Tracey Clissold, Sport and Exercise Lecturer, and Champion Runner
Over the years I have personally experienced symptoms associated with the Female Athlete Triad, sometimes having lapses of years between menstrual cycles. I had a stress fracture in 1995, a “red flag” for the Triad, which put me out of contention for the 1996 Atlanta Olympic Games.
My interest in this area is both personal and professional, as I come into contact with too many young female athletes who fail to understand the consequences of suppressing their monthly menstrual cycle. My concerns are for the long-term consequences of what many coaches still wrongly consider to be “a positive training indicator” for elite female athletes. My primary focus when educating young female athletes is on the achievement of their “peak bone mass” during the adolescent period, with strong reference to nutrient timing and calcium intake.
As an athlete I have personally known elite female distance athletes who have quickly regressed over several short years from champion athletes to frail individuals barely able to bear their own weight. I believe this tragic chain of events can be avoided by educating and empowering female athletes, their coaches and families.
Eske Dost, Sports Nutritionist
My experience with the Female Athlete Triad comes from being a former NZ representative lightweight boxer and working with high performance athletes as a sport nutritionist. Over the years I have learnt that it is possible to achieve our sport, athletic and body composition goals safely and without needing to practice disordered eating behaviours or to train excessively. With the right support and education, help is available.
Long-term health is of utmost importance – far greater than the pursuit of our sporting goals and achievements. Female athletes and exercising women need to take responsibility to educate themselves on how energy requirements and body composition goals can be met without compromising health. Iron deficiency, colds and flu through a depressed immunity and injury are just some short-term effects of low energy availability. Amenorrhea and osteoporosis are some possible long-term effects that can end sporting careers. These effects can also be avoided with an appropriate nutrition approach that meets energy requirements without affecting long-term health.
Wouldn’t it be wonderful to be able to enjoy our sport and health long after our sporting career has met its potential, and to pass on that legacy of good health and well-being to our children, nieces and nephews? My recommendation is seek help from sport providers who have experience in your sport and/or sport nutrition and who can give you the advice, education and support you need.
Dr Stella Milsom, Endocrinologist
Bone mass and bone mineral density (BMD) in an adult, depends on both the peak bone mass achieved by early adulthood and factors that might cause accelerated bone loss. A female accumulates much of her total bone mass between puberty and her early 20’s. Therefore, if total bone mass achieved during this vital time is diminished for any reason, her final bone density will be lower placing her at increased risk for lower BMD and fracture risk later in life.
One of the most important contributors to normal bone mass in a woman is estrogen. Estrogen levels are low before puberty and steadily rise during the pubertal years to peak levels that remain steady until the onset of menopause. Any health issues which delay the onset of puberty, or even cause puberty to regress, will lower estrogen levels and compromise bone turnover. Generally, the first period, known as menarche, should have started by age 14 years, Within 1-2 years periods should come in a regular 2-35 day cycle. Absent or irregular periods can be a sign that estrogen levels may be low which in turn places bone at risk.
Absent or infrequent periods are often associated with restricted dietary energy intake, failing to increase energy intake when physical activity/exercise training load is increased and being under too much personal, work or physical stress. These factors, individually or in combination, can lead to low estrogen levels and cessation of menstruation. Some women may be more susceptible to menstruation ceasing under these circumstances because of additional genetic factors. This problem is called hypothalamic amenorrhea (HA) and can happen at any age in reproductive aged women. When this condition occurs in adolescents, the peak bone mass achieved is compromised and almost impossible to make up later. When HA occurs in women in their 3rd and 4th decades, bone loss is accelerated, just like the accelerated bone loss that occurs at menopause. This means the risk for fracture later in life is significantly increased.
There are other health issues with HA. Fertility is compromised by inhibition of ovulation and there is increasing concern that the lack of estrogen in reproductive aged women may increase the risk of cardiovascular disease.
There are other causes of irregular periods but this is an important sign not to be ignored. Girls and women who are concerned should see their general practitioner who may perform some tests and possibly refer on to an endocrinologist.
What can girls, parents and teachers advise in order to maximise bone mass accrual and reproductive health during these years?
A net energy deficit is a major contributor to continuing hypothalamic amenorrhea so eat well, and include a variety of foods to ensure all micro and macronutrients are consumed. Girls and women with large exercise training loads should take particular care to get nutritional advice. Do not restrict food groups such as carbohydrates or fats, which are necessary for a balanced diet. Calcium and vitamin D are important for bone health. Aim for 1000-1200mg calcium per day (good sources include dairy products and brazil nuts) and enough sunshine to get adequate vitamin D synthesis (30 minutes in early or late part of day without sunscreen). Many dairy products are now fortified with vitamin D, so check nutritional information labels.
Keep a log of your menstrual cycles, if you notice menstrual cycles length increases or decreases as you increase exercise load, you need to eat more!
Report any of the following: menstrual irregularity or cessation >3 months; if periods have not commenced by the age 15 years; or if there is no bust development by the age of 13 years.
Key to reversing HA:
consider changes to energy intake
reduce, stop or change the type of exercise being preformed
develop strategies to minimise both external and internal stress
Vicki Harber, Professor of Exercise Physiology
“Some female athletes struggle to balance the needs of their body with the energetic and psychological demands of their sport. Many body systems can suffer, but three major consequences of energetic insult is impaired reproductive function (e.g. amenorrhea), reduced bone mineral density and greater risk for musculoskeletal injury. This knowledge should be valued and infused into all programmes working with girls and women to avoid the negative implications of energetic insult”
“The advantages of regular participation in sport and physical activity (e.g. prevention of chronic disease, higher self-esteem, better grades, less depression, lower rates of teen pregnancy and engagement in less “high-risk behaviours” such as drug use and smoking) far outweigh any detrimental outcomes. Thus, as unique issues for female athletes are identified, in no way should this knowledge be used to discourage girls and women from training and competing at the highest level. In fact, this knowledge should be valued and infused into all programmes working with girls and women to avoid the negative implications of energetic insult”
“Menstrual status is an indicator of overall health and well-being; it provides information about energy status, risk of musculoskeletal injury, nutritional intake, metabolic and hormonal condition, recovery and other areas relevant to peak performance”
Competitive New Zealand Athlete
“I probably represent the typical “0800 Go Hard” woman of today’s era in that I rarely get the work, sport, life balance right. For a few years there, my relationship with exercise and diet was pretty unbalanced too”.
Competitive Endurance Athlete
“I came off the pill when I started training harder for my sport. My period didn’t return despite me not losing weight or having low body fat. A gynaecologist said if I wanted periods I could go back on the pill. He mentioned an energy deficit but wasn’t concerned about my bones and didn’t suggest I get nutritional help. I should have sought another opinion but time went on and I forgot about not getting my own period.”
Wendy Sweet, Sport and Exercise Nutritionist and Lecturer
For over 25 years I have been involved with high performing New Zealand youth female athletes, clients and students participating in school or club sports. More recently, having a female youth athlete daughter has given me specific insight into the personal challenges that young athletes face in regard to navigating the incredibly challenging and confusing world of elite sporting performance.
Without a doubt, the single most important concern for the female athletes and their parents that I have conversed with, has repeatedly been the conundrum of maintaining appropriate levels of daily energy for training and competing as well as the maintenance of optimal health to support motivation and attention throughout the school day. The plethora of conflicting information on appropriate strength and conditioning methods as well as nutrition, hydration and supplementation means that many coaches, trainers and parents communicate conflicting advice to the female athlete. Alongside this, the younger female athlete must also navigate the ever-present social, cultural and environmental influences on what is portrayed as the image of the ‘ideal’ (younger) female body.
Effective, evidenced training and nutrition strategies for maintaining a healthy body state must become a critical component of the female athlete’s performance ‘tool-box. Attention to strength and conditioning which works in with the female hormonal cycle is a new and exciting area of knowledge. Of course, this, accompanied with a daily strategy of eating for Energy, Performance and Recovery will enable young female athletes to effectively climb each rung of the ladder towards success!
Dr Brett Smith, High Performance and Exercise Physiologist
The challenge for elite female endurance athletes is the strategies most likely to result in success are also likely to increase the risks of amenorrhea and associated health problems. Through a decade of work with successful female Olympic endurance athletes our research has shown that those female athletes who can continue to positively adapt to extreme levels of physiological (and psychological) stress are more likely to succeed. This stress often manifests itself in severe dysfunction in many immune, endocrine and metabolic measures during the intensive phases of the training cycle. In some cases these abnormalities can be observed for a period of weeks.
The health issues for the female athlete are further exacerbated by intervals of negative energy balance (weight loss) where the athlete tries to achieve their race weight. It is important to be aware that success for most female endurance athletes requires maximizing their power to weight ratio. While in some cases maintaining race weight could solve this problem, unfortunately for some, the long-term maintenance of the optimal race weight can cause its own problems (e.g. depressed essential body fat). Hence, while the athlete may be able to tolerate short to moderate periods at this weight, prolonged exposure may cause health problems.
The general adaptation syndrome describes that greater stress results in a both a greater chance of a large adaptation and a greater risk of mal-adaptation. On the other hand a reduced training load decreases both the risk of poor health and the chance of optimizing endurance performance. It is possible that optimizing performance and health are mutually exclusive for elite female endurance athletes. Successful endurance athletes’ often perform an extremely difficult balancing act, constantly cycling in and out of periods of poor health and injury. This creates a difficult challenge for sport scientists and medics, who to be relevant need to support the female athletes quest to achieve their performance goals while trying to maintain good health. The large incidences of amenorrhea in elite female endurance athlete are testament to these difficulties.
It is my belief that any successful strategy must be individualized for the athlete and will require regular monitoring (possibly daily in the early stages) which creates it’s own logistical and financial limitations. Other effective strategies would include better education of coaches to these issues and possibly recruitment of more female endurance coaches. I also believe that it is important that young motivated female endurance athletes are fully aware of the risks associated with being an elite performer.