The Silent Female Athlete Epidemic: The Female Athlete Triad

Let’s explore a scenario:

A young female athlete enters college on an athletic scholarship. She is in a new environment, has new teammates, a whole new lifestyle and the pressure to perform is on. She is now on her own in an environment where she gets to make her own decisions. She is surrounded by females who are considered elite athletes.

She is now living on campus, eating in the dining hall where food is typically unappetizing. She is practicing close to 4 hours per day and on top of that juggling academia. Let’s not forget the weekend road trips and flights to other schools for competition season.

So, after a few weeks, meals start being skipped to get homework done and to make it to practice on time. This athlete also isn’t sleeping whether it be due to school work or her newfound college lifestyle. The young girl begins losing weight and feels great about her appearance. She feels like she is starting to fit in.

This cascade of events, skipping meals and lack of sleep has led to a 15-pound weight loss. This young athlete has noticed she is chronically fatigued and lacking energy. She also loses her menstrual cycle. Her performance starts declining and it is noticeable, especially on competition day. The athlete becomes confused. She always thought losing weight and not having a menstrual cycle meant she was going to be at the pinnacle of her athletic performance.

At the next competition, this female athlete starts complaining about pain in her left shin region. She pushes through even though it is becoming increasingly uncomfortable. She continues to practice and compete even though her performance is poor. She is becoming increasingly frustrated and upset. The pain in her shin continues and she continues to try to hide it until one day where she can barely put weight on it.

She now has a tibial stress fracture and is out for the remainder of the season. Her whole world is shattered. She has lost her starting position and she can’t even train. She’s afraid she is going to regain the weight she lost and that she will no longer have any shot of starting next season. She starts to fall into a bought of depression.

Does this scenario surprise you? Unfortunately, it happens all too often with female athletes and often goes unrecognized. Although this scenario depicts a college aged young woman, it can happen across the lifespan of a female athlete.

So, what happens from here? A team of physicians are now the answer to this athlete’s recovery. In order to properly diagnose this athlete, secondary reasons for loss of her menstrual cycle must be examined by her gynecologist and primary care provider. Once those are ruled out and low energy availability, low bone mineral density or menstrual irregularity are ruled in, this athlete can be diagnosed with the Female Athlete Triad.

To understand the diagnosis, look at the figure above. The green triangle represents a healthy athlete and the red triangle represents an athlete exhibiting signs of the female athlete triad. The green triangle represents an athlete with optimal energy availability, regular menstruation and a healthy bone density. This athlete would be the young girl depicted in the scenario above prior to going to college. The red triangle would be this young female who ultimately suffered from a tibial stress fracture. I must note that an athlete does not require all three aspects to have a diagnosis. Now how does this happen?

Just as a car requires gas to run, our bodies require fuel to function. If we begin to run low on fuel, our bodies will try conserve energy. Unfortunately, humans, especially female athletes, cannot function well in energy conservation mode. In the case of a female athlete, an energy deficiency or this energy conservation mode will cause the body to stop releasing hormones responsible for menstruation and maintaining optimal bone health. Unfortunately, this cascade of events can cause the development of osteopenia and osteoporosis even if they are not of menopausal age. It will also put a female athlete at risk for fractures and delayed healing of fractures.

So, how do we prevent this? Education and observation are key! I remember being told by my mom and coaches as a young athlete that an irregularity in my menstrual cycle was probably because I was “athletic.” I just want all moms, dads, coaches, and athletes to be aware that loss of a menstrual cycle as an athlete is not normal nor is significant and continued fatigue. Although I have mainly spoken about females in this article, male athletes can also suffer from energy deficits of which I will address in another blog at a later date!

To hear more information regarding this topic, we have recently published a video on our Facebook Page titled The Female Athlete Triad or the Podcast version of the talk.. If you have any questions regarding, please do not hesitate to contact us!