The Female Athlete Triad occurs in triathlon as well as other endurance sports.
No- the Triad does not refer to an exotic drug gang or female biker gang.
Rather it is a fairly common syndrome that tends to occur to goal oriented, high achieving athletes. Anyone who reads this blog is driven to excel, to succeed and is someone who will do whatever it takes to improve.
The Female Athlete Triad is extremely common amongst female endurance athletes striving to improve.
(By the way, a similar situation can happen in men too. Sustained calorie deficits may lead to low testosterone, weak bones and low energy. If you are male, have ongoing fatigue, depression and low sex drive, please see your doctor).
The female athlete triad involves 3 distinct and interrelated conditions:
1) Low energy/low food intake (with or without an eating disorder)
2) Menstrual disorders (amenorrhea or irregular cycles)
3) Bone loss (osteoporosis/osteopenia) which leads to weak bones and high risk of a fracture
When women’s bodies are stressed, or underweight, sometimes the reproductive system does not work properly. The body becomes more concerned with survival than reproduction. And whilst the loss of your period for a few months might seem like no big deal, (or even a blessing!) if you are of reproductive age, normal healthy cycles are an important sign of health and their absence is a cause for concern.
Many female athletes are under extreme and constant pressure to have low body weight by their coach or their peers. Others put themselves under pressure to lose weight to perform better or achieve the “ideal” body shape.
If you decide to undergo a new diet designed at weight loss like intermittent fasting, ketogenic diet, paleo diet or if you perform a spell of intense training, be careful to ensure you are doing it without a cost to your health.
Whilst these diets urge you to cut out sugary treats and highly processed foods, most of them are NOT promoting a deficient in calories rather a focus on healthy eating. Even with intermittent fasting, you are still making up the calories later in the day. My book The Ketogenic Diet For Athletes will describe this diet in detail and exactly what to eat and how to train if you are an endurance athlete and wish to improve.
Diets which promote calorie deficits are often not appropriate for athletes as they often result in low energy, impaired health and poor recovery. Focus on better health, maintaining adequate vitamins and minerals and improved performance instead.
A calorie deficit can lead to low estrogen, which results in the loss of monthly cycle. This can result in a 20 year woman having the sex hormone profile of a post-menopausal woman.
Low estrogen promotes bone loss. Young women have been known to suffer a stress fracture in the foot without any cause eg walking! Women can also experience spontaneous fractures in their spine. This can be a very dangerous condition.
Common Risk Factors In Female Athlete Triad Syndrome
Sports which promote being very thin
Sports which highly prize being very thin like gymnastics, ballet, figure skating, diving, endurance running or endurance cycling often produce athletes who have extremely low body weight. The female athlete triad is also seen in non-athletes like models or even school girls who are swayed by magazines by pictures of unrealistic skinny images.
Here is an excellent article found on Chrissie Wellingtons blog from 220 magazine on this very theme- amongst households triathletes names that you would know, plus elite male cyclists. It is more widespread than you might think. Sometimes it is triggered by a throwaway comment from a coach who meant no harm but may have said something insensitive.
Instead take the view that strong is the new skinny.
Favor looking athletic rather than stick-thin. It will enhance your performance and your health. Whilst many female marathon runners are often very skinny, thankfully, many female triathletes these days actually look very healthy and maintain a good weight. Crossfit also promotes strength and health above looking too skinny.
Low Nutrient Intake
Sometimes it is not low calorie intake but low micronutrient intake which leads to low estrogen. Low nutrient content may not give you the required building blocks to lay down strong bones for the future.
It is vital that you lay down strong bones now to see you through your life. Peak bone building years go from the teenage years to your mid-twenties. After that it is more difficult to lay down new bone.
To get some incredible guidance on this, sometimes it is easier to listen to an audiobook rather than do tons more reading. Leanne Vogel, a very knowledgeable nutrition educator has created these excellent audio books on the ketogenic diet so you can gain a ton of information, strategies and practical tips to help you improve your nutrition, get healthier and break the cycle.
As athletes we often take in information better if we listen while on the bike, or walking.
If you are skipping cycles, pay attention and address this immediately. Do not wait like many women unlike you have broken a bone to do something about it. Then it is likely to be too late. Even if you do one thing, you will be making progress towards a better future.
Mood disorders
Depression and anxiety are commonly seen amongst women dealing with disordered eating. Females may have low self-esteem which leads to disordered eating or compulsive over exercise. They may also be lacking adequate fat intake to support proper hormone levels and to kick the depressive symptoms. If you suspect this may be you, increase your intake of good fats and seek out a counsellor or therapist to talk to.
Other problem and warning signs
Compulsive, excessive exercise that does not seem appropriate for the sport is a warning sign. Secretive eating, diet pills, appetite suppressants and pre-occupation with weight are also classic signs. Other signs are frequent sore throats, dental cavities and foul breath (self induced vomiting), fatigue, light headedness,
Taken to excess women may also have anemia, hypotension, and abnormal heart rhythm. Being too thin can turn into anorexia, bulimia, osteoporosis and it can be fatal.
Treatment For Female Athlete Triad Syndrome
If you have had this condition for a long time, recovery may not be a quick fix. Usually recovery involves a team approach and physical, mental and emotional support.
This may require a dietician, physician, coach and mental health provider. A physician will do a full examination to check for other causes of weak bones and missing cycles including PCOS, pituitary tumour, pregnancy, thyroid disease and other checks. Standard tests like DEXA scan to assess bone density should also be done.
Some of the bone loss may not be fully restored though improvement is possible depending on how long these symptoms have been going on.
It is possible for a 20-year-old woman without her cycle during her critical teenage growth period to have the bone mass of a 70-year-old woman. This will predisposing her to stress fractures now while she is young plus osteoporosis and fractures later in life.
Adequate nutrition with weight bearing exercise fosters good bone formation. Calcium requirements for teenage girls and young women with normal menses is 1,200 mg per day. Females with irregular or absent menses require 1,500 mg of calcium and 400 mg of Vitamin D per day.
If you have a change in circumstances like intense training, weight loss or stress and lose your cycle, ensure you address it straight away. If your lost menses is due to one of these factors, and you take action (increase your calories, take a couple of rest days, get more sleep, try meditation or counselling) it should return the next month. If you have taken action and there is no return, get checked out by your doctor as it may be another reason that requires attention. If you have lost your menses for over 3 months also see your doctor.
Female athlete triad can appear insidiously without symptoms (except the lost menses which many ignore). However it is a serious condition which can be fatal and can lead to many problems of early ageing.
In triathlon, hopefully we do not have such intense pressure to be stick thin like in ballet, gymnastics and other sports. Also whilst there are some very thin runners, most female triathlete role models at the top of our sport do appear to have a healthy weight and healthy body image.
There is always the risk though of over-training, skipping meals, being incredibly stressed and time crunched trying to fit it all in, so be aware and take steps immediately if any symptoms appear. Grab the audiobooks if you think you are not as healthy as you could be and improve your nutrition, your energy and your well being.
Our aim is to be fit, healthy and increase longevity and vitality, not to win one race then never be able to compete again.
Happy Training
Charlotte
Hi Charlotte,
This article isn’t dated so I don’t know how recent this is, but I just came across it and wanted to add my thoughts. As someone who has recovered from amenorrhea following chronic energy imbalance from triathlon training, I have done a lot of reading on this subject and I would like to suggest you revise your advice that simply eating sufficient calories will avoid issues associated with the female athlete triad and that a ketogenic diet would be a good option. Many women develop hypothalamic amenorrhea as a result of following low carb or ketogenic diets, with or without lots of exercise added to the equation. Carbohydrates play a key role in the hypothalamus and too little carbohydrates in the body, even if a plentiful supply of fats is coming in, can reduce the hypothalamus’ production of GnRH, leading to a lack of FSH and LH being produced by the pituitary gland and subsequently amenorrhea. What’s more, when carbohydrates are consistently low, cortisol production increases – high cortisol levels are another trigger for the hypothalamus to reduce GnRH production. It is energy imbalance and/or insufficient carbohydrates and stress that are the issue. Everyone’s thresholds are different, but the importance of carbohydrates for female reproduction is well documented. Aside from this there are tons of great points in the article so thank you for posting about this issue.