Hannah joined the track team her freshman year and trained hard
to become a lean, strong sprinter. When her coach told her losing a
few pounds would improve her performance, she immediately started
counting calories and increased the duration of her workouts. She
was too busy with practices and meets to notice that her period had
stopped - she was more worried about the stress fracture in her
ankle slowing her down.
Although Hannah thinks her intense training and disciplined diet
are helping her performance, they may actually be hurting her - and
What Is Female Athlete Triad?
Sports and exercise are part of a balanced, healthy lifestyle.
Girls who play sports are healthier; get better grades; are less
likely to experience depression; and use alcohol, cigarettes, and
drugs less frequently than girls who aren't athletes. But for
some girls, not balancing the needs of their bodies and their
sports can have major consequences.
Some girls who play sports or exercise intensely are at risk for
a problem called female athlete triad. Female athlete triad is a
combination of three conditions: disordered eating, amenorrhea, and
osteoporosis. A female athlete can have one, two, or all three
parts of the triad.
Triad Factor #1: Disordered Eating
Most girls with female athlete triad try to lose weight
primarily to improve their athletic performance. The disordered
eating that accompanies female athlete triad can range from
avoiding certain types of food the athlete thinks are
"bad" (such as foods containing fat) to serious eating
disorders like anorexia nervosa or bulimia nervosa.
Triad Factor #2: Amenorrhea
Because a girl with female athlete triad is simultaneously
exercising intensely and not eating enough calories, when her
weight falls too low, she may experience decreases in estrogen, the
hormone that helps to regulate the menstrual cycle. As a result, a
girl's periods may become irregular or stop altogether. Of
course, it is normal for teen girls to occasionally miss periods,
especially in their first year of having periods. A missed period
does not automatically mean a girl has female athlete triad. A
missed period could mean something else is going on, like pregnancy
or a medical condition. If you have missed a period and you are
sexually active, talk to your doctor.
Some girls who participate intensively in sports may never even
get their first period because they've been training so hard.
Other girls may have had periods, but once they increase their
training and change their eating habits, their periods may
Triad Factor #3: Osteoporosis
Low estrogen levels and poor nutrition, especially low calcium
intake, can lead to osteoporosis, the third aspect of the triad.
Osteoporosis is a weakening of the bones due to the loss of bone
density and improper bone formation. This condition can ruin a
female athlete's career because it may lead to stress fractures
and other injuries.
Usually, the teen years are a time when girls should be building
up their bone mass to their highest levels - called peak bone mass.
Not getting enough calcium during the teen years can also have a
lasting effect on how strong a girl's bones are later in
Who Gets Female Athlete Triad?
Most girls have concerns about the size and shape of their
bodies, but girls who develop female athlete triad have certain
risk factors that set them apart. Being a highly competitive
athlete and participating in a sport that requires you to train
extra hard is a risk factor.
Girls with female athlete triad often care so much about their
sports that they would do almost anything to improve their
performance. Martial arts and rowing are examples of sports that
classify athletes by weight class, so focusing on weight becomes an
important part of the training program and can put a girl at risk
for disordered eating.
Participation in sports where a thin appearance is valued can
also put a girl at risk for female athlete triad. Sports such as
gymnastics, figure skating, diving, and ballet are examples of
sports that value a thin, lean body shape. Some girls may even be
told by coaches or judges that losing weight would improve their
Even in sports where body size and shape aren't as
important, such as distance running and cross-country skiing, girls
may be pressured by teammates, parents, partners, and coaches who
mistakenly believe that "losing just a few pounds" could
improve their performance.
The truth is, though, that losing those few pounds generally
doesn't improve performance at all. People who are fit and
active enough to compete in sports generally have more muscle than
fat, so it's the muscle that gets starved when a girl cuts back
on food. Plus, if a girl loses weight when she doesn't need to,
it interferes with healthy body processes such as menstruation and
In addition, for some competitive female athletes, problems such
as low self-esteem, a tendency toward perfectionism, and family
stress place them at risk for disordered eating.
What Are the Signs and Symptoms?
If a girl has risk factors for female athlete triad, she may
already be experiencing some symptoms and signs of the disorder,
- weight loss
- no periods or irregular periods
- fatigue and decreased ability to concentrate
- stress fractures (fractures that occur even if a person
hasn't had a significant injury)
- muscle injuries
Girls with female athlete triad often have signs and symptoms of
eating disorders, such as:
- continued dieting in spite of weight loss
- preoccupation with food and weight
- frequent trips to the bathroom during and after meals
- using laxatives
- brittle hair or nails
- dental cavities because in girls with bulimia tooth enamel is
worn away by frequent vomiting
- sensitivity to cold
- low heart rate and blood pressure
- heart irregularities and chest pain
How Doctors Help
An extensive physical examination is a crucial part of
diagnosing female athlete triad. A doctor who thinks a girl has
female athlete triad will probably ask questions about her periods,
her nutrition and exercise habits, any medications she takes, and
her feelings about her body. This is called the
Poor nutrition can also affect the body in many ways, so a
doctor might order blood tests to check for anemia and other
problems associated with the triad. The doctor also will check for
medical reasons why a girl may be losing weight and missing her
periods. Because osteoporosis can put a girl at higher risk for
bone fractures, the doctor may also request tests to measure bone
Doctors don't work alone to help a girl with female athlete
triad. Coaches, parents, physical therapists, pediatricians and
adolescent medicine specialists, nutritionists and dietitians, and
mental health specialists can all work together to treat the
physical and emotional problems that a girl with female athlete
It might be tempting for a girl with female athlete triad to
shrug off several months of missed periods, but getting help right
away is important. In the short term, she may have muscle weakness,
stress fractures, and reduced physical performance. Over the long
term, she may suffer from bone weakness, long-term effects on her
reproductive system, and heart problems.
A girl who is recovering from female athlete triad may work with
a dietitian to help get to and maintain a healthy weight and ensure
she's eating enough calories and nutrients for health and good
athletic performance. Depending on how much the girl is exercising,
she may have to reduce the length of her workouts. Talking to a
psychologist or therapist can help a girl deal with depression,
pressure from coaches or family members, or low self-esteem and can
help her find ways to deal with her problems other than restricting
her food intake or exercising excessively.
Some girls with female athlete triad may need to take hormones
to supply their bodies with estrogen so they can get their periods
started again. In such cases, birth control pills are often used to
regulate the menstrual cycle. Calcium and vitamin D supplementation
is also common for a girl who has suffered bone loss as the result
of female athlete triad.
What If I Think Someone I Know Has It?
A girl with female athlete triad may try to hide it, but
she can't just ignore the disorder and hope it goes away.
She needs to get help from a doctor and other health professionals.
If a friend, sister, or teammate has signs and symptoms of female
athlete triad, discuss your concerns with her and encourage her to
seek treatment. If she refuses to seek treatment, you may need to
mention your concern to a parent, coach, teacher, or school
You may worry about being nosy when you ask questions about a
friend's health, but you're not: Your concern is a sign
that you're a caring friend. Lending an ear may be just what
your friend needs.
Tips for Female Athletes
Here are a few tips to help teen athletes stay on top of their
Keep track of your periods.
It's easy to forget when you had your last visit from Aunt
Flo, so keep a calendar in your gym bag and mark down when your
period starts and stops and if the bleeding is particularly heavy
or light. That way, if you start missing periods, you'll know
right away and you'll have accurate information to give to
Don't skip meals or snacks.
Girls who are constantly on the go between school, practice, and
competitions may be tempted to skip meals and snacks to save
time. But eating now will improve performance later, so stock
your locker or bag with quick and easy favorites such as bagels,
string cheese, unsalted nuts and seeds, raw vegetables, granola
bars, and fruit.
Visit a dietitian or nutritionist who works with teen
He or she can help you get your dietary game plan into gear and
determine if you're getting enough key nutrients such as
iron, calcium, and protein. And if you need supplements, a
nutritionist can recommend the best choices.
Do it for you.
Pressure from teammates, parents, or coaches can turn a
fun activity into a nightmare. If you're not enjoying
your sport, make a change. Remember: It's your body and your
life. You - not your coach or teammates - will have to live
with any damage you do to your body now.
Steven Dowshen, MD
Date reviewed: October 2006
Originally reviewed by:
Angela D. Smith, MD
Note: All information is for educational purposes only. For specific medical advice,
diagnoses, and treatment, consult your doctor.
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