Understanding the Female Athlete Triad and How to Beat It

Generally, exercise is known to be a beneficial component to a healthy body. Most people begin an exercise program for the sake of losing weight, which is then coupled with lowering calories and restricting certain types of food. Over time, the weight comes off, you feel more energized, and the benefits of these changes are recognized. Hopefully for the most part these lifestyle habits continue in order to maintain the healthy bodyweight. In the world of sports many athletes, especially women, exercise and diet intensively in hopes to enhance their performance. When it does, the notion is to continue the intense regimen. Little do these athletes know that the long-term effects of these habits become risky, particularly in the female population.

The Female Athlete Triad is a syndrome consisting of three symptoms: energy deficiency, menstrual irregularity, and bone loss. It is significantly common in the running population but can be found in many other sports. Most of these symptoms are ignored initially due to the fact that one is able to perform just fine. The majority will pay attention once an injury occurs. The syndrome usually begins with the intent to lose weight in order to improve performance. For runners, it is the same concept as wearing lighter running shoes—a lower bodyweight versus being overweight generally helps you run faster since your joints have less to carry. Once an athlete realizes the weight loss assists their faster paces, they want to continue getting lighter.

This pattern of dieting and intensively exercising is the beginning of the Female Athlete Triad. This eventually leads to developing eating disorders, menstrual problems and low bone mineral density, yielding a high risk of fractures. For women who were already at a low weight to begin with, the resulting outcomes are expedited. Of course, the end result of a devastating fracture is not something an athlete is seeking by adopting these habits, but in many cases it is inevitable. Although difficult to diagnose early on, this condition is most definitely preventable. The key is to be educated on and aware of the symptoms and what a true healthy body means.

Energy Deficiency

The first and most common symptom of the Female Athlete Triad is energy deficiency. Originally the term used was disordered eating, but over the years, energy deficiency seemed more appropriate because extreme weight loss and poor diet compared to the extreme exercise can exist without an eating disorder in the picture. Younger females already have the pressure these days to be thin, and when sports come into play, the emphasis is much greater. As mentioned earlier, being thinner, rather than overweight, may yield faster finish times for runners. Coaches, teammates, and parents sometimes play a role in the encouragement of “being thin to win”. This along with society’s reinforcement of the beauty of thinness is what eventually leads to eating disorders in young girls.

Anorexia and bulimia are the most common eating disorders among women and are fast and true ways to lose weight. By no means, are these weight loss options anywhere near healthy, though. Restricting calories by extreme dieting and excessive exercise are symptoms that fall into the categories of anorexia and bulimia. The extreme diet will only lead to lack of nutrients, as well as fluid and electrolyte imbalances, that will eventually leave the athlete with very low energy, poor strength and endurance, impaired reaction times, and risk of injury. Initially these outcomes go unnoticed and the athlete is attracted to the improved performance in her sport. The negative outcomes will then arise once there is a significant amount of weight lost.

Menstrual Disorders

Following the poor diet and exercise habits mentioned arises the next component of the Female Athlete Triad. Excessive exercise and calorie restriction leads to extremely low levels of estrogen. Research shows that women in good health who train for marathons can lower their estrogen levels by over 50%. Given this data, it is clear that athletes who are at an unhealthy bodyweight with significantly poor eating habits and incorporate a high level of training, most definitely lower estrogen levels by a much greater amount.

Estrogen is responsible for the growth of reproductive organs, regulation of the menstrual cycle, and the protection of bones. Normally the body will compensate for a large calorie restriction by lowering metabolism in order to maintain body weight. The loss of the menstrual cycle, or amenorrhea, is a sign that the body is in an energy deficient state. Although amenorrhea as part of the Female Athlete Triad is brought about by energy deficiency, it is also linked to low body fat percentage, nutrient imbalances, and physical and mental stress.

Bone Loss

Poor diet and the loss of estrogen are the leading cause of low levels of bone mineral density. Exercise, mostly weight-bearing, is known to be beneficial to bone health. Therefore running should be a healthy sport for the bones. Several studies on the bone health of female athletes have been conducted and the majority conclude that the bone loss occurs in the cases where there are menstrual irregularity, particularly women with amenorrhea. One study even showed that these intense athletes have bone mineral densities comparable to women in their 80s! This low bone density puts females at an extremely high risk of fractures. Stress fractures are in fact more common in athletes who present with menstrual irregularities, due to low estrogen levels.

The cases who eventually gain weight to a healthier point, resume regular menstrual cycles, and get back to a healthy diet for their training improve their bone density levels. Research has indicated that if the negative symptoms of the Female Athlete Triad are not addressed early on there is a chance that some of the resulting bone loss is irreversible. It is crucial to be aware of this condition and the early signs including extreme dieting and excessive training for the means of dropping weight for performance. Although initially an athlete may perform better, the excessive training is not realistic for the long term and will only lead to burnout and injury among other medical problems.

Steps to getting back the much needed energy, a regular menses, and strong bones start with lowering mileage and intensity, adding more calories to your diet, and regularly following up with your doctor, preferably one specialized in sports. It may seem scary to lower your running load and eat more, but taking these steps gradually can assure you get to and maintain a healthy weight and not alter your performance gains.

Race Recap: Miami Marathon 2020

“Dear legs, give me a great race today.” This was exactly what I told myself when my corral was moved up to the start line. This was going to be my 8th marathon attempt and 12th time at the start line of the Miami Marathon & Half Marathon. Even having experienced the Boston and New York City Marathon, Miami is still my favorite race. It has so much to do with the fact that it’s my hometown and I know the streets like the back of my hand, but even the non-locals say it’s great for its amazing scenery, flat and fast course, and pretty comfortable weather. You can’t go wrong with the events surrounding the race either—it truly gets you in the mood to join the running community!

It was 71 degrees, which was probably too warm for everyone else, but it was the perfect racing weather in my book. Although the body has to work harder to keep a proper core temperature and avoid overheating, I have been so used to running in the heat. I had my hydration and fueling plan down-packed and my salt tabs ready. Everyone asks me how I carry these along with an entire 8 gels without a waist belt or armband. I literally stuff 4 in my sports bra with the salt tabs and the others tucked in my running shorts waistband. It’s easy to grab and you get used to just getting chafed and dealing with it for a week or so.

I tried something new this time around—racing with a partner. I actually had two race buddies, Frank, who I had the pleasure of getting in important long runs with throughout my months of training, and Kevin who decided to join in a couple of days before the race. This was the best thing I could have done for myself. To be honest, I had been so nervous to race this time. Well, I am usually a nervous wreck before races, but this time was worse and it was because I stayed away from racing for almost a year because of the miserable bout I had at the end of 2018 and beginning of 2019. This was a mistake. I was fine physically, but without some practice runs leading up to the big day, it messed with me mentally.

My usual self usually throws all of the pacing strategies I spend time creating for myself out the window and goes out way to fast and struggles in that last 10k. The best thing about my partners at this race was that they were so good at pacing so I just stuck with them and I never felt better. Our goal was to start off and run the first 5k around 7:00 min/mile, which is about 10-15 second slower than our goal pace. This first part of the race is the hardest since it includes a pretty long and steep causeway followed by another smaller one, all with a headwind. We averaged the 5k at a 6:59 pace.

 The next goal was to be in the 6:40s by the time we reached 10k. Unfortunately I lost Frank around mile 9 to an upset stomach. Thankfully he felt okay to stick it out and finish the half marathon with a decent time! I was determined to stick with Kevin for the entire race. After all I felt amazing hitting every single mile in the 6:40s, something I felt was going to be impossible to do these days. I was annoyed when my Garmin rang in mile 14 about 200 meters too soon, so from then on my watch was completely off—UGH! 

We made the turn into Key Biscayne during mile 15, and had a strong headwind again. It’s only one mile in and back out, but it feels like forever. For the first half of the mile in I struggled to stay behind Kevin—he could have blocked the wind for me, so I began to separate further and further from him. I ended up speeding up to try to close the gap, but realized halfway that I was going to lose energy so I slowed down and planned on worrying about catching up to him after making the turn to run back with the tailwind. Unfortunately I wasn’t able to catch up, so my plan now was to keep him in sight. I was still averaging 6:49 when I reached mile 18, although my Garmin was inaccurate so I really started to lose track. 

It was right before my watch rang for mile 20 that I felt a sharp pain in the left side of my right hamstring along with a snap. I sort of buckled but kept on trying to run. That lasted for only a few steps and I had to come to a complete stop, pull over on the side of the course and shake out my leg. This must have been at least a 30 second stop. Hoping it was just a cramp or something, I took a deep breath and went out again, to only last about 10 steps before the sharp pain was unbearable. It was at this time that I remembered that around mile 9 or 10 I felt a slight twinge in my hamstring, but it actually felt like my regular piriformis/glute nerve impingement-type pain I get most days. I even felt this in my left glute during my warm up but as always it went away and I was fine. I thought this hamstring issue was related, and I still do, so I ignored it at the time. I kept on feeling a twinge throughout the race once in a while, but it was minor and went away with a little adjustment in my posture and form.

The second time I had to stop was at least for another minute. At this point I had no idea if I was still on track, especially since my watch was completely useless. I eventually got back on the course and my mile 20 rang in at 7:47. From this point on the only way to avoid the unbearable pain was to take the shortest steps possible. I am a major over-strider so this felt so awkward for me but it was the only way to keep a decent pace. Mile 21 rang in at 7:01, so I felt there was hope to speed up again, but once I tried, the sharp pain came to life again. I was so frustrated, and still am, because overall my body felt super strong and able to run fast and the stupid pain just held me back. My endurance and non-existent fatigue felt great to keep with my plan of maintaining my 6:49 pace and speeding it up at the 35k point, but after 2 miles of struggling, I knew this plan was out the window.

Looking back at my paces now, I am impressed I was able to average 7:09 for the last 5 miles of the race, given the pain I was in. I ran well, raced the best I could have, and stayed positive the entire time. As upset as I was at the finish line that I did not reach that long-awaited sub-3 hour goal, I knew that I had it in me. I felt so strong at those paces for the first 19+ miles. It wasn’t a struggle at all to maintain the 6:40s for 2 hours, so that feeling alone has made me proud of the hard work I’ve done.

 I’ve got 7 months until my next attempt, and the goal this time is not just to break 3 hours, but it’s going to be an even bigger goal! Chicago can be tricky with it’s ever-changing weather patterns, but the course is flat and I hear the crowds are super engaging so I believe it’s going to be a good one for me! Bring it on!