Female Athlete Triad: What All Women Runners Need to Know

What Every Female Runner Needs to Know About Female Athlete Triad

Last year, back when this little blog had a mere fraction of the visitors it has now, I wrote about female athlete triad. Since it’s National Eating Disorders Awareness Week, I want to address this topic again, since honestly I feel it deserves a lot more discussion for female runners.

Female athlete triad is not an eating disorder, but it is oftentimes a consequence of disordered or restrictive eating.

Disclaimer: I am not a doctor. I am a certified running coach, but I can only discuss female athlete triad to a certain extent within my scope of practice. All of this information is based off of research, which is linked to the relevant source throughout this post for further reading. Individual metabolisms, hormonal levels, and chronic illnesses can all impact your menstrual cycle, bone density, and body weight as well, and thus do not make female athlete triad an one-size-fits-all diagnosis.

What Every Female Runner Needs to Know About Female Athlete Triad

What is female athlete triad?

Despite what many athletes believe, loss of your period for several cycles in a row (secondary amenorrhea) is not a normal side effect of training. According to the American College of Sports Medicine, exercise alone does not cause amenorrhea. Rather, a combination of factors that lead to a negative energy balance over an extended period of time cause amenorrhea.

Three symptoms indicate female athlete triad: low energy availability, menstrual dysfunction, and low bone mineral density (source).

Typically speaking (but not in all cases), female athlete triad is diagnosed off of low body weight, amenorrhea, and osteopenia (low bone density) or stress fractures.

Low body weight can often indicate low energy availability, but one runner can have her period at a low weight, while another loses it at a healthy but lean weight. Thus, disordered eating habits and low energy levels rather than body weight are better indicators of low energy availability.

Even if you’re not dieting or restricting your eating intentionally, some female runners struggle to fuel their bodies properly while running high volume.

While amenorrhea is the most common indication of menstrual dysfunction, it is not the only indication. Some women may experience suddenly irregular periods, miss one period from time to time, or experience changes in the severity of their PMS.

What are the risk of female athlete triad?

I know that skipping periods sounds awesome, but amenorrhea bears serious health consequences. In addition to infertility, amenorrhea occurs when your body is not producing enough estrogen or progesterone. Since running can reduce your estrogen levels, this is something all female runners need to be aware of.

Estrogen plays a vital role in bone health. Studies find that amenorrheic runners have significantly lower bone density than female runners who get their periods. Without enough estrogen and energy to support a regular period, these women also lack the estrogen necessary for bone maintenance. The more periods you skip, the more your bone health declines, sometimes to an irreversible point. And, of course, as your bone health declines, your risk of stress fractures increases. 

How do I prevent female athlete triad?

Sadly, as this article from Runner’s Connect states, up to 60% of female athletes will experience athletic amenorrhea, which can be a precursor or indicator of female athlete triad. So how do you prevent it?

First off, track your period. Note its duration, its frequency, the severity of your PMS, and any changes in your cycle. You can also record certain signs during the other weeks of your cycle to track ovulation, which will further help you note an irregularities in your cycle. There are several resources available online and in phone apps to help you track your cycle.

Second off, make sure you are eating enough. I’m not a proponent of counting calories, but for some female runners, this practice ensures that they are actually eating enough to balance the calories burnt in running, strength training, cross training, and daily life. Most of all, listen to your hunger and do not restrict your eating.

Finally, take preventative measures to prevent osteopenia. Make sure you are consuming the proper nutrients in addition to eating enough. Calcium, vitamin D, vitamin B12, and iron are all vital nutrients for healthy bones and healthy menstruation. Strength training also promotes a healthy bone density, so include a few weight lifting exercises in your routine as well.

But what if I’m on the pill?

Sadly, there’s not a lot of clinical research available on the impact of the pill on female athlete triad.

Lots of women take the pill to control painful periods (studies are finding that periods can be “almost as painful as a heart attack,” according to this article from Quartz) or to manage hormonal disorders. However, as someone like myself who suffered from secondary amenorrhea due to PCOS or endometriosis can tell you, the pill can make you have a period when your body would not have one on its own.

By that logic (and someone please correct if I’m wrong), the pill can mask amenorrhea in female runners. You still get your monthly period even if your body has stopped ovulating. Women who take the pill continuously face the same problem, as they cannot use their period to gauge whether they are at risk for amenorrhea and female athlete triad.

So what if you’re on the pill? You should discuss this with your doctor and make sure you are eating enough and eating the right nutrients for bone health.

Fully honest disclosure here: I have been diagnosed with PCOS-like symptoms and have also experienced endometriosis-like symptoms (neither can be fully diagnosed without surgery), and my medication keeps me from getting a period. Even if I was not on medication, my period would be too irregular to use as a gauge for female athlete triad, so I make sure I consume enough calories, healthy fats, and nutrients such as calcium and vitamin D.

To put it bluntly, I’d rather be a few pounds heavier (still at a very healthy weight, so we’re talking vanity/racing weight here) than be distance runner waif thin and worry (even more) about osteopenia and stress fractures.

Of course, what works for me may not work for you, so please take the advice of your medical professionals over me when it comes to serious issues like your period, medication, and hormonal disorders.

Treatment of female athlete triad

If you suffer from the symptoms of female athlete triad, please speak to your doctor, OB/GYN, nutritionist, and/or running coach. A break from running will not simply reverse female athlete triad, as it requires addressing your nutrition, training, and overall health. Some runners can recover quickly, while others require more intensive treatment.

Meredith at The Cookie ChRUNicles is talking more today about amenorrhea, female athlete triad, and running, so be sure to check out her post!

I don’t want to ask any pressing questions today due to the sensitive nature of this topic, but I do want to encourage a judgment-free and honest discussion of running and periods in today’s comments.

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20 Responses

  1. Glad you shared this info, as it is so important! I think I was at the most risk for these kinds of issues when I first starting running/working out regularly because it was also around the time when everyone was all about fat-free foods and avoiding fat at all costs. I also didn’t understand the importance of rest days because I was so proud of myself for working out at all, I figured more had to be better. Unfortunately I was on the pill at the time, so I wouldn’t know if I lost my period. Luckily there were no stress fractures or other serious medical issues that I know of, and now I feel like I have found a good balance with my eating and exercise, and my cycle is pretty regular on it’s own. My weight definitely fluctuates depending on if I am training or not, but I’ve come to accept that and realize it’s better to have a few extra pounds than risk all the issues that go along with being underweight.

    1. Thank you! That fat free mentality that so many of us grew up with is so hard to shake, when fat is such a vital nutrient especially for female endurance athletes. I think the weight fluctuation from training to not is good actually – I do the same and it means our bodies are recovering from the intensity and volume of hard training and that racing weight isn’t a fixated number.

  2. thanks for sharing my post!i take this topic so seriously and hope we can help others to understand how serious it is! Many doctors aren’t aware of it, or at the very least, do not jump to think of it when patients come in. we need to know things for ourselves and know our own bodies.

    1. Doctors aren’t! While I think it is important to test for underlying hormonal issues like pcos and endo, doctors need to ask the important questions also and do bone density scans. I feel like sometimes when I go to the doctor they already have in mind what they think it is and begin to diagnosis before I finish talking. I had one GI doctor want to test me for Crohn’s but not for lactose sensitivity, even as I told her that my main problem was drinking milk/eating some cheeses! Needless to say I stopped going to that doctor.

  3. Such an important topic. Female Athlete Triad is a sensitive topic for me because on the surface, I totally qualify: stress fractures, amenorrhea, endurance runner, etc. But I have so many extenuating circumstances. As I try to take the best care of my body that I can, I have to keep an eye on myself, have to be concerned with all of the same issues, but I have to go about it in such a different way because of my chronic illness, the symptoms and side effects of which mimic FAT. I hope that makes sense!

    1. It is SO much more complicated when a chronic illness with autoimmune and inherent hormonal issues comes into play. In my (completely unprofessional) opinion, that’s why we have to know our bodies and look for other symptoms, like how Crohn’s has other telltale symptoms for you. But it’s when the runner doesn’t have a chronic illness or fertility disorder (or those symptoms) that amenorrhea is a significant sign. For those of us with fertility disorders and chronic illnesses, so much then comes down to taking extra care of our bones and overall health, since we don’t have a period to help us know.

  4. It’s so funny since I’m on my lady time right now I was like ughhh the last thing I want to hear about is periods, BUT this is so important and so prevalent! What I liked the most about this article is that you were in no way lecturing or targeting women who do face the triad and I think that’s so important. I’ve run since kindergarten so of course I’ve had seasons of a finicky period, but luckily I’ve always maintained healthy bone density and body image. I just think it’s so important that we provide girls with the facts and then encourage and support them to take care of themselves not coming from a place of judgement and I think you did a great job with that

    1. Thank you! I just believe that lecturing and judging never is as effective in helping as information and compassion, you know? I definitely think girls need to know more about the impact of nutrition, weight, and running on bone density when they’re young. So many think that a low body weight doesn’t have consequences like that – I don’t think I learned about it until my senior year of college when I’d already been running for years.

  5. You know me and my high mileage, right? Well for some reason, I have never missed a period (except when I was pregnant, of course). I read Meredith’s article a while back and she talks a lot about the importance of fat in our diets and I think personally, and this is just a hunch, that I eat a lot of fat and I think this is what makes a difference for me! Fat keeps me healthy.

    1. Fats are so important for female runners! Plus fats are delicious, you know? Just like I said in the post, it’s not exercise alone – it’s energy balance, and high volume runners can balance their energy well while low volume runnners can hit negative, or vice versa. That’s why no one can say how much female runners should and shouldn’t run (unlike that one guy in my coaching class who wanted an exact number for where to cut off the mileage of his female athletes, grrr).

  6. that is seriously terrifying about the pill possibly masking this. i don’t think i am at risk – i am at a healthy (if not over) weight and i am not a hardcore runner. but still, scary. when i was younger and not very healthy, i missed a couple of periods and thats actually what scared me enough to tell my mum who took me to the doctor. but anyway. this was very informative, thanks for sharing!

    1. It is scary, but it is also very preventable with a balanced diet (which includes fats and treats!), listening to your body, and not restricting or overexercising. While I’m not a doctor, your body will also give you signs such as fatigue and, if worse comes to worse, stress fractures if this is happening. Periods can be lost for other reasons as well – that’s why female athlete triad has other telltale signs in addition to just amenorrhea.

  7. Great post and such an important topic, Laura! You are correct in that the pill can mask amenorrhea and sadly, many women go to the doctor after losing their period only to be put on the pill by their doctor as the ‘fix’ to the issue without looking further into why they lost it. I see this a lot and would never recommend a female athlete client go on the pill for this reason. Osteopenia is a precursor to osteoporosis so aside from the fertility issues amenorrhea can cause, this is also a great concern. Speaking on this topic and getting correct information out there is so important so thanks for sharing!

    1. Thanks Angie! I’m glad that I was providing good information. Doctors do seem to use the pill a lot as a fix – I know for my lean PCOS/possible endometriosis diagnosis, the pill is the go-to “treatment” unless I wanted some really nasty medicine with more side effects that may not even work for my symptoms (ugh), but really what concerns me is like what you said, that doctors just slap women on it and then osteopenia and disordered eating just progress. It’s scary to think about women our age have bone problems!

  8. I am curious if you have any insight on the effect of IUDs on the Female Athlete Triad. I am not overly concerned at this point that I am showing signs of it, but I have had an IUD for just shy of 3 years and have not had a period for a bit over 3 1/2 years, so my period is not a good indicator. Mind you, I have been eating 2000+ calories per day while training and take tons of vitamins and minerals including probiotics, calcium, D3, B complex, glucosamine/chondroitin/msm, magnesium/potassium, and a multi-vitamin with iron… and I don’t particularly feel I have to be concerned over it. But I wonder if you might have an idea how it would impact how you would gauge Female Athlete Triad.

    1. Hi Cati! Thanks for commenting. I am not a medical professional and so I do not know anything about the effects of IUDs on female athlete triad directly and recommend you speak with a medical professional. For some runners, 2000 calories is sufficient, but your training volume does impact that significantly so it may be beneficial to contact a certified sports nutritionist if you are concerned. Eating enough healthy fats will help – a study from the University of Buffalo found that women who eat 20-30% of their calories from healthy fats were least at risk for injury and overtraining. Otherwise, without a period the best way to gauge is body fat percentage (since too low can indicate low energy availability/risks of FAT), energy levels throughout the day and during workouts, and any injuries – stress fractures can be a key indicator of FAT. If you are worried I really do recommend talking to a doctor or registered dietician. I hope this helps!

  9. Thank you so much for this article! I’m 19 and have recently stopped getting my period (I have missed two cycles in a row), and I came across this article while browsing the internet trying to figure out just what was happening with my body. I’m currently a little unsure of how to go about regaining my period- I like to mix runs with other cardio and some strength training, and I am hesitant to change my training schedule because of how much I love the one I am currently on! I am also hesitant to increase my calorie intake because I don’t currently feel like I’m restricting- I eat when I am hungry, and I eat healthy food. I have also struggled with body image in the past, and feel like I have recently come to love how my body looks, although I am definitely not the waify physique that many seem to aim for. Although I recognize that health should come before concerns about looks, the idea of putting on a little weight to regain my period still stresses me out.

    1. Hi Charlotte, Thank you for reading! I highly recommend that you visit a gynecologist to make sure that you didn’t lose your period because of any health or hormonal related issues – that can account for unexplained loss of period. If it was due to running and eating, seeing a doctor is important to have your bone density checked. That way you’re not changing your diet and exercise unnecessarily, or if you are suffering from female athlete triad, they can help you figure out how to adjust your diet appropriately and set you up with a nutritionist. Good luck!

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