Nearly all of us have heard of the Female Athlete Triad, and if you haven’t, I’ll give you the shortest possible synopsis of the problem.

Women athletes who train too much, eat too little, and carry too little body fat, stop menstruating, do not produce enough estrogen, and start to lose bone mass. As a result, women are often warned that if we get too lean, we’ll stop menstruating and lose bone. Heck, I wrote a giant paper in my undergraduate studies based on this topic.

I was interested in the issue mostly because I had very irregular periods and went through quite a few episodes of amenorrhea in my teens and twenties.

However, what was most perplexing to me was that all of the literature said that low body fat was to blame for the cessation of regular menstrual cycles. Well, while I wasn’t fat, I definitely wasn’t sporting a six-pack back in those days.

So, that made me wonder if I was just really that messed up in the head (i.e. I was far leaner than what I saw in the mirror) or was there more to this whole amenorrhea thing that simply being too lean?

Was I working out too much? And is it even possible to get super lean and still have a regular cycle? There seemed to be quite a few lean girls who didn’t have the issues I did with their periods. There had to be more to it than just body fat levels.

It turns out there may indeed be more to the story than simply being too lean. It’s not just the amount of fat mass that alters ovulation and your menstrual cycle.

In fact, hypothalamic amenorrhea, what we women athletes tend to develop when we stop having our cycles (and what basically means you aren’t having a cycle and nobody knows why), is a real mind-f*** for researchers and scientist. We just don’t have it all figured out yet.

But, what we do know is that absolute energy balance is actually much more important in the maintenance of regular hormone production, ovulation, and menstruation than body fat percentage.

In fact, it’s pretty easy to dissociate body fat levels and reproductive function, as normal cycles have been shown to “return in some female athletes when energy expenditure is reduced such as after an injury long before there is any change in body weight or an increase in body fate change in body weight recovery.”

So, if it’s not simply low body fat that causes amenorrhea, what is it? The answer seems to be complex and not fully understood, but I’m going to do my best to make this easy to understand.

Issue #1: Body Weight Not Body Fat

First, body weight seems to have a bigger impact on menstrual cycles than body fat. Falling below 85-90% of ideal body weight, no matter what body fat level, usually results in amenorrhea.

I think this has much to do with the issues I personally had as a younger woman. I wasn’t too lean; I was just trying to be too little. But remember, ideal body weight is going to vary quite a bit from woman to woman.

My set point is around 135lbs and if I drift below 125lbs I start noticing a lot of problems and irregularities with my cycle. For some women of the same height, 125lbs would be a perfectly health weight to maintain and their cycles would be fine. It’s all about your body and your ideal weight (health-wise, that is).

Issue #2: When Workouts Stop Working

How hard we are “working at our fitness” has quite a large part in determining how well our girl stuff is working. If we are working out in a healthy way and expend more energy than we are eating, we lose weight. This doesn’t cause menstrual issues for most women.

However, for the more type A, hard-hitting athletes who tend to take their diets and workouts to extremes, this lifestyle can definitely have an effect on menstrual cycles.

If we are pushing ourselves to the max with two-a-days, super long workouts, and crazy metcons, while also eating very little in an attempt to lose body fat, then we run into problems.

If the difference between intake and output is too great, it throws the body for a loop. This increases our production of cortisol and other stress hormones, which in turn decrease gonadotropin releasing hormone (GnRH) release from the hypothalamus.

This results in low levels of follicle stimulating hormone (FSH) and leutinizing hormone (LH), which in turn causes anovulation; low estrogen, testosterone, and progesterone levels; and – NO PERIOD.

Issue #3: Low Leptin Levels

Leptin levels also have an effect on menstruation. Leptin is a protein produced by adipose cells that acts as a hormone on the reproductive axis. It is also the hormone responsible for making you feel full or satiated.

Leptin is commonly thought to be positively correlated with body fat levels (i.e. leptin goes up as fat mass goes up), but lower leptin levels have been found in bulimics and anorexics who were exercising and/or had lower caloric intake than anorexics or bulimics of the same weight.

So, your level of leptin seems to not be specifically tied to body fat levels but on overall energy availability. And when leptin is low, so is GnRH and LH, and this makes ovulation and regular menstruation less likely.

Here is an illustration of the mechanisms in the menstrual cycle. You can see how GnRH, FSH, and LH are all essential in the initial (follicular) phase. So if they are low, things have to go haywire.

The Answer?

While there are many other hormones and outside factors that can cause menstrual irregularities in female athletes, I think it’s safe to say that it’s not simply body fat levels or workouts that make your cycle go crazy.

Amenorrhea in athletic women is more related to overall energy balance. If you’re having irregular cycles, you need to ask yourself:

• Are you are eating enough to support your activity level?
• Are you trying to lose body fat by ramping up your workouts and cutting way back on your caloric intake?

If you doing these things, you are basically shooting yourself in the foot and you can expect your periods to go bonkers.

Also, you should know that your metabolism, thyroid, growth hormone, and testosterone production will also slow to a standstill. Irregular cycles, stalled progress in the gym, and stagnant weight loss despite enormous efforts are your body’s cry for help and rest.

The answer is not to push through or to “suck it up.” The answer is to back off. That’s a really tough thing to do if you’re the type of person who expects a lot of herself. But, trust me, don’t waste months or even years fighting your body. It will win. It’s smarter than you.

The more slowly you lose body fat, the more muscle you carry and the closer you stay to your body’s ideal body weight, and the more moderate you are with changes to your calories, the more regular your cycles will be and the more happy, cooperative, and responsive your body will be to your training.

References:

1. Ackerman, K., et al, “Higher ghrelin and lower leptin secretion are associated with lower LH secretion in young amenorrheic athletes compared with eumenorrheic athletes and controls.” American Journal of Physiology – Endocrinology and MetabolismPublished 1 April 2012Vol. 302no. E800-E806 DOI: 10.1152/ajpendo.00598.2011

2. Comninos, A., et al, “The relationship between gut and adipose hormones, and reproduction.” Hum. Reprod. Update (2013) doi: 10.1093/humupd/dmt033

3. Davis, J, Segars, J, Glob. libr. women’s med., (ISSN: 1756-2228)2009; DOI 10.3843/GLOWM.10296

4.The ESHRE Capri Workshop Group, “Nutrition and Reproduction in Women.” Hum. Reprod. Update (May/June 2006) 12 (3): 193-207. doi: 10.1093/humupd/dmk003

Photos 1,2&4 courtesy of Shutterstock.

Menstruation chart by Npatchett [CC-BY-SA-3.0], via Wikimedia Commons

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Prevention

The first step in prevention the female athlete triad is educating athletes, coaches, trainers, and parents. Athletes should be educated about basic nutrition concepts, burn out and over training, rest and recovery, healthy weight management, energy levels, and bone health. Female athletes, regardless of sport, should have a solid understanding of the importance of a healthy menstrual cycle.

It is also recommended that females keep a record of their monthly period, and consult a physician if they have menstrual dysfunction. Athletes should be encourages to seek counseling and consultation from a nutritionist to formulate an appropriate nutrition plan that is specific to their sport and energy needs. Open communication between athletes and their coaches, trainers, parents and medical professionals should be always available if they sense a problem or need to ask a question.

Implications for Coaching

Coaches should advise athletes on basic nutrition concepts, emphasizing that nutrition is an essential element of sports training and performance. Coaches should focus on cultivating a positive body image and a holistic perspective on training, nutrition, rest, and recovery. The NCAA, recommends de-emphasizing weight loss as a factor in performance, and frequent weigh-ins or punitive consequences for weight gain are not recommended. Coaches, trainers, and teammates should avoid pressuring athletes to diet and lose weight quickly. Coaches should have referrals for athletes in need of additional care including; nutritionists, counselors, and medical personnel.

Athletes should be encouraged to seek consultation and treatment immediately, when any symptomology might be present to prevent further complications. The best time to educate and screen for triad related symptoms is during sports participation physicals and yearly wellness check ups. Parents, coaches, medicine professionals, and athletes should be aware that even moderate dieting or poor nutrition combined with any menstrual cycle changes can be early indicators of the spectrum of the triad.

• The Female Athlete Triad – Are You at Risk?
• The Female Athlete Triad: Screening and Treatment Strategies

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Screening and diagnosis of the female athlete triad can be challenging for coaches, athletes, and medical professionals due to the fact that not all aspects of the triad are apparent or fully developed. Diagnosis and screening for the Triad requires a complete understanding of each component as well as an understanding of the athlete in question. Research suggests that the optional screening times for female athletes could occur at any sports physical exam, annual gynecological exam, or annual wellness check with a family physician. If an athlete is identified as being at risk for the triad then a follow up consultation would be scheduled with a team of medical professionals. A detailed medical history, menstrual history, psychosocial history, psychiatric history, and athletic/exercise history would be taken and evaluated.

Tests and Assessments

Laboratory tests should be administrated and can include an assessment of electrolytes, full chemistry profile, complete blood count, erythrocyte sedimentation rate, C-reactive protein, thyroid functioning test, and urinalysis. Sometimes an electrocardiogram may be advised for evaluating any arrhythmias and other issues. Additional laboratory testing may be required based on an athlete’s medical history, and physical examination.

Bone Mineral Density Testing

If an athlete has had a history with repeat injuries, chronic pain, stress fractures, or broken bones, a bone mineral density test may be administered. This testing is usually performed using dual-energy X-ray absorptiometry.

Treatment Recommendations

Initially the treatment plan should focus on immediately implementing an appropriate nutritional plan, and modifying athletic training and exercise. A team approach is best for the treatment of this complex condition. This team can include family members, a family physician, gynecologist, athletic coach, nutritionist, and psychotherapist. Treatment of the Triad should be focused on examining and resolving all aspects of the of the spectrum.

Cognitive Therapy/Psychotherapy

Many times athletes are referred to sports psychologists or general therapists to treat the many of the underlying issues present in the spectrum. Cognitive therapy is a popular choice for teaching athletes to alter their thinking and behaviors by examining the results of their choices and actions.

Nutritional Counseling/Supplementation

Monitoring the nutrition of the athlete as well as adding any additional supplementary vitamins and minerals may be necessary. Calcium, Vitamin D, and Vitamin K can be recommended to augment the therapeutic plan.

Pharmaceutical Therapy

Oral contraceptives may be recommended to combat amenorrhea, irregular menstrual cycle and bone health.

Overwhelmingly the current research suggests, the best way to prevent the detrimental health effects of the Triad is through educating coaches, athletes, and parents about early screening of female athletes that might be at risk.

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The triad is defined by the American College of Sports Medicine as, “interrelationships among energy availability, menstrual function, and bone mineral density, which may have clinical manifestations including eating disorders, functional hypothalamic amenorrhea, and osteoporosis.”

Populations most at risk for the triad are usually females participating in sports where lower body weight is optimal, including running, weightlifting, biking, cross country, gymnastics, figure skating, ballet, diving, swimming, and endurance sports. Societal pressure of an “ideal body type” can foster the development of low self esteem and negative body issues associated with the triad. Intense scrutiny, pressure in competition, weigh-ins, and social isolation may perpetuate an environment that can increase the risk for developing the triad. Many athletes do not meet all of the criteria for the triad but may manifest the disorder and behaviors as part of a syndrome.

Three Components of the Female Athlete Triad Defined

• Energy Deficit/Disordered Eating – This can be defined as a pattern of obsessive dieting and/or poor nutrition, and can be more be severe as in the presence of a clinical eating disorder. Inadequate nutrition and low caloric intake results in lower energy levels and extreme fatigue in these athletes.
• Menstrual Disturbances/Amenorrhea – Menstrual irregularity or amenorrhea, the complete absence of a menstrual cycle for six months or more. Amenorrhea is often a symptom that is unreported and not commonly discussed between athletes and coaches.
• Bone Loss/Osteoporosis – Bone loss is the most dangerous component of the triad, as weaker bones may lead to osteopenia and later osteoporosis causing stress fractures and injuries. Stress fractures and broken bones often manifest in the hips and vertebral column of athletes.

Common Symptoms

• Lower energy levels, fatigue, excessive tiredness, and problems sleeping.
• Eating issues including low calorie and or low fat diet, obsessive eating patterns and strange diets, and weight loss.
• Physical changes including; hair loss, dry skin, cold extremities, frequent colds, infections, or illnesses.
• Irregular or absent menstrual cycle.
• Recurrent sports related injuries, bone breaks, and stress fractures.

The true prevalence of the triad is somewhat unknown. Studies have reported disordered eating in 15-62% of female college athletes and amenorrhea in 3.4-66% percent of female athletes. Research in Medicine and Science in Sports and Exercise examined 669 elite female athletes and found that over 60% of the female athletes were classified as at risk of the Triad.

Another study in the Journal of American College Health examined bone mineral density of elite endurance runners. Researchers found that 34.2% of the of athletes studied had low bone mineral density at the lumbar spine, and osteoporosis was present in 33% of the sample. Other aspects of the triad including menstrual dysfunction, disordered eating, and low bone mineral density were present in 15.9% of the athletes studied.

The triad is an alarming health concern that can leave females with enduring health problems, and in an extreme form can be fatal. Education and collaborative efforts by strength and conditioning professionals and coaches is extremely important in the prevention of the triad. If you are experiencing these symptoms you should seek qualified medical advice.

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