Female Athlete Triad

Female Athletic Triad

The Female Athlete Triad (Triad) refers to three health problems that are linked to each other:  Low energy availability or energy deficiency ("under-fueling"), menstrual problems, and weak bones.  Menstrual problems include irregular or missed periods.  Bone problems can include stress fractures and reduced bone density for your age. These health problems, especially when they occur at the same time, require prompt medical attention.  Having just one part of the Triad is enough, however, for any girl or woman who wants to stay active to seek help.  Luckily, the key to avoiding menstrual problems and building strong bones is simple -- eat enough calories to fuel your body during exercise and at rest.

The Female Athlete Triad

Participation in sports is highly encouraged for girls – involvement in these organized activities has been proven to help improve girls’ social lives and prevent teen pregnancies. And exercise has been shown to boost mood and decrease depression in women.

But with increasing pressure in today’s society to be extremely thin, some females take involvement in athletics or exercise too far. Fear of becoming overweight or out of shape can lead to the “Female Athlete Triad,” a condition that can lead to bone loss, stoppage of menstrual periods, and eating disorders.

Girls who participate in sports that emphasize thinness, such swimming or gymnastics, are especially at risk. Parents and coaches should not encourage weight loss, and should monitor young athletes’ eating habits to ensure they are not skipping meals or eating very little.

Any woman who may be experiencing the Triad should seek advice from a qualified sports medicine or exercise science professional, counselor, or dietician.

Signs & Symptoms

•Irregular or absent menstrual cycles
•Always feeling tired and fatigued
•Problems sleeping
•Stress fractures and frequent or recurrent injuries
•Often restricting food intake
•Constantly striving to be thin
•Eating less than needed in an effort to improve performance or physical appearance
•Cold hands and feet

Less Common Symptoms

•    Depression:  Being underweight or malnourished can cause physiological changes that can affect mood.  Symptoms of depression include feelings of sadness, irritability or anger, loss of interest in activities that were once enjoyable, difficulty sleeping, fatigue, poor concentration, and sometimes even thoughts that the sufferer would be better off dead.  
•    Anxiety:  Athletes who develop disordered eating may have significant anxiety or worry about their athletic performance, body weight or shape, and other areas of their lives, including school performance and relationships.  Research shows that there is a correlation between restrictive eating disorders, e.g., anorexia nervosa, and perfectionism. Perfectionism is a personality trait in which people place emphasis on precision and organization, the striving for unrealistic personal standards, and self-criticism if these standards are not met. Perfectionists often suffer from anxiety and worry about a number of things in their lives, including those things listed above.  Apart from perfectionism, other symptoms commonly seen in people with anxiety include difficulty sleeping, fatigue, poor concentration, irritability, physical restlessness, muscle tension, and physical symptoms such as headaches and stomach aches.    

Female Triad Scenarios

Question: One of our top athlete looks like she lost quite a bit of weight.  She’s not having any problems with the training but I think she might be having a problem with food.  She rarely eats at our team functions and I hear from some of her teammates that she skips school lunch. How should I approach this?
Answer:   Have a private meeting with the athlete and discuss your observations and concern for the athlete’s health.  Discuss how under-fueling (i.e., dieting) can lead to drops in performance, injury, and health problems such as irregular menstruation, anemia, and low bone density.   Ask the athlete what she typically eats on a training day.  Many athletes will report eating a “healthy diet” by avoiding “junk food”, soda, and drinking “lots of water” but do not know how much food/fuel their bodies need to support their training.  Sometimes this can result in eating very small portions or skipping meals because there is nothing “healthy to eat”.  This is a frequent excuse for avoiding school lunch or fast food meals.  Also, drinking water to excess can be a concern.  Excessive water intake can result in eating small portions causing low calorie intake, can mask hunger, or can cover up food avoidance.  Share a sample training day menu based on the athlete’s weight (MENU HERE) and point out areas for improvement.

MYTH: Runners are the only athletes who develop eating disorders.
FACT:  It is true that athletes in sports in which leanness is emphasized (e.g., cross country, track and field, gymnatics, figure skating, diving, swimming) are more likely to develop eating disorders.  However, we see athletes in any and all sports develop eating disorders.

MYTH: Boys never develop eating disorders. 
FACT:  Studies are showing that more and more boys are developing eating disorders too.  This often happens in sports such as wrestling, cross country, and track and field, but like females, it can happen in male athletes of any sport.

MYTH: If an athlete’s performance has not started suffering, then they must not have a problem.  
FACT:  Even if an athlete’s performance has not started to suffer yet, it eventually will.  Not taking in enough calories to match activity level is not sustainable in the long-run.

MYTH: It is normal for female athletes to stop menstruating. 
FACT:  It is never normal for a female athlete to stop menstruating, and it often means that she is not taking in enough calories to match her activity level.  There are serious health risks, especially bone loss, to not menstruating.  Research shows that after three years of not menstruating, bone loss is likely to be permanent.  Loss of future reproductive function could also occur.  Any athlete who has been without a menstrual period for three months should be referred to a physician for an evaluation.

MYTH: It is normal for female athletes to have changes in their menstrual patterns when exercising heavily. 
FACT:  It is NOT normal for athletes to stop menstruating or to have lighter menstruation or lighter flow, even during heavy training.  

MYTH:  If athletes are not losing weight, they are probably eating enough.
FACT:  Weight loss does not always happen when an athlete under-eats.  The body can compensate by slowing down metabolism.   Fifty percent of the time when an athlete restricts calories, menstrual cycle changes are the first symptoms to appear. Thus, discussions with athletes about the menstrual cycle are extremely important.  

MYTH: If an athlete who loses her period goes on the birth control pill to start menstruating, her bones will be protected.  
FACT:  An athlete is likely to start menstruating again by going on the birth control pill, but if she has not started eating more, then this is just treating the symptoms and not the underlying problem.  No medication, including birth control, has been shown to restore bone loss.  

MYTH: If an athlete is not eating enough to match activity level, she/he is aware of what they are doing.  
FACT:  Denial is powerful.  Athletes will very often feel that they are being as healthy as possible, and that meticulous attention to diet is a sign of dedication to sport.  Coaches, parents, and professionals will need to help the athlete see the problems with the behaviors.  It will probably take time, education, and convincing for the athlete to see there is a problem.

MYTH: An athlete who eats “healthy,” is a top performer on the team, and excels in class is unlikely to have an eating disorder.
FACT: Traits that are desirable in an athlete can make them more at risk of developing an eating disorder.  Mental toughness, pursuit of excellence, performance despite pain, commitment to training, and being a team player  are very similar to excessive exercise, perfectionism, denial of discomfort, asceticism, over-compliance, and  being self-less.   What looks like a “good athlete” may also be a person with a serious eating problem.

Question:  Last season we had several girls injured with stress fractures.  This year at our team meeting we talked about preventing stress fractures and how not having a period can be a warning sign.   Today one of my athletes told she has not had a period for a couple months.   In addition to suggesting she see her physician, is there anything else I can do?
Answer:  One of the risk factors for irregular periods is not eating enough calories to meet the demands of training. You can discuss with her what and how much she normally eats on a training day.  Key fueling times are the 3 meals and a pre/post workout snack.  Some athletes eat healthy, but not enough.  Share the sample training day menu posted on the WIAA website  (MENU HERE) for an example of what, when, and how much she needs to eat to fuel her training.

Question:  I am concerned about an athlete and would like to send her to a physician or dietician who is knowledgeable about the Triad.  However, I do not know of any providers in our area who have experience or expertise working in this area.  Is there anything else I can do?

Answer: It is possible that the professionals to whom you send your athlete might not be very knowledgeable about the Female Triad and thus could be dismissive of its symptoms.  To help them out, you can send this brochure along with your athlete to her appointment: www.femaleathletetriad.org/wp-content/uploads/2010/03/Final_Hoogenboom_Public_Flyer-10.pdf

Question: I am concerned about one of my athletes, who has lost quite a bit of weight and has stopped getting her period.  I sent her to a doctor, but the doctor was not concerned and said the athlete could continue competing.  Is there anything else I should do?
Answer:  Some professionals are not sufficiently educated about the Triad to fully understand the seriousness of its long-term consequences.  You should have your athlete see a different provider who is knowledgeable about the Triad. Types of professionals to whom you should consider sending your athlete include:  physicians (family medicine, internal medicine, pediatrics, sports medicine, or psychiatry), registered dieticians, psychologists or other therapists, school counselors, and athletic trainers.  Additionally, the coach is the one who determines the athlete’s workouts.  Thus, the coach can cut back on the amount of training the athlete does, even if she is officially ‘cleared’ to return to sport.

Question:  I am concerned about an athlete that I coach, but she and her parents refuse to get help.  How can I convince them, and what else should I do? 
Answer:  Talk about the potential negative consequences of the Triad with the athlete and her parents.  Explain that the athlete could develop life-long struggles with eating disorders and other mental health problems.  The sooner disordered eating is addressed, the more likely it is to permanently resolve.  Also, explain that irreversible bone loss and osteoporosis are more likely to occur the longer insufficient calorie intake goes on.  Additionally, you should insist that she see a professional prior to her continuing to participate on the team.

Further video examples of athletes who have struggled with the Triad are available on the International Olympic Committee website here: http://www.olympic.org/hbi.  Feel free to share these with your athletes and their parents.   

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Wisconsin Interscholastic
Athletic Association
5516 Vern Holmes Drive
Stevens Point, WI 54482-8833
Phone (715) 344-8580
Fax (715) 344-4241
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