Too Little Eating, Too Much Exercising? Risks for Female Athletes

Does this situation sound familiar to you?

A young woman with a passion for working out, participating in a competitive sport, and taking pride in taking care of her body. In order to maintain her lean figure, she only consumes enough calories to feel relatively full. As she feels herself becoming fitter, she continuously increases her training time and exercise intensity while reducing the number of rest days.

Although she realizes her energy needs are rising, she is reluctant to eat more, rest more, or slow down. Soon, she notices irregular periods, experiences more aches and pains, and struggles to sleep. She eventually develops chronic foot pain but continues to exercise, until one day she sustains an injury and is rushed to the ER.

Female athlete triad is a syndrome that affects women, especially young women and teenagers, caused by an energy deficiency. Essentially, it involves consuming too few calories while simultaneously “burning” too many, often due to overtraining. The symptoms of female athlete triad occur on a “continuum of severity,” meaning that some women experience more severe consequences depending on genetic factors, hormone levels, stress loads, and energy needs.

Young women are particularly at risk for experiencing an energy deficiency due to several factors, including societal pressure to be thin, the rise in popularity of female sports, the growth of the diet industry in recent decades, and the pressure to exercise (sometimes excessively).

Symptoms

The three most prominent interrelated symptoms caused by female athlete triad are:

1. Experiencing an energy deficiency of calories (which can be caused by an eating disorder in some cases but not always)
2. Having menstrual abnormalities, including missed periods
3. Experiencing bone loss/osteoporosis

Not all three symptoms need to be present for a doctor to diagnose female athlete triad. Sometimes one or two of the symptoms may be experienced, but the woman’s history of eating and exercising can be sufficient to convince the doctor.

It is also possible that female athlete triad can occur alongside other health problems, such as hormonal imbalances, thyroid disorders, eating disorders, polycystic ovary syndrome (PCOS), and autoimmune disorders.

Common signs and symptoms of female athletic triad include:

• Irregular periods and missed menstrual cycles
• Low bone density and increased risk of osteoporosis
• Frequent injuries, including fractures, sprains, and breaks
• Muscle aches or pains
• Fatigue
• Depression and anxiety
• Appetite and weight changes (usually weight loss)
• Thyroid dysfunction
• Digestive issues, especially constipation
• Trouble sleeping (due to high cortisol levels)
• Low body temperature

While the effects of female athlete triad can be serious and even permanent, for many women who treat the problem early, the long-term prognosis is considered good. Suffering permanent infertility, bone loss, or requiring hospital visits and surgeries to correct injuries is not common when women address the underlying issues, such as their diets and energy needs.

Who’s Affected by Female Athlete Triad?

As the name implies, female athletes are at the highest risk for female athletic triad, but this does not mean you have to be a college athlete, competitor, or professional. Every young girl or woman is capable of experiencing female athlete triad if they expend more energy than they consume!

The groups of women who are at the highest risk for developing female athletic triad include:

• Female athletes who train vigorously (such as high school, college, or professional athletes), especially if they are under a lot of pressure from teammates, coaches, or parents – this can increase the likelihood of overtraining.
• Women who practice sports regularly for fun, especially sports with an aesthetic component (such as dancing, ballet, figure skating, or gymnastics).
• Women who practice exercises or sports tied to fitting within a weight class (such as tae kwon do, judo, or wrestling).
• Women with eating disorders like anorexia or bulimia (and not practicing intuitive eating).
• Women who are “chronic dieters” or “yo-yo dieters” who follow a low-calorie diet and can approach starvation mode.
• Women with compounding psychological disorders, such as anxiety, depression, or obsessive compulsive disorder.
• Women with other hormonal issues, such as PCOS, adrenal fatigue, or chronic fatigue.

The American Academy of Orthopedic Surgeons recommends asking yourself these questions to see if you (or a daughter, friend, sister, etc.) might be at risk:

1. Are you dissatisfied with your body?
2. Do you strive to be thin?
3. Do you continuously focus on your weight?

Other questions to ask include:

• Do you regularly play sports, especially sports that reward being thin for appearance (such as figure skating or gymnastics)?
• Are you currently focused on increasing your training to improve your athletic performance (such as distance running or rowing)?
• Do you follow trends and advertising that might encourage you to try to reach an unhealthy weight level?
• Do you suffer from low self-esteem or depression and focus on weight loss often?
• Do you feel pressure to lose weight from athletic coaches or parents?

Causes

In its simplest form, female athlete triad is caused by not providing a woman’s body with enough “fuel” to keep it going. In many ways, the delicate balance of hormones in the female body boils down to having enough positive “energy.”

An energy deficiency is an imbalance between the amount of energy consumed and the amount of energy expended. Low-calorie diets, overtraining, and stress all deplete energy, while getting enough rest and eating enough calories increase energy. We lose energy through exercise, experiencing trauma or low-grade chronic stress, skipping sleep, and having a poor diet that taxes the body.

For some women, female athlete triad is caused by a conscious restriction of food intake or an eating disorder. Keep in mind that not every woman dealing with “disordered eating” will be diagnosed with anorexia or bulimia – there is a large gray area that includes millions of women who are essentially “chronic dieters” who struggle to lose weight. This is usually triggered by problems with body image and a “high drive for thinness” due to societal pressure. Attempting to lose weight repeatedly or to maintain an unrealistically low weight can cause some women to eat less than their bodies require for months or years at a time.

At the same time, more and more women are taking up competitive sports and intense exercise programs, which both require a lot of energy. There are numerous proven benefits of exercise, but in some cases, too much exercise can cause as many problems as too little.

When women exercise vigorously – for example, by training or practicing a sport for many hours a week, such as during college – their energy needs significantly increase.

However, when a woman is unwilling to eat more calories to prevent an energy deficiency, a hormonal imbalance can develop. When female sex hormone levels drop due to the body being overly stressed and fatigued, several dangerous symptoms occur in the following ways:

Symptom 1: Irregular Periods/Amenorrhea

Many experts consider hormonal issues, menstrual disturbances, and amenorrhea (missed periods) to be the most serious risk associated with the triad. Too much exercise combined with not eating enough calories decreases hormones such as estrogen, estradiol, and progesterone, which are responsible for regulating a woman’s menstrual cycle.

Amenorrhea is defined as having no menstrual period for three months or more. Although many female athletes can still have fairly regular periods or irregular periods that come and go (known as “functional hypothalamic amenorrhea”), they may still be suffering from serious hormonal problems in other ways. Reports show that women with female athlete triad also often experience “oligomenorrhea,” which is defined as a menstrual cycle greater than 35 days.

Why does an energy deficit cause periods to change or stop? The female body is highly sensitive to perceived states of “famine” or starvation. This is a built-in survival mechanism that has evolved over thousands of years to prevent pregnancy when a woman’s body cannot meet the high energy demand.

Many women with female athlete triad will stop having their periods completely, notice they become less frequent/irregular, and experience fertility problems. Young girls/teenagers who play sports intensely and under-eat may never have their periods start as the body requires a high amount of energy to complete the puberty process.

Missing a period can be a result of several different hormonal issues besides female athlete triad (such as PCOS or even pregnancy), but it is usually a warning sign that something is not right or has changed. When you miss your period, it also means that other parts of the body may be suffering as well, such as your mental processes/mood, digestive system, and ability to maintain bone health.

Symptom 2: Bone Loss/Osteoporosis

One of the primary ways that hormonal disturbances in women damage their health is by increasing their risk of low bone mass, sometimes leading to weakened bones or osteoporosis. Low female sex hormone levels, including estrogen, weaken bones and can increase the likelihood of fractures, injuries, stress fractures, and breaks.

Estrogen is usually abnormally low in girls with female athlete triad, especially when they do not eat a nutrient-dense diet. For example, developing a vitamin K, vitamin D, or calcium deficiency due to a low-calorie, low-nutrient diet increases the risks of low bone mass.

Ironically, having strong bones is essential for being an athlete, and osteoporosis or bone fractures can ruin a female athlete’s sport career, exercise hobby, or passion. What’s more unfortunate is that during the teenage years and through her 20s, when she needs to build strong bones the most, skipping eating enough nutrients/calories to support this process can cause permanent damage to the skeletal system that can last a lifetime. Unfortunately, some women may not even realize they are damaging their bones until it is too late when they reach menopause and bone loss accelerates further.

Symptom 3: Fatigue/Mood Changes

Eating low in calories (often a low-fat or low-carb diet), coupled with hormonal changes and constantly feeling tired or achy, is enough to make many women feel more anxious and depressed than usual. Over-exercising and under-eating can both increase cortisol levels, which is the body’s primary stress hormone that makes it difficult to sleep well, have lasting energy, and maintain a positive outlook on life.

How to Treat Female Athlete Triad

1. Increase the Amount of Energy (aka Calories!) Going In

According to the American College of Sports Medicine, “energy availability is the cornerstone on which the other 2 components of the triad rest. Without correction of this key component, full recovery from the female athlete triad is not possible.” In fact, the International Olympic Committee even proposed changing the name of the female athlete triad to “relative energy deficiency in sport” to represent the need to increase calories and address health issues caused by low energy availability!

Even in women who do not consider themselves “athletes” or excessive exercisers, changing their eating habits and dieting can cause their periods to change or even stop, energy levels to plummet, moods to change, and so on. Chronically running low on calories can also have effects such as slowing the metabolic rate, lowering immunity, inhibiting normal protein synthesis, and damaging cardiovascular and psychological health.

Following low-calorie diets and being prone to disordered eating can cause dehydration, muscle fatigue and weakness, an erratic heartbeat, kidney damage, and other serious conditions. Active teenagers, young girls, and women may require more calories than they realize. For example, studies show that calorie needs for physically active women of “reproductive age” may be underestimated.

Women in their teens and 20s who are relatively active usually need between 2,000-2,400 calories every day just to keep up with their energy demands and maintain their weight! For some female athletes, that calorie demand may reach 3,000 or above. If you suspect you may be under-eating for your needs, it is a good idea to figure out how many calories you really require every day and ensure you eat around that amount. Also pay attention to your body’s “biofeedback” so you can make adjustments. Are you losing weight easily? Feeling fatigued and not sleeping well? Dealing with bad digestion? If yes, then you might need to increase calories more.

2. Slow Down the Amount of Energy Going Out (aka Too Much Exercise!)

Many women with female athlete triad need to drastically reduce exercise in order to resolve their underlying issues – some even need to quit completely for a while. Although it may seem scary, unnecessary, or too drastic, giving your body enough fuel and rest is crucial for fixing hormones. If you are unsure how much exercise you can tolerate, you may want to consult a physician, personal trainer, or physical therapist to take a fitness test, have a bone mineral density test done, and check your heartbeat and other vital signs. If you have recently significantly increased your physical activity, you will want to back off and perhaps try more gentle forms of exercise, such as walking, yoga, or swimming. It may be difficult to put your favorite vigorous sports on hold for a while, but not all exercise programs are suitable for everyone, especially if they are causing you to become injured, tired, and sick.

3. Get Enough Sleep and Rest Between Workouts

Skimping on sleep only makes it harder for the body to recover and bounce back after workouts. Your body needs sleep to produce and balance hormones, repair damaged tissue fibers, and regulate your appetite and mood. Do you feel like you are always tired but cannot sleep? Ironically, overtraining and stress can increase cortisol, which can make it even more difficult to sleep well at night. If you currently find it difficult to sleep no matter what you try, focus on reducing stress more, eating more nutrient-dense calories (possibly including a snack before bed), and lowering the intensity of your exercise.

4. Reduce Stress Levels and Inflammation

Chronic stress and inflammation can make any health condition worse, including hormonal imbalances, mental disorders, and bone loss. High levels of stress alone can sometimes change a woman’s menstrual cycle and alter her reproductive hormone balance. Inflammation can exacerbate menstrual problems, make sports-related injuries worse, and complicate other health issues. It is important to do whatever you can to reduce the impact of stress in your life, such as journaling, meditation, prayer, or speaking with a therapist. When it comes to lowering bodywide inflammation, focus on eating a nutrient-dense diet with plenty of anti-inflammatory foods while also reducing your intake of sugar and processed foods.

5. Consider Talking to a Professional

If you think the condition has become worse, try talking to your doctor, a physical therapist, or a psychologist to get the help you need. Your doctor will likely want to know about your medical history, including: your physical activity, what you eat, your history of menstrual cycles, your hormone levels and whether you use birth control pills, if you have ever suffered from fractures or injuries