Female Athlete Triad: What Is It? Why do so many experience it?

I want to start this post with a really important message: the female athlete triad is not a given for runners. It’s not an inevitable thing that’s going to happen. Running alone doesn’t make you stop menstruating or cause health problems.

Whewwww, needed to get that off my chest because I think this is a HUGELY important topic which Tina Muir helped really push in to the spotlight.

But I backed away from talking about it previously because it seemed that the message became “this will happen if you run as a woman”.

Not true. BUT it does happen more frequently than it should, which is why I’m thrilled to have one of the RunToTheFinish coaches, Alexis founder of Lane 9 Project, guest posting today talking about her experience and what she’s learned to help others stay the healthy path.

Female Athlete Triad: What Is It? Why do so many experience it?

Why Alexis Became Interested

We’re taught that you’ll get your period one day and then it will come every 28 days for the rest of what seems like forever, but that didn’t happen to me.

I got my period, and then it vanished, and continued to be irregular for the next 10 years. To me it seemed normal for a female athlete to have an irregular period and no one ever told me any different.

Now, 15 years wiser, I know that idea is wrong. It may be common for female athletes to have irregular periods (or have no period at all) but it isn’t normal and it certainly isn’t healthy.

What I know now is that I was suffering from the Female Athlete Triad (now called RED-S). Read my full story on the Lane 9 Blog.

“92.5% of runners have never heard of the Female Athlete Triad.”
(Survey of 300 ultramarathoners) –Dr. Stacy T Sims 

What is the Female Athlete Triad?

The Female Athlete Triad is a syndrome consisting of three conditions: low energy availability, amenorrhea (irregular periods), and low bone mineral density.

The condition now formally referred to as RED-S, Relative Energy Deficiency in Sport acknowledges that low energy availability can lead to a slew of health consequences that are not included in the triad and that men can be impacted, as well.

Low Energy Availability (calorie deficit)

When we’re talking about the Female Athlete Triad, we first need to address low-energy availability.

At the most basic level, low energy availability occurs when an athlete is not eating enough to sustain the level of activity they are engaging in.

This imbalance may occur as a result of disordered eating or an eating disorder, but it doesn’t have to.

Many athletes fall into a state of low energy availability on accident. It’s easy to make small increases to your training and not recognize the need to increase caloric intake.

{Amanda’s Note: I see this happen a ton in the summer months when we just feel like eating less because of the heat!! Find things like green smoothies you can pack with nutrients and good fats to drink if you can’t stomach a post run meal.}

Before you know it, your body starts sending signals that you need more fuel to keep going. In my personal experience, it started by unknowingly underfueling as a young teenager, but I eventually fell into an eating disorder later on.

Read more on determining how many calories you need to fuel your workouts.

Amenorrhea

One of the first signals the female body may send to indicate underfueling is amenorrhea, the loss of your period. When your body isn’t getting enough energy to sustain levels of activity, it finds ways to keep you going and essentially enters into survival mode.

Nonessential functions begin to shut down and your reproductive system is one of the first to be affected. Many women (my past self included) welcome the loss (No cramps! No feminine hygiene products! Yay!) and accept it as a normal consequence of sport, but in reality, it’s a red flag.

I cannot it emphasize enough, it is not normal or healthy to lose your period.

Yes, amenorrhea is common, but it should not be brushed off. It’s both a sign of underlying issues and a risk factor for bone injury and other serious problems.

{Amanda’s Note: While I too went through some massive hormonal throw offs, we were able to determine it wasn’t because of running or not eating enough. So remember to start by examining these issues, but go to a doctor and make sure you know the absolute cause.}

Low bone mineral density

On to the third part of the triad. When a period is lost, there’s an adverse effect on bone health, which is specifically detrimental for teens, as women reach peak bone mass around age 19.

Low bone mineral density increases an athlete’s risk of injury, specifically stress fractures. Low bone density and stress fractures are not only short term setbacks that cause you to take a couple months off from running and should be treated seriously.

Poor bone health can be irreversible and have lasting consequences including osteopenia or osteoporosis. Women experiencing the triad may be diagnosed with these conditions at a very young age, as early as their teens.

Female Athlete Triad Symptoms

Awareness is half the battle. As stated in the earlier quote, most athletes haven’t even heard of the triad. I was one of those athletes until a couple of years out of college.

Once I learned about the triad, I was able to take steps to restore my health. There can be many signs and symptoms that you’re experiencing the triad, here are some to lookout for:

• Amenorrhea
• GI Stress
• Significant or sudden weight loss
• Stress fractures (especially if you’ve had multiple)
• Weakness and fatigue
• Anxiety and/or depression
• Body dysmorphia
• Significant changes in diet and/or disordered eating behaviors
• Overexercising
• Preoccupation with food and body
• Difficulty concentrating

Female Athlete Triad Treatment

If you’re already experiencing the triad it is important to know that you are not alone, it’s not your fault, and recovery is possible.

First and foremost, the best medicine for the Female Athlete Triad is prevention. But prevention can only occur with knowledge, which is why we’re talking about this today.

There’s a lot of shame and stigma around women’s health issues and especially periods. So talking about it and educating women and key stakeholders is of utmost importance.

If you’re able, share information about the triad with those around you, especially those who may be vulnerable or in positions of power to vulnerable populations (ie. coaches, teachers, parents).

1. Eat Enough.

To put it simply, you’ve gotta eat enough.

An Intuitive Eating approach is a good way to ensure you’re properly fueling your body by listening to what it wants and needs, but if you’ve been counting calories for years that may not be the place to start. You could need to talk with a sports nutritionist to start getting you back on the right track.

De-emphasizing weight and appearance is important, especially in running, a sport where success and thinness are so often (wrongfully) correlated.

2. Strength Training

Building a well rounded runners body is something Amanda talks about a lot. In this case, we know that strength training will help you to maintain bone health and help to prevent injuries by working through muscle imbalances.

Along with strength training, your doctor might recommend Vitamin D and Calcium supplementation to help increase bone mass.

3. Behavioral and Cognitive Modifications

One of the biggest changes will start with reducing the volume or intensity of your workouts. That alone can be a difficult piece if we’re focused on a big goal or have simply created such an intense routine for ourselves.

Don’t try to muscle through it alone, ask for help.

Find the doctor, coach, registered dietitian or physical therapist to help you chart a healthier course. You may have heard incorrect messages as a kid about our bodies from teachers or the media, maybe you just went about training without enough knowledge.

There’s no shame in this!

There is the responsibility to make a change so you can have long term health and run for many, many, many years.

And last, if you think you are experiencing an eating disorder, seek specific treatment.

Open up to someone close to you or call the NEDA helpline in order to be supported in finding adequate care for recovery from your ED. Again, recovery is possible, I know because I’ve been there.

The NEDA Helpline is available Monday-Thursday from 9AM to 9PM ET, and Friday from 9AM to 5PM ET. Contact the Helpline for support, resources and treatment options for yourself or a loved one.

HUGE thank you to Alexis for sharing her experience and so much information on this common issue.

Alexis is a teacher, runner, coach and co-founder of Lane 9 Project. Lane 9 Project is a volunteer-run non-profit organization dedicated to educating active women and girls, and their support systems, on issues including women’s health, eating disorder recovery, fertility, and sport. Alexis was a collegiate runner and continues to chase big goals at the half marathon and marathon distances. Her perfect day is a morning run, followed by plenty of coffee and cuddles from her giant lap dog, Troy.

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