Women’s athletic triad – Running to win or to be thin?

I first met the female athletic triad a few years ago when a young recreational runner contacted me who decided to run the Ljubljana Marathon even though she was aware that she had a stress fracture of the tibia. She had seen another doctor a couple of months before my examination because of lower leg pain. Ignoring his advice to rest, she proudly ran the marathon. She came to my office for a completely different reason, she stopped getting her menstrual cycle and felt tired and old, the opposite of what she expected when she started preparing for the marathon.

Girls and young women face a unique set of psychological pressures in sport. Western society has placed a strong emphasis on the ideal body shape and size for women. Female athletes’ desire to improve performance, a win-at-all-costs mentality, combined with an over-ambitious parent or coach, can increase the risk for the development of the female athletic triad.

The female athletic triad is a condition in physically active young women that includes low energy availability, menstrual dysfunction, and low bone mineral density. Although exercise is associated with positive health outcomes in most individuals, it can be detrimental if it is associated with low energy availability. Low energy availability leads to hormonal adjustments, which in turn result in menstrual irregularities and compromised bone health.

Female athletes, especially those who play sports where a slim figure and low weight are competitive advantages – such as dance, gymnastics, ballet, figure skating, long-distance running, etc. – more often have the female athletic triad.

Many athletes, doctors, parents and coaches are not aware of this condition. A study from 2015. showed that only 37% of doctors in the US had heard of this syndrome. It is necessary to increase awareness among health professionals about the female athletic triad, which can then be transmitted to the sports community, parents, teachers and athletes. Early intervention using a team approach is essential in female athletes with any component of the triad to prevent long-term adverse health consequences.

Low energy availability was categorized as intentional (ie, due to eating disorders) or unintentional (ie, due to non-dietary activities). Persistent low energy availability is often associated with eating disorders and subsequent low self-esteem, depression and anxiety disorders.

The prevalence of eating disorders is most pronounced in elite athletes – up to 30%, compared to 6-9% in the general population. The prevalence of eating disorders is as high as 47% in lean sports, such as running and gymnastics, compared to 20% in non-lean sports, such as basketball and soccer.

Calorie restriction is a common phenomenon. In a study of 15 elite ballerinas and 15 matched control women with similar characteristics, it was determined that the ballerinas consumed only about 3/4 of the calories per day compared to the control group (1,577 vs. 2,075 kcal/day). The prevalence of menstrual dysfunction is as high as 70% in female dancers and 65% in long-distance runners. The prevalence of osteopenia in athletes who have already lost their menstrual cycle is 22-50%, and the prevalence of osteoporosis is up to 13%, compared to 12% of osteopenia and 2% of osteoporosis in the general population.

Why do these disorders occur? Low energy availability can contribute to menstrual disturbances as the body suppresses reproductive function to prevent pregnancy. An undernourished, exhausted body switches to “survival mode” and makes it impossible to conceive, that is, to achieve pregnancy. For an organism that is in “survival mode”, pregnancy is a luxury and an excessive burden. Menstrual abnormalities can appear as early as 5 days after a woman enters a state of low energy availability. In animal studies, reducing dietary intake by more than 30% resulted in infertility.

Athletes with the female athletic triad are usually silent about eating disorders and menstrual cycle disorders. They come to the doctor because of stress fractures: bone damage caused by repetitive loading forces that exceed mechanical elasticity. Female athletes with this condition may not be able to achieve optimal bone mass in adolescence, which is the time of maximum bone formation – and thus expose themselves to a greater risk of osteoporosis later in life.

Undernutrition has two important consequences for bone health. Firstly, there may be a lack of calcium. Also, the reduction of body fat is associated with a reduced level of estrogen. Women who have a low percentage of body fat (below 22%) have a low level of estradiol, which is insufficient for the production of estrogen. (On the other hand, women with very high levels of body fat also have low levels of estrogen). Without adequate levels of this hormone, bone remodeling is impaired. Bone remodeling is a process by which (micro)damages caused by regular activity are repaired.

Activities that apply cyclic loading forces can lead to the formation of microfractures. (Running is the prototypical activity of “cyclic loading forces”, but not the only one). When the rate of damage accumulation becomes greater than the rate of remodeling, these microfractures can extend and coalesce, resulting in a bone stress fracture. Female athletes with a stress fracture will present with an insidious onset of pain that worsens acutely with strong impact activity and subsides at rest. The pain often occurs several weeks after a noticeable increase in known physical activity and is not related to a specific injury. For example, a runner who recently increased her training from 5 to 10 kilometers per day may have new symptoms.

What to do?

The primary goal is to restore body weight, maximizing nutritional and energy status by modifying diet and adjusting exercise to increase energy availability. Creating an energetically positive state is the result of increasing intake, decreasing energy consumption, or a combination of these two approaches. In order to maintain normal physiological function, an energy availability of at least 45 kcal/kg/day is recommended. Goals include a BMI of at least 18.5 kg/m2 in adult women and a body weight of at least 90% of that predicted in adolescents.

The involvement of a sports nutritionist can help ensure that the athlete is consuming an adequate amount of macronutrients and micronutrients necessary for bone growth; they include calcium, vitamin D, iron, zinc and vitamin K. For athletes with disordered eating, it is important to refer to a psychologist to help them avoid pathological eating behaviors, change negative emotions related to food and their body.

Although positive effects such as normalization of metabolic hormones can be seen within days or weeks of achieving a positive energy balance, it may take several months for menstrual function to improve and years for bone recovery and measurable improvement in bone mineral density. Supplemental calcium (1,000-1,500 mg per day) and vitamin D (2,000-5,000 IU per day) should be included in the treatment of low bone mineral density.

However, weight gain alone does not normalize bone mineral density. Resistance training is encouraged to increase muscle mass, although care must be taken to prevent fractures during weight-bearing activities. It can take up to several years for bone mineral density to improve and may not be fully reversible.

After 6-12 months of intensive lifestyle intervention, if there is no evidence of menstrual recovery, the next step in treatment is estrogen replacement therapy.

Other agents currently being considered as treatments for low BMD are commonly used in postmenopausal osteoporosis, but have not been extensively studied in young women with functional hypothalamic amenorrhea, particularly in female athletes.

What to pay attention to?

Certain types of personality and behavior can be risk factors, such as perfectionism, obsessiveness, frequent weight changes and overtraining. Additionally, it is important to determine how the athlete receives criticism and comments regarding performance or body image from coaches, parents, or teammates, and whether sport-specific training began early in life. If any of the components of the triad are evident, a more in-depth evaluation of the problem should be performed.

Early intervention is essential in female athletes with any component of the triad to prevent long-term adverse health consequences. Successful treatment is strongly correlated with the relationship of trust between the athlete and the multidisciplinary team involved in her treatment.

When the athlete achieves her set goals, she can temporarily return to sports under the close supervision of a sports doctor. A written contract, including goals set by the multidisciplinary team, should be carefully monitored as the athlete continues to participate in the sport.