The passage of Title IX in 1972 signaled the rise of the female athlete. Unfortunately, it also marked the increase of a less-celebrated phenomenon—a condition called the “female athlete triad.”
“The female athlete triad is a syndrome of three interrelated components — nutrition, bone health and menstrual function — that often lead to sports injuries and general health concerns,” explains Kate Temme, MD, CAQSM, Director, Penn Center for the Female Athlete. “When an athlete doesn’t get enough nutrition to support both her sport and her physiologic function, her body goes into emergency shutdown to save calories.”
According to Dr. Temme, this shutdown involves many functions, including metabolism, bone growth and reproduction.
Symptoms of the Female Athlete Triad
"Common symptoms of the triad include a missing or infrequent period or a history of bone stress fractures,” explains Penn Medicine Ob/Gyn Kirstin Leitner, MD, who sees patients with Dr. Temme at the Penn Center for the Female Athlete. “Often these girls will have some sort of eating disorder — where they aren’t putting enough energy into their body to account for the calories they’re burning.”
While the female athlete triad has been around for decades, it wasn’t until around 2007 that the condition was thoroughly understood and defined. Since then, physicians such as Dr. Temme and Dr. Leitner, have been working to raise awareness for the triad among female athletes and their parents, coaches and healthcare providers.
“This is a condition that can be difficult to treat, and it requires a multidisciplinary team — such as the one we offer at the Penn Center for the Female Athlete — to assist with all aspects of the triad,” says Dr. Leitner. “This team includes sports medicine physicians and dietitians, physiologists, endocrinologists, gynecologists and sometimes behavioral health professionals.”
“It may also include athletic trainers and coaches, as well as the support of the family and teammates for a successful recovery,” adds Dr. Temme.
Tackling Athlete Nutrition
While missing periods and stress fractures are often the first signs of the triad, it’s the athlete’s nutrition that the Center is most interested in initially.
“When a woman is referred to us with triad symptoms, we will have her speak with our counselors and nutritionists to determine if there is a known eating disorder or nutritional deficit,” explains Dr. Temme. “The core component of the female athlete triad is nutrition — also known as energy availability. When this is present, the athlete’s bone health and menstrual function are also affected. By treating the nutritional deficits, we are also helping to treat these other conditions. The challenge is identifying these athletes early, since full bone density recovery may not be possible — especially in more severe or prolonged cases.”
Missing Periods and Hormonal Imbalance
In athletes with a missing or infrequent period, Dr. Leitner explains that she looks for any other underlying causes that need to be treated.
“A missing period in an athlete is never ‘normal’ and shouldn’t be dismissed,” she says. “It could be a sign of another problem, such as the triad, or even Polycystic Ovarian Syndrome, which isn’t uncommon in this age group. I use blood work and ultrasounds to make this determination. Then, if a hormone imbalance is to blame, our team will work with the woman to help achieve a return — or start — of a normal period.”
According to Dr. Leitner, the absence of a period doesn’t necessarily affect the woman’s reproductive organs, but it is an indicator of a potentially greater hormonal problem that can lead to osteoporosis or cardiovascular issues later in life if left unchecked.
“Not having a period when not on birth control is not a healthy thing,” Dr. Leitner adds.
“Many of these women are taking contraceptive pills, which is not what’s best for their bone health,” she continues. “We often have to convince them to stop birth control until their hormone levels and energy imbalances are corrected and then we talk about other contraceptive options such as the copper intrauterine device. This is effective but contains no hormones and allows for menstruation.”
Bone Health Key to Success
When a female athlete experiences a bone stress fracture, Dr. Temme is adamant that her healthcare providers look for other signs of the triad.
“While stress fractures may simply be related to training errors or overtraining, they may also be the first warning sign of the triad,” she says. “It’s important that providers determine if there are any nutritional or menstrual abnormalities that may be contributing to her injury or if there are red flags for low bone density. These need to be addressed to ensure recovery and prevent future injury.”
According to Dr. Temme, the adolescent years — especially the years surrounding a girl’s first menstrual period — are a critical time for bone growth.
“We often think of osteoporosis as affecting only older women,” she says. “The truth is that it can be seen in women who are post-menopausal — having lost the protective effect of estrogen on bone — or who failed to reach peak bone density in their youth. In severe cases, osteoporosis can be seen in teenagers and young adults and can be related to the triad.”
Supporting Female Athletes
All of this aside, Dr. Temme and Dr. Leitner agree that sports are great for women.
“Girls who play sports have higher self-esteem, graduation rates and better mental and physical health,” says Dr. Temme. “However, to achieve these positive outcomes, girls must be provided with a healthy environment in which to train and compete. This means ensuring a well-balanced diet with sufficient variety and caloric intake at the right times.”
She suggests that athletes work with a sports dietitian to ensure that their individual nutritional needs are met. Dr. Temme also recommends cross training to prevent overuse injuries and advises against sports specialization at young ages as this can increase the risk of overuse injuries and burnout.
“Bottom line, parents, coaches, healthcare providers and the athletes themselves just need to be aware of the triad,” adds Dr. Leitner, “and be on the lookout for any signs of a problem.”