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The Female Athlete Triad

29 Comments

As a dietitian, I’ve worked with a variety of individuals (ranging from those with eating disorders to  neurological conditions) improve their health through nutrition and other lifestyle modifications.  Often times when I meet with clients, the desired goal is weight loss, but when it comes to women that can come at a cost.

Whenever we talk about weight loss everyone has theories on what constitutes the “best” program.  For some people, that means doing a very low carbohydrate/ketogenic approach, for others that means focusing on that “old school” calories in vs calories out equation.  Whatever the method you use to get there, there is one thing we all need to consider.  Women are fragile.

Now, before you start attacking that statement and showing me how many 200 lb snatches you can do, let me rephrase that statement.  Women’s hormones are fragile.  For this very reason I am extremely prudent when working with women who want to tinker with intermittent fasting, frequent metabolic conditioning greater than 20 minutes, very low carbohydrate diets, or other stressful lifestyle “hacks,” as some call it.

There has been some discussion about this in the community and for that I am very grateful.  Just as we talk about certain foods or diets not fitting into a one-size-fits-all model, we absolutely need to take into consideration the differences between the female and male anatomy when it comes to handling stressors.

Women’s health is my passion.  I am dedicated to having women understand how their bodies work and empowering them to take actions that help support their beautiful temple.  With that being said, I’d love to introduce a topic to this community that hasn’t really been discussed.

Enter: The Female Athlete Triad.

 

 

So what IS the Female Athlete Triad?

The word triad signifies three, so it makes sense that this syndrome would include three different interrelated conditions.  These three problems include:

  • Low energy availability/intake – this is with or without an eating disorder
  • Menstrual disturbances – amenorrhea or irregular cycles
  • Bone loss – osteoporosis/osteopeniaTriad

*Please check out Figure 1 from the position paper by ACSM for a fantastic model showing the progression of the triad here.

As I mentioned before, these conditions are interrelated.  If a female athlete is experiencing one of the conditions of the triad, the others should also be considered.

An example of how these conditions flow together is as follows:

Scenario:

A female athlete is trying to maintain her lean body composition and struggles with an eating disorder.  She is not consuming adequate calories to meet the requirements of her sport and due to this calorie deficit she starts to lose her cycle.  She may go a few months, or even years, without having a period.  The stress from the low energy intake starts reprioritizing which hormones she makes and her sex hormones get the back seat.  She is now looking at a low estrogen state, even having a sex hormone panel similar to a post-menopausal woman. Since estrogen is important factor in bone health, the lack of estrogen prompts bone loss. One day during practice, she ends up fracturing her foot even though there was minimal impact to the area.

 

Who is at risk?

Any female is susceptible to the triad, but it is commonly seen in female athletes whose sports emphasize low body weight or leanness – think gymnasts, ballerinas, or endurance runners.  The female doesn’t have to be an athlete nor do they need to be in a sport that emphasizes leanness.  It could simply just be a woman who is  restricting her calorie intake.

**As a side note: while it is not technically called the Female Athlete Triad for guys, energy deficits can also lead to problems with bone health and hormone disturbances for men too.  Low testosterone anyone?  It doesn’t matter who you are or what sport you play, there has to be balance.  Too few calories and too much exercise is a recipe for hormonal havoc.

 

Problems associated with the triad

 

Low nutrient intake:

When we’re looking at a low energy intake, we also need to think of a likely low micronutrient (vitamin/mineral) intake.   The female is probably not getting adequate building blocks for proper bone formation in addition to having low estrogen.

Do you think having a low bone density is a problem for a female athlete?  Most definitely.  Think about sports where the body is constantly “pounding the pavement” or participating in high impact sports.  You’re just “cruisin’ for a bruisin’” if your bones are weak.  And what about the fact that during your reproductive years your bones are building their potential?  You’re putting the breaks on a very important time for peak bone density.

In fact, sometimes women have no idea that they are experiencing the female athlete triad until they present to the doctor with a broken bone.  It sounds crazy, but even signs and symptoms, such as a lack of a monthly period, become second thoughts to these women.  Sometimes they are even happy about not having to DEAL with a monthly cycle.  This is not okay.  Women are supposed to have monthly cycles during their reproductive years.

 

Fertility is a sign of health – whether or not you want to get pregnant.

 

Mood disorders:

Depression and anxiety are commonly seen amongst women dealing with disordered eating.  Females may have low self-esteem which leads to disordered eating or compulsive over exercise.  They may also be lacking adequate fat intake to support proper hormone levels and to kick the depressive symptoms.

Other problems:

Complications such as electrolyte disturbances, anemia, hypotension, and abnormal heart rhythm should also be reviewed amongst women who have disordered eating behaviors.

 

What does an athlete do to recover?

Recovery is not something that will happen overnight.  Unfortunately there is no 30-day solution to this problem.  A female’s body that has been suffering from the triad has been beaten down for months, if not years, at a time.  It’s going to take some time and patience to re-regulate the system.  Depending on how long it has been going on, the age of the female, and how severe, some of the bone loss may not be reversible, but it can definitely be improved from this point on.  There are also metabolic and hormonal abnormalities that may impair health and fertility in these females that take time to bounce back.

 

Women should not try to be their own doctor.  It takes a team approach.  While the athlete may not technically have an eating disorder, they may have a hard time throwing back extra calories.  A treatment team should consist of a physician, dietitian/nutritionist, and athletic trainer, and a mental health provider.

 

  • The dietitian or nutritionist should help the female understand her calorie needs and find ways to gently introduce more calories into the diet.  According to the position statement by the American College of Sports Medicine, most effects appear to occur below an energy availability of 30 kcal/kg of fat-free mass per day.

 

  • The trainer needs to figure out a plan that would be safe and restorative.  They may also consider reducing exercise energy expenditure.

 

  • The mental health provider will be able to help discuss what happened to get the athlete to that point and break down roadblocks for advancing through the healing stages.

 

  • The physician should look at the female’s menstrual abnormalities as well as conduct a DEXA scan to understand their current bone status, among other treatments.  The loss of period may be due to PCOS, pregnancy, a pituitary-secreting tumor, or anatomical defects.  Bone loss could also be due to other factors.  Regardless of whether or not bone loss and amenorrhea are due to the triad, it is important to correct and treat these symptoms.

 

If you think you are currently dealing with the female athlete triad, know someone who is, or are a trainer working with female athletes, please check out the resources below and work with someone who can help support the female athlete before the symptoms progress.

I will explore more areas of the female athlete triad in future posts, but I first wanted to present a quick introduction to the topic.  If this is of interest, please stay tuned for more information!

Be patient, be informed, and be willing to move forward with where you are at.  It’s never too late to heal.

 

 

 

 

Resources:

http://europepmc.org/abstract/MED/9140913/reload=2;jsessionid=PuKl3QDUGn3Fer7k2UMA.6

http://www.aafp.org/afp/2009/0315/p489.html

http://journals.lww.com/acsm-msse/Fulltext/2007/10000/The_Female_Athlete_Triad.26.aspx

http://www.femaleathletetriad.org/for-athletes-coaches/what-is-the-triad/

Photo credit:By Faeryan (Flickr) [CC-BY-2.0 (http://creativecommons.org/licenses/by/2.0)], via Wikimedia Commons

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  1. Katie
    June 20, 2013 at 9:29 am

    Thanks for this, I was recently thinking of trying out intermittent fasting. Tried it a few times and felt AWFUL. I know there are some women who say that it works amazingly well for them but I think articles like this make the online rhetoric more balanced.

    • Stephanie
      June 20, 2013 at 9:58 am

      Thanks for the comment, Katie. What works for some, doesn’t work for others. However, from my understanding and experience, intermittent fasting is not something I would recommend for most women.

  2. erik
    June 20, 2013 at 1:39 pm

    Good article, However I would add that it’s not just women that are dealing with all these types of hormonal issues, I think that it is easier to diagnose a woman with hormonal issues due to the cessation of periods and weight loss(particularly Lean body mass) I see all the time men who overtrain, overwork, undersleep and eat crap and end up with reduced testosterone, insulin resistance, and various eating pathologies. As a man who has experienced many of the above symptoms I can say with certainty that these issues exist equally among men and woman. Overall I believe it is a problem of lifestyle, and not just that of female athletes. Just my two cents.
    e

    • Stephanie
      June 20, 2013 at 2:29 pm

      Erik – absolutely! I made a slight note of this in my blog, but I agree that overtraining, stress, and lack of sleep lead to negative health impacts for men as well. My primary focus is women’s health, but we can all agree that a balanced lifestyle is a requirement for all.

  3. Barb
    June 20, 2013 at 10:39 pm

    Hi Stephanie,

    Wonderful article… please do more on the topic. I have struggled with excess weight since childhood. About 10 years ago, I got down to a healthy weight, and then between 5 and 8 years ago, I did a really stupid thing… I dieted down and competed in a a few bodybuilding shows. The diet and training were beyond insane, and the cessation of periods, diminishing energy and awful moods were almost considered in the bodybuilding clique to be some sort of demented “badge of honour”, and a sign that your diet and training were ‘working’.

    I suspect that my lifelong battles with weight were likely a sign that I was metabolically misfiring for many years, and doing this to myself seemed to be the kiss of metabolic death. Now, I am unable to achieve a healthy body weight, regardless of diet method (ketogenic, low carb, moderate carb, high carb), or exercise modality (weight training, LISS cardio, HIIT cardio, sitting on my arse or a combination).

    The most frustrating thing is that all of my tests reveal normal hormones, insulin, etc. Everything (and I have had every test imaginable) is perfectly normal. But, what is happening with me is not normal. Some people think that if you go a little too far and start developing problems, all you have to do is take some time off from the gym and resume eating more calories and everything will just correct itself. For me, it never did. It feels like a switch is stuck somewhere, and I can’t find it.

    I hope that anyone out there who is overtraining and over dieting seriously takes your good advice to heart.

    • Stephanie
      June 21, 2013 at 7:38 am

      Thanks for sharing your story, Barb. Have you worked with an endocrinologist or integrative practitioner to look at your levels of neurotransmitters and other key players in your health puzzle?

  4. Amy B.
    June 21, 2013 at 6:11 am

    Sean Croxton did a great show on the female athlete triad on his Underground Wellness podcast a while back. The doctor he had on was very knowledgeable about the nutritional aspects, the hormones, and the long-term destructive effects. (She talked a lot about the lack of estrogen and bone density, etc.)

    It was a great show.
    http://undergroundwellness.com/podcasts/female-athlete-triad-syndrome/

  5. Nitasha
    June 21, 2013 at 6:41 am

    This sounds like my biography a couple of years ago. I was at a bmi of 18.7 and trained 5 hours a week with tons of intense running and not many calories and didn’t menstruate for 2 years and just recently started menstruating without the help of birth control pills or progesterone pills. When I asked my physician if it was athletic amenorrhea, he said that my high testosterone levels were to blame and that it was unrelated to exercise and that I just have PCOS.

    Do women who experience the effects of the female athlete triad sometimes have high testosterone vs just having low estrogen levels?

    • Stephanie
      June 21, 2013 at 8:02 am

      Thanks for the comment, Nitasha. Testosterone levels can really go either way in the triad. Hormones function together and dysfunction together, so it would be common to see low testosterone levels in these women. However, in some studies oligomenorrheic athletes have shown greater diurnal testosterone levels, along with PCOS, which suggests essential hyperandrogenism as a secondary mechanism of menstrual dysfunction.

      Study: doi: 10.1007/s11932-007-0059-y

  6. Noemi Bostrom
    June 21, 2013 at 10:09 am

    This is very informative. This triad is really scary for us women especially athletes. When I get depressed, I tend to eat a lot of unhealthy food.

  7. Brenna
    June 21, 2013 at 1:30 pm

    Great Post. This is something more coaches and athletic trainers need to know about. As a xc and track runner, I developed 4-5 tibial stress fractures starting in 8th grade and finally stopped them when I was put on BC in 11th grade. I wasn’t actively trying to restrict my diet, I just thought my hummus sandwiches, lowfat yogurt, and carrot sticks were a healthy diet… Instead of bandaiding me with hormones (didn’t get my period until 16, when I couldn’t run from yet again another fracture), I wish my doctors/coaches/trainers would have sent me to a nutritionist or simply told me to eat more! I’m sure that would have almost solved my problems. Maybe even made me a better runner. Of course this was late 1990s and early 2000s so I don’t think the issue has truly come to light until the last 5-7 years.

  8. Deb Roby
    June 22, 2013 at 7:45 am

    Stephanie,

    Thank you for this post. I’m working on getting a good team in place to help me with my challenges: low energy level -I KNOW I don’t consume enough calories but can’t seem to eat more; metabolic syndrome (high cholesterol, blood pressure and blood sugar)!

    Add to that the post-meno 30# fat gain and I’m in a place I so don’t understand. (and most of the internet doesn’t either!)

  9. Jen
    June 23, 2013 at 5:06 pm

    Thanks for this. I’ve recently been told that I’m suffering from this following a tibial stress fracture that has been recurring for the past two and a bit years and more than a year of abnormal periods (once I came off the pill which was masking it). The problem I’ve had is that the Doctors and Dietitians I have seen have all then tried to change my diet from Paleo back to the SAD diet – trying to incorporate large amounts of dairy, soy and grains. I struggle with how to address this whilst consuming a paleo diet, which is by far what I would prefer to eat. Thanks for the information though – very useful.

  10. Naturopath Melbourne
    June 28, 2013 at 6:40 am

    It is hard to compete properly if you have problems in your body.

  11. aniken5er
    July 22, 2013 at 11:24 am

    I wonder if this is contributing to my health problems. I’m 46 and have been a distance runner since age 14 and have a fracture across my SI joint that is healing very slowly. Lost 10 lbs after the fracture to current weight of 88 lbs. A dexa scan revealed osteopenia in my spine, and my periods have become very light and spaced at least 50 days apart since the weight loss. I also was iron deficient (ferritin=13) and had 2 iron infusions, which helped the fatigue tremendously. however, not sure of true path to recovery… I have 3 doctors, and none has ever mentioned this, and I haven’t been able to recover all of my pre-fracture weight. I substituted running with cycling since it doesn’t cause pain, or at least not much, and have been able to continue training at a high level but I am still concerned about protecting my bones and avoiding fractures in the future.

    • Christopher
      July 22, 2013 at 1:06 pm

      I would definitely look into that, and seriously question high level endurance training.

  12. Megan
    August 13, 2013 at 4:03 am

    This article is fantastic! I have been investigating a number of food intolerances in the last few months, but it was also brought to my attention that i have low energy levels, unstable blood sugar levels and hyperacidity. I exercise 4-5 times a week, and have noticed that my periods have been very intermittent (I believe my last cycle was a few months ago). I worry i may be experiencing conditions from triad, and that my body is under a lot of stress (with the dietary problems, as well as stress, anxiety, imbalances, etc). Any suggestions on how to best improve this? Thanks for the insight

  13. Sauna Chic
    October 11, 2013 at 3:51 pm

    Food intolerance’s can absolutely kill your ability to compete athletically. But so can overtraining. The over dieting makes it hard for the body to get what it needs. I hope everyone who is overtraining reads this article.

  14. Ellamaye
    April 24, 2014 at 5:13 pm

    So this sounds a bit like me…

    I workout just about everyday – ok, everyday (variety of dance, kickboxing, crosstraining, light weight lifting and am starting crossfit) and likely under eat, but since I am not losing weight I have been afraid to up my caloric intake. Not that I need to lose weight (I don’t weigh myself but I am 5’3″ and somewhere between 105 and 110lbs), but I don’t want to gain it either. I have not had a normal period in ages and have no sex hormones to speak of but somehow my panels come back as normal. Any suggestions on how to figure out whats going on? If I was truly not eating enough wouldn’t I be losing weight?

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