Extreme Exercise and Dieting Can Lead to The Female Athlete Triad

By: Anna Camille Moreno, DO NCMP • Marie Schaefer, MD • Posted on September 21, 2018

What is The Female Athlete Triad?

We are always encouraged to get involved in a physical activity - whether it is sports, exercise or fitness. It is a fundamental component of living a healthy, balanced lifestyle due to its positive effects on health, social and mental well-being.

Team sports, in particular, allow us to engage in physical activities that push us to strive for athletic excellence and improve personal performance. What some of us don’t know is that for many young females (and some males) playing sports or exercising too intensely can have major short and long term health consequences. They are at risk for a disorder called, the Female Athlete Triad, also now known as Relative Energy Deficiency in Sports (RED-S).

Triad Factor #1: Low Energy Availability (with or without disordered eating)

• Refers to burning more calories than one is taking in
• Athletes may intentionally calorie restrict, which can ultimately lead to eating disorders such as anorexia or bulimia
• May unintentionally have low energy availability by being unaware of the amount of calories needed to offset training

Triad Factor #2: Menstrual Dysfunction

• Exercising too intensely can suppress our body’s reproductive function and decrease hormones that help regulate the menstrual cycle
• Menstrual disorders related to the triad include:
  • Amenorrhea: absence of menstrual periods
  • Oligomenorrhea: more than 35 days between menstrual periods
• Symptoms can include vaginal dryness, infertility and decreased bone mass

Triad Factor #3: Low Bone Mineral Density

• Low energy availability, poor nutrition, and low estrogen levels compromise bone health and density leading to bone disorders such as osteopenia and osteoporosis
  • Osteoporosis is a condition that thins and weakens bones which can cause stress fractures and other injuries

Who gets Female Athlete Triad?

Any female athlete! Especially those who participate in highly competitive sports that emphasize a thin appearance and leanness, such as track, cross country, figure skating, ballet, gymnastics and cheerleading. Adolescents and young adults are particularly at risk.

Pay close attention to those with certain personality factors and behaviors such as perfectionism, obsessiveness, anxiety, over-training and frequent weight cycling.

What are the signs of Female Athlete Triad?

1. Signs of dietary restriction such as recent weight loss
2. Low body mass index (BMI)
3. Delayed menarche (first menstrual cycle) after age 16
4. Amenorrhea or oligomenorrhea (menstrual disorders)
5. Bone stress reactions, “shin splints,” or fractures
6. Orthostatic hypotension (fainting)
7. Slow healing of any musculoskeletal injury
8. Signs of eating disorders (restrictive, purging, binging)
9. Anxiety, depression, or compulsive behavior

Your period is a good way to monitor if you have appropriate energy availability. It is NOT normal to lose your period or for it to become lighter or farther apart when you are training, exercising or competing. All athletes and fitness aficionados should track their period regularly to help ensure appropriate energy availability.

Treatment Requires a Team of Essential Players

Early intervention is essential and requires a multidisciplinary team, including parents, coaches, athletic trainers, sports medicine doctors, nutritionists, dietitians, psychologists, exercise physiologists, and adolescent and women’s health providers.

• Once an athlete is suspected of having components of the Triad, she needs to stop competing and training in her sport immediately.

• The primary goal is to restore body weight and increase energy availability by modifying the diet and adjusting exercise behavior. This will improve bone mineral density and normalize menstrual and reproductive function:
• Optimal energy availability is > or = 45 kcal/kg/day
• Calcium intake of at least 1000-1200 mg/day
• Vitamin D3 of at least 1000-2000 IU daily

For patients with other conditions including anxiety, depression, bulimia nervosa, and obsessive-compulsive disorder, primary care providers can refer to mental health professionals or prescribe medications such as antidepressant and anti-anxiety medications.

Be Strong. Be Healthy. Be in Charge!
-Anna Camille Moreno, DO NCMP
-Marie Schaefer, MD