Last year, back when this little blog had a mere fraction of the visitors it has now, I wrote about female athlete triad. Since it’s National Eating Disorders Awareness Week, I want to address this topic again, since honestly I feel it deserves a lot more discussion for female runners.
Female athlete triad is not an eating disorder, but it is oftentimes a consequence of disordered or restrictive eating.
Disclaimer: I am not a doctor. I am a certified running coach, but I can only discuss female athlete triad to a certain extent within my scope of practice. All of this information is based off of research, which is linked to the relevant source throughout this post for further reading. Individual metabolisms, hormonal levels, and chronic illnesses can all impact your menstrual cycle, bone density, and body weight as well, and thus do not make female athlete triad an one-size-fits-all diagnosis.
What is female athlete triad?
Despite what many athletes believe, loss of your period for several cycles in a row (secondary amenorrhea) is not a normal side effect of training. According to the American College of Sports Medicine, exercise alone does not cause amenorrhea. Rather, a combination of factors that lead to a negative energy balance over an extended period of time cause amenorrhea.
Three symptoms indicate female athlete triad: low energy availability, menstrual dysfunction, and low bone mineral density (source).
Typically speaking (but not in all cases), female athlete triad is diagnosed off of low body weight, amenorrhea, and osteopenia (low bone density) or stress fractures.
Low body weight can often indicate low energy availability, but one runner can have her period at a low weight, while another loses it at a healthy but lean weight. Thus, disordered eating habits and low energy levels rather than body weight are better indicators of low energy availability.
Even if you’re not dieting or restricting your eating intentionally, some female runners struggle to fuel their bodies properly while running high volume.
While amenorrhea is the most common indication of menstrual dysfunction, it is not the only indication. Some women may experience suddenly irregular periods, miss one period from time to time, or experience changes in the severity of their PMS.
What are the risk of female athlete triad?
I know that skipping periods sounds awesome, but amenorrhea bears serious health consequences. In addition to infertility, amenorrhea occurs when your body is not producing enough estrogen or progesterone. Since running can reduce your estrogen levels, this is something all female runners need to be aware of.
Estrogen plays a vital role in bone health. Studies find that amenorrheic runners have significantly lower bone density than female runners who get their periods. Without enough estrogen and energy to support a regular period, these women also lack the estrogen necessary for bone maintenance. The more periods you skip, the more your bone health declines, sometimes to an irreversible point. And, of course, as your bone health declines, your risk of stress fractures increases.
How do I prevent female athlete triad?
Sadly, as this article from Runner’s Connect states, up to 60% of female athletes will experience athletic amenorrhea, which can be a precursor or indicator of female athlete triad. So how do you prevent it?
First off, track your period. Note its duration, its frequency, the severity of your PMS, and any changes in your cycle. You can also record certain signs during the other weeks of your cycle to track ovulation, which will further help you note an irregularities in your cycle. There are several resources available online and in phone apps to help you track your cycle.
Second off, make sure you are eating enough. I’m not a proponent of counting calories, but for some female runners, this practice ensures that they are actually eating enough to balance the calories burnt in running, strength training, cross training, and daily life. Most of all, listen to your hunger and do not restrict your eating.
Finally, take preventative measures to prevent osteopenia. Make sure you are consuming the proper nutrients in addition to eating enough. Calcium, vitamin D, vitamin B12, and iron are all vital nutrients for healthy bones and healthy menstruation. Strength training also promotes a healthy bone density, so include a few weight lifting exercises in your routine as well.
But what if I’m on the pill?
Sadly, there’s not a lot of clinical research available on the impact of the pill on female athlete triad.
Lots of women take the pill to control painful periods (studies are finding that periods can be “almost as painful as a heart attack,” according to this article from Quartz) or to manage hormonal disorders. However, as someone like myself who suffered from secondary amenorrhea due to PCOS or endometriosis can tell you, the pill can make you have a period when your body would not have one on its own.
By that logic (and someone please correct if I’m wrong), the pill can mask amenorrhea in female runners. You still get your monthly period even if your body has stopped ovulating. Women who take the pill continuously face the same problem, as they cannot use their period to gauge whether they are at risk for amenorrhea and female athlete triad.
So what if you’re on the pill? You should discuss this with your doctor and make sure you are eating enough and eating the right nutrients for bone health.
Fully honest disclosure here: I have been diagnosed with PCOS-like symptoms and have also experienced endometriosis-like symptoms (neither can be fully diagnosed without surgery), and my medication keeps me from getting a period. Even if I was not on medication, my period would be too irregular to use as a gauge for female athlete triad, so I make sure I consume enough calories, healthy fats, and nutrients such as calcium and vitamin D.
To put it bluntly, I’d rather be a few pounds heavier (still at a very healthy weight, so we’re talking vanity/racing weight here) than be distance runner waif thin and worry (even more) about osteopenia and stress fractures.
Of course, what works for me may not work for you, so please take the advice of your medical professionals over me when it comes to serious issues like your period, medication, and hormonal disorders.
Treatment of female athlete triad
If you suffer from the symptoms of female athlete triad, please speak to your doctor, OB/GYN, nutritionist, and/or running coach. A break from running will not simply reverse female athlete triad, as it requires addressing your nutrition, training, and overall health. Some runners can recover quickly, while others require more intensive treatment.
Meredith at The Cookie ChRUNicles is talking more today about amenorrhea, female athlete triad, and running, so be sure to check out her post!
I don’t want to ask any pressing questions today due to the sensitive nature of this topic, but I do want to encourage a judgment-free and honest discussion of running and periods in today’s comments.