Dr. Violeta Nikolov: We must not ignore menstrual health in female athletes

In an interview on October 30, 2026, Dr. Violeta Nikolov, a gynecology specialist at Veles Clinical Hospital, urged coaches, parents and sports organisations to stop overlooking menstrual health among female athletes. She warned that disruptions in the menstrual cycle are often an early sign of relative energy deficiency in sport (RED‑S) and can affect training and long‑term health.

RED‑S and why it matters for performance and health

Dr. Nikolov explained the condition in clear terms: "RED‑S is the syndrome of relative energy deficiency in sport. It occurs when the body over a prolonged period does not receive enough energy from food to cover the demands of training, growth and normal functioning. It can affect hormones, the menstrual cycle, bones, immunity and sports performance."

She highlighted that delayed menarche or the disappearance of an established menstrual cycle should not be ignored. "The timing of the first menstrual period varies, but if it has not appeared by the age of 15, a medical evaluation is needed. Also, a medical assessment should be sought if menstruation does not occur within three years of breast development. Intense training and insufficient energy intake can be part of the causes, but they are not the only possible factors."

On secondary amenorrhoea, Nikolov warned: "That is the absence of menstruation after it has already started. If menstruation is absent for three consecutive months, the athlete should consult a physician, especially if she previously had regular cycles. It should not automatically be attributed to intensive training, because there may be other causes."

She also stressed that missing periods is not a sign of healthy adaptation to training. "No. The absence of menstruation can be a sign that the body is not receiving enough energy to meet the needs of training and normal functioning. It should not be considered a normal consequence of sport, but a warning sign that medical assessment is needed."

On prevention, Nikolov called for combined measures: "Prevention implies sufficient food intake according to the real needs of the body, adequate rest, individually planned training load and open communication among the athlete, parents, coach and health professionals. When there is suspicion of RED‑S, an individual approach is required, not just a change in training. However, I believe that here, to have good prevention, first of all we must raise awareness of the seriousness of this problem at all levels – starting from the athlete, through parents and coaches, up to health professionals. A multidisciplinary approach is necessary."

She reminded that the menstrual cycle is an important health indicator even for athletes who are not planning pregnancy: "Yes. The menstrual cycle is an important indicator of reproductive and general health, regardless of whether the athlete plans to have children."

Dr. Nikolov also cautioned that hormonal contraceptives can mask underlying problems: "Not necessarily. Contraceptive pills can cause bleeding that does not reflect the natural functioning of the menstrual cycle, thus hiding the problem. Therefore it is important to determine the cause of the missing menstruation and treat the underlying condition."

The interview concluded with a clear appeal to create sporting environments where young women feel safe to speak up and seek care. The project "Women's Sports Stories" was carried out with the openness and cooperation of the Handball Federation of North Macedonia and the Basketball Federation of North Macedonia, and with support from Triglav Life Insurance AD Skopje.

Photo: Privatna arhiva na Violeta Nikolov