There is an epidemic happening in the endurance female athlete community that is dramatically impacting not only performance, but long term health. The Female Athlete Triad (the Triad), a term coined in 1993 by the American College of Sports Medicine, refers to a syndrome commonly seen in athletic women. It involves an interrelationship of disordered eating, menstrual irregularity and low bone mass. Although the exact prevalence of the Triad is unknown, studies have reported disordered eating in up to 62 percent and amenorrhea (absence of menstrual cycles) in up to 66 percent of female athletes. Components of the Triad are often undetected because of the secretive nature of disordered eating and the common misconception that missed periods are a normal result of training. At its extreme, athletic women with this disorder have a severe eating disorder (ex. anorexia or bulimia), are amenorrheic, and have osteoporososis (severely low bone density). However, more commonly in our rowing community, it is more of a subtle continuum.

We’ve all seen or heard of certain lightweight rower behavior: “Oh, I remember that summer when I didn’t get my period for four months, and I still sucked seven pounds off for Canadian Henley.” “I once binged on 10 vending machine candy bars at a rest stop when driving back from U.S. Nationals my first summer of being a lightweight.”

In fact, Skittles took on a whole new meaning for me as our lightweight quad sucked on them and spit them out to lose that last collective half pound at world’s weigh-ins years ago. There’s no question that lightweight rowers, since the beginning of the sport, developed some strange and unhealthy habits. There are very few lightweight women who haven’t experienced at least one skipped menstrual cycle during their rowing careers.

The Triad is increasingly common among female athletes of all sizes. Many open weight women have admitted to losing their menstrual cycles during their most rigorous training as well. How is that possible? Isn’t it just a low weight and body fat issue? That was the old theory. It is now better understood that the Triad is largely an energy deficit issue. If you expend more energy (through exercise and stress) than you consume, your body will adjust to conserve energy.

Energy Availability (EA) = Dietary energy intake (EI) - Exercise energy expenditure (EEE) normalized to fat-free mass (FFM): EA= (EI- EEE)/FFM

For example, using a 60 kg (132 pound woman) with 12 percent body fat, who eats 2,000 calories a day and burns 650 calories in a practice:

EI= 2000 kcal/d, EEE= 650 kcal/d, FFM= 60 - (60 x .12) = 52.8 kg

EA= (2000-650)/52.8 = 25.6 kcal/kg of FFM/d

Studies have shown that when animals or humans had their energy availability cut from 45 kcal/kg of FFM to fewer than 30 kcal/kg of FFM, the normal variation of hormone secretion was drastically changed. Low energy availability alters levels of metabolic and reproductive hormones including estradiol, leptin, insulin, cortisol, growth hormone and thyroid hormone. Such hormonal changes can disrupt the menstrual cycle, which has a large influence on bone density.

In women, 90 percent of adult bone mass is acquired by age 16 or younger, and peak bone mass is achieved by around age 30. Thus, disrupting the menstrual cycle during adolescence and early adulthood has a profound effect on bone health. Women with low bone mass fracture more easily. In rowing, this often translates into frequent rib stress fractures, and later in life, non-traumatic vertebral and hip fractures.

So what’s a woman to do?

Adjust your training: Quick weight changes, absence of specific nutrients and prolonged nutritional deficits all stress the body and can result in menstrual irregularities. There are some basics to which all women should adhere. Weight-bearing exercise should be part of every woman’s routine. Rowing puts positive stress on the spine, increasing bone density in the vertebrae. Similarly, running puts stress on the pelvis and legs, increasing hip bone mass. Cross training breaks up the monotony, while also helping with muscle balance and bone strength.

Supplement your diet: Premenopausal women should get about 1,000 to 1,200 mg of calcium a day. The body does not absorb more than 500 mg at a time, so this calcium intake should be divided up to total the daily goal. As women become postmenopausal, they should increase calcium intake to 1,500 mg a day. All individuals should also have a vitamin D level of 32 mg/dL or more. About 1,000 IU of vitamin D and some sun exposure can usually achieve this. After this, food intake gets a bit trickier, so meeting with a nutritionist to analyze individual caloric needs is an excellent start. It’s easy to get into eating ruts, skipping vitamins and nutrients, calling coffee breakfast while rushing out the door. It’s also difficult to be aware of caloric expenditure. Energy availability should not drop below 30 kcal/kg of FFM. Periodization of training should be accompanied by periodization of eating. Heart rate monitors and scales are only rough guides to caloric balance. Working with a nutritionist can help find concrete nutritional deficits or imbalances.

See a doctor: If a woman doesn’t experience resumption of her menstrual cycle, or continues to suffer bone injuries, it is also extremely important to see a physician. Sometimes an apparent case of the Triad can actually be another hormonal disrupting cause such as polycystic ovary disease, a pituitary tumor, thyroid dysfunction or another issue requiring medical or surgical therapy. For young athletes suspected of the Triad, doctors may order bone density measurements (DEXA scans), which were formerly reserved for older post-menopausal women. Catching the problem earlier can help focus the treatment. While oral contraceptive pills are often a short-term solution to supplying estrogen to a non-menstruating woman, finding the true cause of the missed periods and trying to resume normal menstruation has proven more effective for building and maintaining bone density.

Don’t ignore it:  Finally, the stresses of competing largely influence an athlete’s diet and training habits. We need to use more resources including sports counselors, psychologists and psychiatrists to help girls and women develop good habits early, and not sabotage their performance or health with poor habits or coping mechanisms. Coaches need to be aware of the Triad and find ways for athletes to have a comfortable forum to discuss eating issues, menstrual irregularities and injuries. This is not just a problem of the few extreme, emotional or “unbalanced” athletes that often stand out on a team. It is a problem even for the most well-intentioned, disciplined, successful leaders in the group. The Triad will most likely affect you or a teammate at some point in your athletic career. It is very important that young women don’t ignore these issues, but seek the advice of coaches, nutritionists, therapists and medical specialists to get their bodies back in balance and positioned to perform optimally.

Dr. Kate Ackerman is a former national team member and current rower specializing in sports medicine and endocrinology in Boston. Contact her at kathryn.ackerman@childrens.harvard.edu.