore to to help with that, too. as a followup. So, I have obviously an interest in bone, not what I studied. So, thank you for your contributions, but I always found it interesting and we looked at this, it's it wasn't always bone density that was low. It was poor muscle quality because you had all these runners and endurance athletes not uh lifting weights. And so, as a followup, you know, maybe it's time off your feet, but actually improving the size and the quality of the muscle.

[00:35:01]And it doesn't mean don't train, but do something slightly different.

[00:35:04]>> Of course, the muscle researcher does a a plug for go so well together.

[00:35:11]>> I feel like the muscle and the bone is this like symbiotic relationship that they both need to feed into each other.

[00:35:16]And I think I'm so glad you brought up resistance training, strength training as a a really good bone building activity and that needs to happen. I would say as another um ad too when you are thinking about risk, what is your strength training program and how can you um build your bones that way? And I think a lot of times people hear, "Oh, you have to lift heavy, especially women." And they don't really realize that it doesn't mean heavy. You're not sitting there with plates and plates and plates. It just means you're lifting time under tension. You've got some load, >> right?

[00:35:47]>> And it doesn't have I don't think it has to be that daunting. Um, and so I I always encourage people maybe they don't know how >> either find a friend who is knows what they're doing. They can kind of show you the ropes. It might even be worth hiring a trainer for a few sessions just to kind of understand the language. And my other favorite thing you hear is I don't want to get too big.

[00:36:08]>> Yeah, I hear that.

[00:36:09]>> I've been waiting my whole life to build my biceps. You know, >> you know, it's like you're trying. So, I really appreciate this conversation. I'm going to let the gens if they have a free floating question. Do you guys have a free floating question that would be curious to you?

[00:36:22]>> Yeah, sure.

[00:36:23]>> Fun >> from the audience. Going back to estrogen, um, what sort of estrogen would you recommend for women over 50?

[00:36:32]What what what kind of intake?

[00:36:34]>> Okay.

[00:36:35]>> Like, it's too late, John.

[00:36:38]>> I saw on Instagram. It's not too late.

[00:36:40]It's not too late. I will.

[00:36:42]>> So, the question is if if you were older, was you, you know, is it the p like what type of estrogen are you are you able to talk about?

[00:36:50]>> Yeah. I mean, full disclosure, I I I don't have as great of specialty in um per menopausal prescription and medication, pharmacologic prescription, but I um would say that the patch or the transdermal estrogen is going to likely be your best bang for your buck. And hopefully there are some nods that I'm seeing here that can >> I mean, there's options, which I think is important. Yes. Yes. There's sort of poo pooed because it's real strong in the beginning, right? And then it's sort of le like there's just certain ways.

[00:37:20]>> I like more of like a cream versus a patch. Different >> do you like the cream more? I like the patch because I don't have to think about it.

[00:37:28]>> You need a permenopausal specialist on your podcast.

[00:37:30]>> I think we do need that. I know. I want to adjust.

[00:37:33]>> I'll take all of it. My doctor calls it the happy patch and I love it.

[00:37:37]>> Do you not see a change?

[00:37:39]>> You change it. It's two two >> twice a week. Every three or four days.

[00:37:44]I mean, you know, you >> feel a change.

[00:37:46]>> Totally. Yeah.

[00:37:47]>> Yeah. So, sleep. Get your hormones checked. Check your period as an indication.

[00:37:52]>> Fuel enough.

[00:37:53]>> Yes.

[00:37:53]>> What's your favorite? You talked about fueling. What's your favorite snack food?

[00:38:00]>> Oh, Dr. Emily Krauss eats bone marrow.

[00:38:02]What do I, >> you know? I'm on a I'm on like a morning waffle kick.

[00:38:07]>> Oh, any kind of waffle.

[00:38:08]>> Yeah. Um, it's the Kodiak.

[00:38:10]>> Oh, I love the Kodiak. Okay. That's waffles. Yes. It's like super quick with Piper. Piper loves the Kodiak. I I love the Kodiak.

[00:38:18]>> Is it like a ego?

[00:38:20]>> Kind of like Yeah. Yeah.

[00:38:22]>> It's a healthier one.

[00:38:23]>> It's a healthier one. Little nut butter.

[00:38:26]Yeah. Yeah. It's my like quick fuel. I'm like thinking about quick fuel these days.

[00:38:30]>> What's one thing about you we wouldn't know by reading your your bio. Tell us something about you, Emily.

[00:38:36]>> Oh my gosh. Well, I already gave the Nebraska fun.

[00:38:41]>> I lived in Iowa or grew up in Iowa.

[00:38:43]>> Okay. Yeah. So, I think um I'm going to I'm going to tease that again. I I grew up in a small town in Nebraska. Um, >> did you play sports?

[00:38:49]>> I played I played sports all through high school. I played basketball, tennis, cross country. I played golf in the summer >> and I play like grew up playing volleyball. I have two older brothers that I just looked up to so much and and yeah, we all now we live all across the country.

[00:39:04]>> The question from someone who is a parent who has a very active uh student athlete daughter uh very you know she's playing indoor volleyball and beach volleyball.

[00:39:16]and she, you know, my friend's always saying like she feels like the sleep police, the kids begging to stay up till 11:30 to do homework and then has to get up at 6:30 for school. Um, you know, I think a lot of parents go, "Well, what is enough sleep?" And is I know you're not a sleep expert, but is there sort of a a a sweet spot?

[00:39:35]>> I recommend eight for male and female athletes.

[00:39:39]>> Any age?

[00:39:40]>> I I mean, honestly, any age. Like, if you can as you get older.

[00:39:43]>> Yeah. I I don't know. I feel good. I feel better with eight, that's for sure.

[00:39:47]I I will also say that sleeping shorter durations during the week and then trying to make up for it on the weekend isn't a great strategy.

[00:39:58]>> I love a good nap time.

[00:39:59]>> Well, like some some small naps.

[00:40:01]>> She's saying you can't pack it in on the weekend.

[00:40:04]>> You want consistency. You want you want to aim for eight every night. And I will also tell that mother that if that athlete is is overscheduled with the volleyball practices, the the other extracurriculars, the the homework, maybe something's got to give for a little bit, especially during really high stress times of the school year, cuz I just worry that that you're burning the candle from both ends. I worry about overuse injuries or just kind of feeling stressed about everything in life and um sub-optimal performance, a little energy deficit and and over time I think that that can just build upon each other. So, usually I recommend at least one rest day per week, just full day off and try not to do double training. So, the the two sports in the same day um has become popular but is is not going to be good for for either sport they're playing.

[00:40:54]Something I always tell my college students too is as many years as I went to school, I never pulled an allnighter.

[00:40:59]It's because it you can't actually learn anything that late. And so sometimes I tell the them just just go to sleep.

[00:41:05]You're going to learn it better anyways.

[00:41:06]>> Right. Right. Turn the brain off. We actually had a really good study at last mills that was if people it was about students and if they cra right before a test or if they do um yoga or mindfulness which one is going to help them perform better and it's the yoga and mindfulness. I think it's kind of different but similar like you can try to cram it all in >> but you'll get overwhelmed or exhausted and your brain's not functioning properly and you're anxious and and that the whole spiral.

[00:41:38]>> Totally. Yeah. It's a big It's a big hard one. Balance >> life lesson.

[00:41:43]>> I'm still working on it.

[00:41:44]>> Dr. Emily Krauss, thank you so much for joining us and sharing what you're seeing in the lab. It helps not only the other athletes that you're working with, but all of us here. We really appreciate it. And um just remind people if they want to go deeper into this where they can find you and find some of this research.

[00:42:01]>> So they can go to faster.stanford.edu ed f a str and they can also follow us on Stanford faster is our Instagram and then they can also check out the Wai Human Performance Alliance. It's full of really great researchers and collaborators and some other other projects along the topic.

[00:42:20]>> Well, thanks for joining us and uh we look forward to learning more from you in the future. Thank you.

[00:42:24]>> Thanks for having me.

[00:42:25]>> Thanks, Emily.

[00:42:26]>> And 40 is not old. Calm down.