Female Athlete Triad

Male readers, this isn’t a post that directly applies to you—although it may be worth passing on to your girlfriends/wives!

Today we’re going to talk about an issue that uniquely affects female athletes, especially female runners: female athlete triad. I feel like periods are still something that we are shy talking about, when in reality menstrual disorders affect an alarming number of women.

Female Athlete Triad 

Female athlete triad is characterized by three major symptoms: low body weight (often due not eating enough), secondary amenorrhea (the loss of your period for several months), and osteopenia (abnormally low bone density) or osteoporosis (weak and brittle bones due to low bone density and low bone mass). Female athlete triad is a chain reaction: low body weight leads to lower levels of estrogen, and without sufficient estrogen levels, our bodies cannot maintain healthy bone density or menstruation.

At first it’s tempting to be excited about not getting periods because, let’s face it, periods are uncomfortable, inconvenient, and (for some women including myself), downright disruptive of normal life because of the pain, nausea, and PMS.  Periods really stink during athletic training or, the worst, when you get your period right before a big race. However, losing your period is a sign that your body is not functioning properly. The physiological changes that accompany loss of period, most notably the drop in bone density, put you at a higher risk for injury, especially stress fractures. Low body weight and not getting enough calories can also put you at a higher risk of overtraining. Additionally, female athlete triad will lead to a decline in athletic performance due to your body being underfueled and hormonal imbalances.

As Brown University’s website on female athlete triad points out, the low body weight is not necessarily due to intentional undereating. Lots of medical professionals automatically associate female athlete triad with an eating disorder, but this is not always the case. Some female athletes, particularly those who participate in high intensity and endurance sports such as running, appear to eat plenty and don’t deprive themselves but are not supplying their bodies with all the calories and nutrients they need. Runners who run high mileage each week are especially susceptible to this, especially if high mileage is new to them and they are still learning how to fuel that much running.

That said, some runners do intentionally limit their eating to unhealthy extremes. There’s an idealization of being super thin in our society, and for runners (especially high school and collegiate runners), there is the notion that thin equals fast. While it is true that losing extra weight will make you faster, there is a definite point of diminishing returns once you are at a lean and healthy weight. At that point, thinner does not equal faster, it equals injury and health problems.

One of the problems, however, is detecting female athlete triad when you’re not already getting regular periods. You may be on the Pill or have a medical condition such as polycystic ovarian syndrome (PCOS), endometriosis, premature ovarian failure, or other hormonal problems that cause irregularities in your menstrual cycle. Whether you use the Pill for personal reasons or, as it seems for many women who use it, for medical reasons, you’re not actually getting periods, you’re just getting withdrawal symptoms when you take the placebo pills. This is especially true for women who suffered secondary amenorrhea before going on medication, since they weren’t ovulating and getting periods before going on the Pill and now aren’t ovulating while on the Pill. Furthermore, lack of ovulation from conditions such as PCOS or other ovulatory disorders can put you at further risk of low bone density.

So if you can’t use your period to monitor for symptoms of female athlete triad, how do you keep an eye out for female athlete triad? If you’re on the Pill, it may help prevent low bone density, but too much training and too low body weight could still negatively affect your bones. Having periods due to the Pill could even mask the other symptoms of female athlete triad, since the most obvious marker, amenorrhea, won’t be present.

 

Some doctors will prescribe the Pill, especially the same low-dosage ones as prescribed for PCOS, endometriosis, and other menstrual disorders, for women with female athlete triad. Some doctors believe that the Pill will prevent osteoporosis or osteopenia by regulating estrogen levels in the body, since low estrogen is a cause of low bone density. More recent studies, as cited by Brown University in their article, that the Pill does not protect the bones against osteoporosis. As with PCOS, endo, and others, the Pill only manages the symptoms of female athlete triad, rather than actually treat them.

Fortunately, female athlete triad can be easier to treat than other menstrual disorders, especially if you are aware of it and catch it early on. By gaining weight and increasing your body fat levels (gaining muscle won’t help), including healthy fats and good sources of calcium in your diet, and decreasing your training, you can get your estrogen levels back to a healthy place and re-strengthen your bones. Check out this helpful article from Janae Jacobs (Hungry Runner Girl) on how she overcame female athlete triad.

Even without loss of period and the detrimental effects of female athlete triad, female runners who do not eat enough calories or consume enough healthy fats are at higher risk of injury (see this University of Buffalo study). Read my recent article on Verily Magazine about the importance of eating enough healthy fats for more information on healthy fats and female athlete triad.

 

It’s important to realize also that losing your period when running is not just part of training. Statistics show up to 60% of female athletes experience some form of athletic or other amenorrhea. Yes, some women do lose their periods during high-volume training cycles but do not have female athlete triad, perhaps due to how their estrogen levels were before training. However, it’s better to consult your doctor than to just ignore loss of menstruation. Even if you don’t have female athlete triad, no periods could be the sign of another condition.

There are so many factors that go into female athlete triad and amenorrhea, and it’s important to remember that every single woman is different! A weight and training volume that is healthy for one woman may cause female athlete triad for another. Female athlete triad is not a reason to stop running; rather, it’s a reason to be sure to monitor your body and emphasize care for yourself, including good nutrition. And please: if you have any signs of amenorrhea, please see a doctor to find out if you have female athlete triad or another condition!

(Disclaimer: I am not a medical professional, nor have I had personal experience with female athlete triad.)

Question of the Day:
Since this is a sensitive topic, I don’t want to ask any prying questions, but please feel free to share anything on running, periods, and female athlete triad, or anything related. There’s no such thing as TMI amongst runners! 

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11 Responses

  1. You know, I don’t think I realized how prevalent it is until I started reading blogs. Now I see so much under eating going on out there and I just now the triad has to be hitting many of these girls. It’s sad!

    1. It is so sad! I saw it hit a lot of girls in high school and college, and even going to an all-girls school that talked a lot about eating disorders, we never learned about it!

  2. Great post, you’ve got really good info here! It’s sad that society glamorizes thinness and that females feel such pressure to achieve unrealistic goals. It’s also sad that runners feel an added pressure to lose weight in order to help them achieve running goals. I love the trend of strong and healthy females promoting unconventional body images!

    1. Thank you, Beth! I think one of the great things about the running blog trend is that there’s the example out there of healthy women who aren’t underweight and doing amazing thing in running.

  3. I lost my period for 2 years, and I went crazy. Now that I am in a firm recovery from my eating disorder, along with exercise restriction, I have it back! What worked for me was eating 3,000 calories and completely stopping exercise for 10 months. It was mentally extremely tough, however it was the best decision of my life. I now have it back and have slowly worked my way back into moderate exercise. I only gained the weight my body needed. Our bodies are very smart and a re good at protecting us. 🙂

  4. I have been running and playing sports pretty seriously since I was really young (soccer since I was 5, running since I was 11-12ish). When I was in high school I didn’t get my period until I was 16 (the average age is 12). My doctor said this was probably due to running and how active I was, but I never thought much about it. It’s interesting how LITTLE information there is on the subject!

    1. I agree, there isn’t much information given on the subject! Doctors never bring it up nor do health classes but it’s so vital for women of all ages to know about!

  5. Such an important post–and definitely something that we all need to keep in mind as we train and in general! Often we are doing way more harm to ourselves than we originally thought.

  6. This was a great informational blog. I didn’t realize that working out and playing sports could really hurt you if you don’t focus on taking care of your body!

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