Female Athlete Triad
With dreams of Olympic trials and college scholarships in her mind, 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 didn't hesitate to start counting calories and increasing 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 her health.
What Is Female Athlete Triad?
There's no doubt about it - playing 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. 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 are at risk for a problem called female athlete triad. Female athlete triad - also known as female athletic triad - is a combination of three conditions: disordered eating, amenorrhea (pronounced: ay-meh-nuh-ree-uh, which means loss of a girl's period), and osteoporosis (a weakening of the bones). A female athlete can have one, two, or all three parts of the triad.
Triad Factor #1: Disordered Eating
Girls who have the disordered eating that accompanies female athlete triad often have many of the signs and symptoms of anorexia nervosa or bulimia nervosa, such as low body weight for their height and age and episodes of binge eating and purging. But girls with female athlete triad try to lose weight primarily to improve their athletic performance. Sometimes the disordered eating that accompanies this condition isn't technically an eating disorder. Many girls with female athlete triad are simply trying to become better at their chosen sports. But like teens with eating disorders, girls with female athlete triad may use behaviors such as calorie restriction, purging, and exercise to lose weight.
Triad Factor #2: Amenorrhea
Because a girl with female athlete triad is simultaneously exercising intensely and reducing her weight, 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. (In many cases, of course, a missed period indicates another medical condition - pregnancy. If you have missed a period and you are sexually active, you should 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 - this is called primary amenorrhea. Other girls may have had periods, but once they increase their training and change their eating habits, their periods may stop - this is called secondary amenorrhea.
Triad Factor #3: Osteoporosis
Low estrogen levels and poor nutrition can also 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 due to weakened bones. Because of poor nutrition, a girl's body may not be able to repair the injuries efficiently.
Usually, the teen years are a time when girls should be building up their bone mass to their highest levels - called peak bone mass. Female athlete triad can lead to a lower level of peak bone mass and a lot of time on the sidelines. After she becomes an adult, a girl may also develop health problems related to osteoporosis at an earlier age than she would have otherwise.
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 performances. 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 scores.
Even in sports where body size and shape aren't as important for judging purposes, 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" would improve their performance. 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 bone development.
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, such as:
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)
Girls with female athlete triad often have signs and symptoms of eating disorders, such as:
preoccupation with food and weight
continuous drinking of water and diet soda
frequent trips to the bathroom during and after meals
presence of lanugo hair (fine, soft hair that grows on the body)
tooth enamel that's worn away from frequent vomiting
anemia (fewer red blood cells in the blood than normal)
sensitivity to cold
heart irregularities and chest pain
What Do Doctors Do?
It may be easy for girls with female athlete triad to keep their symptoms a secret because information about their periods and any damage done to bones usually isn't visible to friends and family. And lots of girls become very skilled at hiding their disordered eating habits.
A doctor may recognize that a girl has female athlete triad during a regular exam. An extensive physical examination is a crucial part of diagnosing the triad. A doctor who suspects 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. Because poor nutrition can affect the body in many ways, a doctor might also test for blood problems and nutritional imbalances. Because osteoporosis can put a girl at higher risk for bone fractures, a doctor who suspects female athlete triad may also request tests to measure bone density.
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 all work together to treat the physical and emotional problems that a girl with female athlete triad faces.
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, a girl with female athlete triad may have muscle weakness, stress fractures, and reduced physical performance. Over the long term, a girl with female athlete triad may suffer from bone weakness, damage to 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 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 a girl's 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 Female Athlete Triad?
A girl with female athlete triad can't just ignore the disorder and hope it goes away - she needs to get help from a doctor and other health professionals. If your 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 her parent, coach, teacher, or school nurse.
Looking for ways to be supportive to your friend with female athlete triad? You may worry about being nosy, but don't: 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 physical condition:
Keep track of your periods. It's easy to forget when you had your last visit from Aunt Flo, so keep a little 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 your doctor.
Don't skip meals or snacks. You're constantly on the go between school, practice, and competitions, so it may be tempting to skip meals and snacks to save time. But eating now will improve your performance later, so stock your locker or bag with quick and easy favorites such as bagels, string cheese, unsalted nuts and seeds, raw vegetables, energy bars, and fruit.
Visit a dietitian or nutritionist who works with teen athletes. He or she can help you get your dietary game plan into gear and can help you 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 an activity you took up for fun into a nightmare. If you're not enjoying your sport, make a change. Remember: It's your body and your life. Any damage you do to your body now, you - not your coach or teammates - will have to live with later.
Updated and reviewed by: Steven Dowshen, MD
Date reviewed: October 2003
Originally reviewed by: Angela D. Smith, MD
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