The Female Athlete Triad
“Why do I feel so tired all the time?”
“I slept plenty, but I don’t know why I still feel exhausted.”
“I keep trying to push myself in my workouts, but I’m not making the progress I think I should be based on my efforts and training plans. What gives?!”
Chronic fatigue is a common issue especially amongst females, and even more so for those who participate in physically demanding sports like running. There are a number of reasons for this with the most common being related to:
- Inadequate recovery between workouts
- Insufficient nutrition for activity demands
- Disordered eating habits
- Low iron (anemia)
- Drop in sex hormones, most notably estrogen and progesterone
These reasons above cause a drop in healthy Estrogen levels, which result in the following changes:
- Irregular or complete loss of menstrual cycle
- Decrease in bone mineral density (stress fractures, osteopenia, osteoporosis)
- Decrease in circulation efficiency
- Reduced fitness performance
- Inefficient recovery post exercise
- Fatigue and difficulty concentrating
- Hair loss
- Pelvic pain
- Low libido
- Fertility challenges
- Mental health challenges – depression and anxiety
These symptoms collectively contribute to what is formally known as The Female Athlete Triad. This condition speaks specifically to the interconnectedness of how inadequate nutrition prevents our body’s ability to maintain monthly menstrual cycles, which in turn contributes to bone mineral density disparities. It’s a domino effect. While these are the three cornerstones of The Female Athlete Triad, they are by no means mutually exclusive to the other symptoms listed above. They are intertwined and multifaceted in nature. I’ve worked with so many women who have soldiered on through chronic fatigue, convincing themselves that they just need to train harder. Often, training harder exacerbates this condition, even though I understand why many assume training to be the solution. Training volume is only one piece of a bigger puzzle. We must consider the fuel (type and volume) that is being put into our systems to support our activities. When we’re running on empty for too long and too often, it’s only a matter of time before our bodies lose their ability to perform optimally.
Think of your menstrual cycle like a vital sign. It’s a monthly benchmark to let you know things are operating smoothly on an internal level. If the body is capable of maintaining a regular monthly cycle during one’s reproductive years, then that’s usually a positive sign that you’re likely fueling well to support your daily activities. This also means your estrogen levels are staying within a healthy range. When we have adequate estrogen levels, the body is able to participate at higher levels of activity with improved performance and recovery, have improved circulation efficiency, and facilitate proper osteoblast activities which maintain our bone mineral density stores. Didn’t know estrogen was so important? Neither did I until I started to specialize in women’s health. Now think about what happens when the opposite is true…it accelerates the body into a chronic fatigue storm. Think about your body like a fancy sports car that requires premium gas, but all you put in it is regular. You’ll get by for a short time without any major issues, but keep that up and you’ll soon find yourself on the side of the road broken down.
Another important factor to consider with female athletes is their use of hormonal birth control. If a women is using any type of hormonal contraceptive, then that could help her maintain a monthly cycle despite still suffering from The Female Athlete Triad syndrome. While I just suggested that one’s monthly cycle is a helpful benchmark, we can’t let that be our only point of reference. Similarly, there are cases where women will loose their monthly cycles completely while using hormonal contraceptives, especially those using an IUD, and that does not necessarily mean they are suffering from The Female Athlete Triad syndrome. So, we cannot simply rely on our monthly cycle as the only benchmark. It must be looked at within the presence/absence of other related symptoms. Education early on for women and those who work with female athletes is critical for early detection and interventions.
If an athlete suffers from The Female Athlete Triad for too long, it can have long lasting implications. The first major consequence is a decrease in bone mineral density, which accelerates the development of stress fractures and osteopenia/osteoporosis conditions. The latter is irreversible. From 18-22 years of age, women are establishing their bone mineral density stores for the rest of their lifetime. Read that last sentence one more time. Think of this as a bone mineral density savings account that needs to last you for the rest of your lifetime. If women are suffering from irregular cycles during these critical years, then they’re also not reaching their full bone mineral density potential. Similarly, if women aren’t being thoughtful about continuously maintaining their bone mineral savings account throughout their reproductive years, they will quickly deplete their bone density supplies prematurely. This can result in chronic stress fractures and early onset of osteoporosis.
The Female Athlete Triad is highly prevalent, yet can often be difficult to detect since there are multiple factors that must be considered to properly rule in a diagnosis. This is why we must support active females in a holistic way by providing education around common warning signs to aide in early detection. Irregularity or a full loss in one’s menstrual cycle is a cardinal sign to investigate further, along with low body weight, high intensity training schedules, complaints of chronic fatigue, and diets lower in healthy fats. Maintaining a healthy amount of good fats has been shown to play a critical role in maintaining healthy Estrogen levels, thus preserving monthly cycles.
If you or your athlete are unsure about what’s “normal” in their specific case, the best place to start is by having a conversation with their physician to better assess their case individually. It is highly recommend that they have a full blood panel ordered, including vitamin D, fasting glucose, iron and ferritin levels. While blood work like this gives only a snapshot in time about one’s health, it can provide a lot of helpful information about the quality of the nutritional support being achieved. If there are any noticeable deficits, working with a registered dietician provides invaluable support in this arena. It is also highly beneficial to work with physical therapists that specialize in strength and conditioning (even better if you can find one who also focuses on women’s health!) to evaluate your training schedule to ensure that you’re optimizing your workouts and recovery phases appropriately. It takes a village, but it’s so worth the investment in your health and building your healthcare support team.
As I mentioned earlier, education around The Female Athlete Triad is so important for early detection. Be part of the solution. Share this with a friend, teammates, coaches, trainers, and anyone who works with female athletes. The more we keep open communication about this topic, the better we can support women’s health!
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- Berenson, Abbey B., et al. “Effects of hormonal contraception on bone mineral density after 24 months of use.” Obstetrics & Gynecology5 (2004): 899-906.
- Nichols, Jeanne F., et al. “Prevalence of the female athlete triad syndrome among high school athletes.” Archives of pediatrics & adolescent medicine2 (2006): 137-142.
- COBB, KRISTIN L., et al. “Disordered eating, menstrual irregularity, and bone mineral density in female runners.” Medicine & Science in Sports & Exercise5 (2003): 711-719.
- Michaëlsson, Karl, et al. “Hormone replacement therapy and risk of hip fracture: population based case-control study.” Bmj7148 (1998): 1858-1863.
- Prior, J. C. “Progesterone as a bone-trophic hormone.” Endocrine Reviews2 (1990): 386-398.
- Mountjoy, Margo, et al. “The IOC consensus statement: beyond the female athlete triad—Relative Energy Deficiency in Sport (RED-S).” Br J Sports Med7 (2014): 491-497.