Brain Health Is Performance Health: A Call to Action for Healthcare Providers

The Athlete We Failed

I want you to picture an elite runner. She's twenty-three years old and at the peak of her career. Her training data looks flawless—every split perfectly timed, every watt measured, every metric meticulously tracked. But over the course of six months, something changes. Her performance crumbles in a way that doesn't make sense.

Her coach responds the way most coaches would: he pushes harder. She tries everything anyone suggests. New interval training. Altitude camps. Even working with sports psychologists. But nothing helps. Nothing changes.

Here's what no one thought to consider: her brain.

It turns out the problem wasn't in her legs at all. It was a combination of Relative Energy Deficiency in Sport (which we call RED-S), hormonal disruption, and lingering concussion symptoms that had never been properly assessed. Her brain, which is actually the ultimate performance engine for any athlete, was running on empty. And we just kept asking her to push the gas and pedal harder.

Now, this isn't really a story about one athlete's failure. When you look at it closely, it's actually a story about ours—about the healthcare system's failure to understand and support female athletes.

For decades now, we've been tracking every performance metric we can see. Mile splits, heart rate variability, power output—you name it, we measure it. But the most critical performance engine of all, the brain, has remained something of a black box. And when it comes to female athletes specifically, we've been operating with a broken compass, essentially using maps that were drawn for entirely different terrain.

So the question is no longer whether brain health matters for female athletes. We know it does. The real question now is this: What are you going to do about it?

What We Know: The Brain as the Performance Engine

Let me walk you through how brain health actually drives athletic performance. It works through three interconnected systems that you can think of as the operating system your athletes run on. When these systems work together smoothly, performance soars. But when even one component falters, the entire system can break down.

The Neuro-Hormonal Axis

Here's something that might surprise you: hormones like estrogen and progesterone aren't just reproductive signals. They're actually powerful neuromodulators, which means they fundamentally change how the brain functions on a week-to-week, sometimes even day-to-day basis.

Let me give you a concrete example. During the luteal phase of the menstrual cycle, a female athlete's metabolic demands increase significantly. Her energy needs shift. Even her stress response changes. Yet most training plans still rely on rigid protocols that were designed for bodies with stable hormonal patterns. In other words, they were designed for male physiology and then applied to female athletes without much adjustment.

When energy availability drops too low—which is what happens in RED-S—the brain becomes one of the first systems to suffer the consequences. You'll see decision-making slow down. Mood becomes unstable. The hypothalamic-pituitary-ovarian axis can actually shut down, and it often takes the menstrual cycle with it. If you want to understand more about how this unfolds, you can learn more about RED-S and why it's such a critical issue for endurance athletes.

Cognitive Function

Here's something that becomes obvious once you think about it: on the field, in the pool, or on the trail, cognitive function essentially is performance. Think about what actually determines success in those critical moments. It's reaction time. It's the ability to make split-second decisions under pressure. It's spatial awareness and the capacity to maintain focus when everything is on the line.

All of these cognitive skills depend on having a brain that's well-rested, properly fueled, and free from injury. When athletes experience sleep deprivation, when they're not getting adequate nutrition, or when they have a history of concussions, these critical cognitive skills start to degrade. And here's what makes concussions particularly concerning: they compound over time. Even concussions that seemed minor at the time can affect processing speed and emotional regulation long after the initial injury appears to have healed.

The Psychological State

Now, when we talk about anxiety, depression, and perfectionism in athletes, it's tempting to think of these as purely mental health concerns. But they're actually much more than that. These psychological states trigger chronic activation of the nervous system's threat response, which fundamentally changes how the brain allocates resources.

A stressed brain operates in survival mode, which makes it an inefficient performance brain. When your nervous system perceives threat, it prioritizes immediate survival over everything else. That means it diverts resources away from recovery, away from adaptation, and away from the kind of growth that leads to improved performance.

So when we see what looks like a "choke" in competition, or when an athlete enters what we call a "slump," what we're often witnessing is actually a nervous system that's desperately signaling its need for rest. It's not a character flaw or a sign of mental weakness—it's biology asking for what it needs.

How We Created the Perfect Storm—And Then Blamed the Athletes

Now I need to share an uncomfortable truth with you, one that our field needs to confront directly. Until very recently, most sports science research systematically excluded female subjects. Let me say that again because it's important: female athletes were left out of the research entirely.

The reason given was that hormonal fluctuations were too complicated to study. Researchers labeled them as "confounding variables" and decided it was easier to just focus on male athletes. As a result, we built our entire model of athletic performance on male physiology. We created all our protocols, all our benchmarks, and all our standards based on male bodies. And then—and this is the critical part—we simply asked female athletes to fit themselves into that model.

Understanding the Systemic Failure

This wasn't just a simple research oversight that we can chalk up to innocent mistakes. What happened was actually a cascading series of failures, each one building on the last and creating larger problems.

It started with what we call the data gap. Female athletes were systematically excluded from research studies, which created a foundational knowledge gap that still persists today. We simply don't have the same depth of evidence-based knowledge about female athletes that we have about male athletes.

Then came the male-as-default model. Every protocol, every training plan, every recovery recommendation was calibrated for stable hormonal patterns and male physiology. This became the standard, the baseline, the "normal" against which everyone was measured.

Next came what I call the dangerous translation. We took findings from research on male athletes and applied them directly to female athletes without questioning whether they were appropriate or even safe. We assumed that what worked for men would work equally well for women, just perhaps with some minor adjustments for body size.

And finally, on top of all these biological vulnerabilities and male-designed protocols, we layered on intense cultural pressures. Female athletes were expected to be lean, to be agreeable, to be uncomplaining. They were expected to be "strong" enough to push through anything. These weren't just suggestions—they became the unspoken rules of what it meant to be a successful female athlete.

The Three Myths That Made Everything Worse

Let me walk you through three myths that emerged from this flawed foundation. These myths have caused real harm, and they continue to shape how we approach female athlete care today.

The first myth is that "a calorie is a calorie." Standard energy availability models don't account for the higher metabolic cost that comes with the luteal phase of the menstrual cycle. They ignore how low energy availability uniquely impacts the female brain, disrupting neurotransmitter production, mood regulation, and cognitive function in ways that are distinct from what we see in male athletes. What this means in practice is that athletes following these models are often told they're eating enough when their bodies are actually screaming otherwise. The numbers look fine on paper, but the athlete's brain isn't getting what it needs.

The second myth is that "concussion is gender-neutral." Research has now shown us clearly that female athletes have higher concussion rates and experience symptoms differently than male athletes do. They often have more prolonged symptoms, particularly when it comes to headaches and mood disturbances. This isn't about female athletes being weaker or more fragile. It's about real hormonal differences, disparities in neck strength, and biomechanical factors that our baseline protocols simply weren't designed to capture. Yet despite this evidence, we continue using the same assessment tools, the same return-to-play criteria, and the same recovery timelines that were developed primarily for male athletes.

The third myth might actually be the most damaging of all: the idea that "mental toughness means pushing through." For female athletes, what we call "pushing through" often means ignoring symptoms of RED-S, hormonal imbalance, or overtraining. It transforms what is actually a physiological problem into what appears to be a psychological failing. Think about what this means: we've been praising athletes for their resilience when what we were really doing was rewarding them for successfully overriding their own biological warning signs. We were teaching them that listening to their bodies was a form of weakness.

The Perfect Storm We Created

When you put all of these pieces together, you can see how we created what amounts to a perfect storm. You have biological vulnerabilities that are inherent to female physiology. You layer on protocols that were designed for male bodies. You add cultural pressures to perform at all costs, to never complain, to always push harder. The result is that athletes suffer in silence.

They don't report symptoms because they've been taught, both explicitly and implicitly, that reporting symptoms means they're weak, uncommitted, or "not tough enough." Meanwhile, clinicians don't look for these symptoms because they're working with assessment tools that weren't built to detect them in the first place. The tools weren't designed with female physiology in mind.

And then—and here's perhaps the cruelest part of this entire system—we blame the athletes when they inevitably break down under this impossible burden. We call it a "mental health issue" when it's often actually a brain health crisis. We suggest that what they need is to be "mentally tougher" when what they actually need is proper fuel, adequate sleep, and protocols that account for their physiology.

We created the storm. And then we had the audacity to ask why they couldn't weather it.

The Call to Action: What Healthcare Providers Must Do Now

Here's the good news in all of this: we can change this pattern starting right now. Not next year after more studies are published. Not after we develop new protocols. We can start Monday morning with the very next female athlete who walks into your clinic.

But I want to be honest with you about what this requires. It requires genuine self-reflection. It requires a commitment to continued education. And perhaps most challenging of all, it requires a willingness to question the very foundations of how you've been trained to think about female athlete care. Some of what you learned in your training may have been incomplete or even incorrect when it comes to female athletes.

Move From Silos to Integration

The first thing we need to understand is that brain health cannot be treated as a specialty concern that only the psychologist worries about. It's foundational to every single aspect of care. The physical therapist, the physician, the psychologist, the dietitian, the coach—all of these professionals need to be in regular communication with each other.

When one member of the team sees a red flag, everyone else needs to know about it. This means you need to create systems within your clinic or organization that prioritize information sharing and truly collaborative care. So let me ask you directly: Does your clinic currently have a protocol for this kind of integration? If the honest answer is no, then building that protocol needs to be your first task.

Ask Better Questions—Every Single Time

I want you to think about a typical assessment. Most of us ask "How's the knee?" or "How's that hamstring feeling?" These are important questions, but they're not enough. You need to add questions that take about sixty seconds to ask but reveal information that standard physical assessments will miss entirely.

Start asking every female athlete these questions at every check-in: "How has your sleep been this week?" "Are you getting your period regularly, and what does your cycle look like?" "How's your energy level at different times of the month?" "On a scale of one to ten, how would you rate your mental focus during practice compared to during competition?"

Now, I understand that asking about menstrual cycles might feel uncomfortable, especially if you haven't been trained to have these conversations. But here's the hard truth: if you're not asking about menstrual cycles, you're not getting the full picture of your female athlete's health. If bringing up this topic feels uncomfortable to you, I'd encourage you to examine where that discomfort comes from. Your discomfort should not be allowed to stand between an athlete and the proper care she deserves.

Broaden Your Baseline

Baseline testing in most clinics stops at concussion protocols. That's a start, but it's nowhere near sufficient for comprehensive female athlete care. What you need to do is create a much more comprehensive picture of each athlete's individual "normal."

This means incorporating menstrual cycle tracking so you can understand how hormonal patterns impact that specific athlete's performance and wellbeing. It means using basic mood and energy logs that help you spot changes before they escalate into full crises. It means gathering sleep data to ensure that recovery is actually adequate. And it means including cognitive function assessments that take hormonal fluctuations into account rather than assuming cognitive function is stable across the month.

When you establish this kind of personalized baseline for each athlete, you create the ability to identify deviations early. You can intervene proactively, before the athlete reaches a point of crisis. This is fundamentally different from our current reactive model where we wait until something breaks before we try to fix it.

Educate Athletes, Coaches, and Parents

Knowledge really is power in this context. When athletes understand what's happening in their own bodies, they transform from passive recipients of care into active partners in maintaining their health. This shift is crucial for long-term success.

But education means we also need to fundamentally reframe the language we use. A missed period is not a badge of honor that shows how hard an athlete is training. It's a vital sign that something is wrong. Mood shifts aren't signs of weakness or character flaws. They're data that tell us something important about what's happening physiologically. Fatigue isn't always about "being soft" or lacking mental toughness. It's often biology asking clearly for rest.

Your job includes providing resources, hosting educational workshops, and actively challenging the toxic narratives about "toughness" that end up harming athletes. If you're not sure where to start with this kind of education, learning how to find a sport psychologist who specializes in working with female athletes can be an invaluable first step.

Reframe Recovery as Performance

We need to stop treating sleep, nutrition, and psychological rest as "time off" from training. These aren't breaks from the real work of athletics. They are active training for both the brain and the body. Recovery is when adaptation actually happens. It's when the body integrates the stress of training and emerges stronger.

This means you need to frame recovery as a non-negotiable part of any performance plan. Learning how to incorporate rest and recovery into training protocols doesn't hinder performance—it's what makes improved performance possible in the first place.

Building female athlete mental health into your protocols from day one rather than treating it as an add-on when problems emerge is essential. Your job isn't just to fix athletes after they break. Your job is to build athletes who are so in tune with their own systems that they can prevent the break from happening in the first place.

Stay Current—This Is Non-Negotiable

The research on female athlete brain health is evolving rapidly right now. What was considered standard practice five years ago may well be outdated today. What we thought we knew for certain is being revised as new studies emerge.

This means you need to commit to continuing education as an ongoing practice, not a one-time checkbox. Read the latest studies. Attend conferences that specifically focus on female athlete health. Most importantly, question your own assumptions regularly. If you're working with female athletes but haven't updated your knowledge base in the last two years, I need you to understand that you're working with incomplete information. Your athletes deserve better than that.

The New Standard of Care

The health of a female athlete's brain dictates the arc of her entire career. It determines her performance in the moment, yes, but it also shapes her longevity in the sport and her wellbeing long after her competitive career ends. That's why this work matters so much.

The work I'm describing isn't simple. It requires real effort and real change. But it's absolutely essential if we want to do right by the next generation of female athletes.

When we move beyond the outdated male-as-default model, we don't just become better clinicians in some abstract sense. We become better advocates for our athletes. We become guardians of not just their athletic potential, but of their fundamental humanity and wellbeing.

Three Questions Every Provider Must Answer

Let me leave you with three questions that I believe every healthcare provider who works with female athletes needs to answer honestly.

First: What if we treated a missed menstrual cycle with the same urgency as a torn ACL? Think about that for a moment. Both conditions signal that something is seriously wrong. Both have significant long-term consequences if they're ignored. Yet we routinely dismiss one as "no big deal" while treating the other as a medical emergency. Why is that?

Second: What uncomfortable truth does our field need to confront about how we've defined "mental toughness" in female athletes? Have we been using the phrase "mental toughness" as code for "ignore your body's warning signs"? Have we been actively praising athletes for harming themselves? These are hard questions, but we need to ask them.

Third: What if the most powerful performance enhancer available isn't a new technology or a novel training technique—what if it's simply the permission to rest? What would your practice actually look like if you truly prioritized brain health and recovery as essential performance tools rather than treating them as luxuries or afterthoughts?

Let's Start Today

To the physicians, physical therapists, athletic trainers, psychologists, dietitians, and coaches who are reading this: you are the frontline of female athlete care. You are the ones who have the power to change this trajectory.

The next generation of female athletes is counting on you to do better than we've done up to this point. They're counting on you to ask the hard questions that need asking. They're counting on you to challenge the broken systems we've inherited. They're counting on you to prioritize brain health not as an afterthought, but as the absolute foundation of comprehensive care.

This is your call to action. The question is: How will you answer it?

If you want to learn more about optimizing brain health for female athletes, explore how our individual sessions can help you align your clinical approach with current best practices in female athlete care.