New Zealand wicketkeeper-batter Bernadine Bezuidenhout couldn't make it two minutes without throwing up. She was extremely weak, struggling to sleep and eat, had "hectic" water retention in her legs, and struggled to climb a single flight of stairs. She had not had her period in years.
"I went out to bat against Australia [in 2018] and I was so dizzy, I'd just come back from the toilet vomiting," she says. "I went from that series to the Caribbean [T20 World Cup] as sick as I can be. I couldn't explain to people how sick I actually was and kind of kept it to myself. I got back and I was like, 'I can't carry on like this.'"
Bezuidenhout was diagnosed with RED-S (Relative Energy Deficiency in Sports) in 2018 by Lesley Nicol, the former New Zealand national netball captain, who is now a sports-medicine specialist. "She basically said to me, 'Bernie, I don't think you're ever going to play professional sport again.' I was 26 at the time and that's a tough pill to swallow," Bezuidenhout says. "I just remember thinking, 'Well, I'm going to give it my best shot.'
That bleak forecast was not fulfilled but she was out of the game for two years. It turned out she had had the condition for a decade.
"I completely isolated myself and it takes a mental toll. You're agitated, you feel depressed," she says. "These are real implications of RED-S and many people don't understand."
In female athletes, RED-S is a term used for a combination of three interrelated conditions - low energy, menstruation dysfunction, and low bone density. The condition can affect athletes of any gender and ability level, and typically is caused by a person consuming too few calories relative to the amount of energy they spend. RED-S can potentially impact metabolic rate, hormones, immunity and cardiovascular health, and can have deadly or lifelong health effects.
"I was eating 1000 calories a day and burning 5000," Bezuidenhout said. "And that's how I got into the state that I was. [I thought] the thinner I was, the better.
"I couldn't continue to do that - I had to gain weight. I realised that if I wanted to come back to professional sport, I needed to make a change."
Bezuidenhout, who relocated from South Africa to New Zealand for her career, admits she kept her problems to herself for the sake of her future. "At that point in my career I was fighting for a spot within the team, so you keep quiet and you just push through things," she says.
"As a female athlete, you love not having your period. Like, no period - great, don't have to worry about the pain and all those other things. Can play a full game of cricket. It was something I kept from myself for a long time."
She is not alone in thinking this way. According to a survey by Project RED-S and Kyniska Advocacy, two athlete-led organisations that work on awareness, prevention and support for RED-S among other things, more than a third of female athletes in the UK intentionally ignored missed periods because they believed it was common for an active person to have that happen; 19% believed missing periods would help their performance.
RED-S is just one of a number of conditions female athletes need to deal with. Others include endometriosis, a disorder that causes painful periods, severe cramps and debilitating pelvic pain. Welsh Olympic cyclist Elinor Baker, who suffered from the condition for years, said the pain it caused felt like someone was "wringing out my organs as if they were a tea towel".
Pelvic Floor Dysfunction (PFD), a group of disorders characterised by mild to severe dysfunction of the pelvic-floor muscles, is more common in female athletes than in males and can cause pelvic and spinal structural instability as well as urinary leakage during activity.
PCOS (Polycystic Ovarian Syndrome), an endocrine illness that impacts overall health, is a common condition among elite female athletes. Aside from irregular menstrual cycles, some athletes with PCOS may experience cravings for carbohydrate-heavy foods, leading to trouble managing blood-sugar levels and high insulin levels. Women with PCOS also have relatively higher anxiety, depression and fatigue on average.
Heavy menstrual bleeding (menorrhagia), which causes iron deficiency and anemia, is a condition prevalent in women who exert themselves physically. Iron deficiency can cause loss of endurance, fatigue, high heart rate during exercise, low power, and frequent injury.
Research suggests athletes - across genders - are more susceptible to eating disorders than the general population because of the rigours and stresses of participating in sport. Up to 45% of female athletes and 19% of male athletes struggle with them, according to a 2018 study. According to a report in the Sports Journal, female athletes are specifically vulnerable because of societal pressures and the cultural focus placed on weight.
"When you're an athlete, you have a fear of gaining weight and you have a fear of getting fat," Bezuidenhout says. "Because society is kind of moulding us to think that only boys can eat in a certain way. If [women] eat like that, we're going to become fat."
Physiotherapist Anuja Dalvi, who has worked with the Bangladesh national team and with UP Warriorz in the WPL among other women's cricket teams, agrees. Though she says women cricketers, especially in India, are much more conscious about their fitness now than when she began working in 2009, there are sociocultural forces at play. "As a girl there are some social stigmas. 'I should look this way.'
"They want to train hard, they want to play stronger, but they don't want to increase the quantity of food [they eat]."
It is easy to draw a line between the fatigue, lowered energy levels and hormonal changes associated with menstruation and a higher potential for musculoskeletal injuries. Injury rates in female athletes have been found to be higher during the pre-menstrual and menstrual phases of the cycle. Women are also at higher risk of Anterior-Cruciate Ligament injuries (which are more common in women than men to start with) during the ovulation phase (typically day 14) of their menstrual cycle, and report increased fatigue and poor moods through the luteal phase (days 21 through 28).
The pain, exhaustion, and other symptoms that accompany menstruation can also have a significant influence on athletes' ability to play and train. Dalvi says that while a few players take painkillers during their periods, many others go through with games or training as is, even if they are in pain or have heavy bleeding. "There are cases where they have severe pain and they even faint," she says.
"Psychological stress, mood swings and sleepless nights during that phase are also common. All this can give you secondary musculoskeletal injuries."
Apart from coverage of the physical injuries that these health conditions cause, most of these disorders and syndromes are rarely given much attention in sport and particularly in cricket.
Bezuidenhout says that periods are still a "demon subject" in a male-dominated sport like cricket. Also, like in her own case, the fear of losing your spot in the team can make women cagey when it comes to speaking out about their health issues.
Dr Shuaib Manjra, Cricket South Africa's chief medical doctor, says that having female doctors or physios on the backroom staff can help players speak freely about their health issues. Reluctance to approach male staff is particularly pronounced in places like the Indian subcontinent, where there are sociocultural taboos relating to menstruation. When ESPNcricinfo contacted the Pakistan Cricket Board for this story, for instance, they declined to comment on how their players deal with menstrual health, saying it was a matter of "sensitivity and cultural issues".
Alyssa Healy, the Australia wicketkeeper-batter, says competitions like the WPL can help normalise talk about menstruation. "In Australia we're really lucky as we learn about a lot of this stuff at school," she says. "It's normal to learn about your body and the changes in your body at a young age. [In India] it's a bit taboo to talk about it. In world cricket, we can have those discussions a little bit more and we potentially help one another out. For example, us coming into an environment like the WPL, if [the players in my team are] comfortable having those conversations, I think that's going to be great."
Though women have been playing the sport since about 1745, there has been little significant research specifically on female cricketers and the challenges they face in terms of their physical and mental health. "[We need research on whether] specific injuries are more common in women's cricket, injury rates, DSD [Differences of Sexual Development], effects of menstrual cycle in performance, psychological elements, nutrition, fitness standards," Dr Manjra says. "We shouldn't treat women's cricket merely as a female form of a male game."
It is difficult to monitor each player's menstrual-cycle needs in a team sport where practice and preparation are also largely done collectively. This is where the concept of cycle tracking, which many sports teams now use, comes in.
Cycle tracking, using apps and digital wearables, helps athletes better understand their bodies and also helps in tailoring their training and performance to their individual needs. Work capacity and strength are at a high during the follicular phase, the first one in a woman's cycle, starting from menstruation and lasting for 14 days till ovulation. Logging the length and other details - like accompanying symptoms and moods - of a sportsperson's most recent cycle enables the tracking app to offer personalised recommendations for workouts and diet, and to explain the bodily changes in that phase of the cycle. The 2019 World Cup-winning US women's football team credited their success to an advanced menstrual-cycle-tracking strategy.
"I'm 32, I've been going through it for a long period of time," Healy says about matching training needs to the stages of the menstrual cycle. "I can kind of pick and choose where I'm feeling my best. But maybe a young player is not quite sure of what that feels like. I guess having these discussions is great, because then the young players might be able to sort of check in on themselves a little bit more and know when they're at their best and when they're not, and they can use that to their advantage."
Among cricket teams, Cricket Australia tracks its players' periods, while New Zealand Cricket has made it optional for players to track their periods. CSA doesn't do it, but the South Africa women's team trainer keeps track of the players' periods.
Cycle tracking helps not just players but also team doctors, physios and trainers. Menstrual irregularities or painful periods may sometimes be signs of underlying illnesses - like fibroids or endometriosis - that need to be diagnosed, Dr Manjra says.
In the CSA set-up, players can request to have their fitness tests postponed if they're on their period, he says - though he has rarely heard them say they can't play because of painful periods.
"There has to be awareness on how to manage your period pain-free," Dr Manjra says. "But if you can't even function on a daily basis, approaching the right medical practitioners and [getting] psychological support is key.
"We need to make sure we are spreading awareness about it, equipping them and their families to handle it as well."
Bezuidenhout too speaks about the importance of knowledge and awareness in dealing with health challenges. "I am a lot more educated within this area [RED-S and female athletes' health] now," she says. "All of us as females really need to listen to our bodies, because we are different [from men]."
Awareness has also been on the agenda for the ICC, which conducted workshops on menstruation for all participating teams at this year's women's Under-19 and T20 World Cups in South Africa with a view to normalising talk on the topic and imparting knowledge on how athletes can enhance their performance on the pitch while on their periods.
"It was really about encouraging open communication: 'Talk about it, tell your coaches, because they're here to help you, and unless they know, they can't help you and support you,'" Snehal Pradhan, manager of women's cricket at the ICC, says.
The workshops covered a range of topics, from types and uses of different menstrual products to hormonal changes, breast health, pelvic-floor health and RED-S. Male coaches and support staff were also part of the workshops.
"Communication, openness and normalisation were the themes that we structured the sessions around," Pradhan says. "We're also educating them - that if you're experiencing something that is not normal, you need to talk to your doctor, coach and your physio."
In India, an organisation called Simply Sport Foundation that aims to support the grassroots sports ecosystem in the country runs an initiative called Simply Periods, which focuses on educating young athletes at various academies in India, and their coaches and parents, about menstrual health. Through their workshops, SSF says they have reached about 3000 athletes around India so far. The goal, according to Aditi Mutatkar, the head of women's projects at the foundation, who is also a former Indian national badminton player, is to not have young female athletes keep their period-related problems a secret and not have them train like men.
"I think a majority of the coaches are male and sometimes their intention is to make a boy out of a girl and see if you are 'as strong as a boy'," Mutatkar says. "[Women's] requirements are different - we eat differently, our body digests food differently. That's why it reacts differently. We have the whole hormones thing that is completely different from the guys.
"The initiative is not just about periods but it's about looking at how we can create a resource, which basically focuses on training a girl like a girl. That's a very important narrative which needs to come out, especially in India."
It is a thought echoed by Bezuidenhout. "What I've realised is, I've trained like a man. I've learned so much about myself [since]," she says.
"I want to tell young girls to listen to your body. Don't compare yourself to the boys in the park and what they are doing - just listen to your body, eat well, and make sure that you know what your limits are. Boys can also experience it - just young people in general, young athletes that are going through something similar, but don't know what they're going through or don't know who to speak to."
For long, female athletes have expressed reservations about wearing white while playing during their periods. Women cricketers are not required to wear whites as frequently as men because they do not play as much Test cricket, but they nevertheless feel anxious when required to wear light-coloured trousers. England batter Tammy Beaumont told the Telegraph in 2021 that it was a "daunting prospect" to play a Test match when she was on her period.
The England women's football team had the colour of their shorts changed from white to blue last April, thanks to concerted campaigning from senior squad members. The New Zealand women's football team followed suit. Wimbledon's traditionally rigorous rules requiring all-white apparel for its players were relaxed in 2022, and female tennis players were allowed to wear dark-coloured undershorts beneath their skirts or shorts.
"Sometimes it [period] might just come three days before or three days after, so you never know exactly when it's going to come," South Africa fast bowler Shabnim Ismail says. "But then you obviously wear tights underneath your clothes, and make sure that you have extra clothing in your bag, because you don't know exactly when it's going to come, so you can prepare yourself in advance. It's never easy, but that's what we go through."
Healy is of the same opinion. "You're probably worried about [getting your period] on the field more than anything. That's probably where most people are most worried - that you're playing on television and something could go wrong."
Players have been allowed to leave the field in such cases. Should women be granted longer breaks during a match in general? "Yeah, 100%," Ismail says. "I would actually love that if that could happen."
With the help of a team of specialists - a nutritionist, strength and conditioning coach, physiotherapist, and Lesley Nicol - Bezuidenhout was able to play cricket again after a two-year layoff that she said was the most challenging part of her battle with RED-S.
She also got her period back after ten years, in July last year, which was an indication that her health was improving. "I literally - it sounds ridiculous - celebrated it, because for me, it was a massive achievement," she says. "It was a short period, but I knew that I was in the right direction. I'm still irregular, but I keep track of it. For me, it was like I reached the top of the mountain. It was a massive, massive achievement."