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 her health.

What Is Female Athlete Triad?

Sports and exercise are part of a balanced, healthy lifestyle. People who play sports are healthier; get better grades; are less likely to experience depression; and use alcohol, cigarettes, and drugs less frequently than people 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 as a way to improve their athletic performance. The disordered eating that accompanies female athlete triad can range from not eating enough calories to keep up with energy demands to 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

Exercising intensely and not eating enough calories can lead to decreases in the hormones that help regulate the menstrual cycle. As a result, a girl's periods may become irregular or stop altogether. Of course, it's normal for teens to occasionally miss periods, especially in the first year. A missed period does not automatically mean female athlete triad. It could mean something else is going on, like pregnancy or a medical condition. If you are having sex and miss your period, 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. Others may have had periods, but once they increase their training and change their eating habits, their periods may stop.

Triad Factor #3: Osteoporosis

Estrogen is lower in girls with female athlete triad. 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 now can also have a lasting effect on how strong a woman's bones are later in life.

Who Gets Female Athlete Triad?

Many girls have concerns about the size and shape of their bodies. But being a highly competitive athlete and participating in a sport that requires you to train extra hard can increase that worry.

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 athletes 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, 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, 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:

  • 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)
  • other 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 medical history.

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 someone at higher risk for bone fractures, the doctor may also request tests to measure bone density.

Doctors don't work alone to help a girl with female athlete triad. Coaches and trainers, parents, physical therapists, pediatricians and adolescent medicine specialists, sports medicine doctors, nutritionists and dietitians, and mental health specialists can all work together to treat the physical and emotional problems that a girl with female athlete triad faces.

It might be tempting to shrug off several months of missed periods, but getting help right away is important. In the short term, female athlete triad may lead to reduced physical performance, stress fractures, and other injuries. Over the long term, it can cause bone weakness, long-term effects on the reproductive system, and heart problems.

A girl who is recovering from female athlete triad might work with a dietitian to help reach and maintain a healthy weight while 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 her 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 food intake or exercising excessively.

Some girls may need to take hormones to supply their bodies with estrogen to help prevent further bone loss. Calcium and vitamin D supplementation can also help when someone has bone loss as the result of female athlete triad.

What If I Think Someone I Know Has It?

It's tempting to ignore female athlete triad and hope it goes away. But it requires 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, you may need to mention your concern to a parent, coach, teacher, or school nurse.

You might worry about seeming 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 physical condition:

  • Keep track of your periods. It's easy to forget when you had your last visit from Aunt Flo, so keep track of your periods on a calendar 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. If you're constantly on the go between school, practice, and competitions you 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 athletes. He or she can help you get your dietary game plan into gear and find out if you're getting enough calories and 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.
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