A study of 240 health care providers found that less than half of physicians and physical therapists—and less than 10 percent of coaches—could identify the three triad components. (Illustration: Katherine Lam)
A study of 240 health care providers found that less than half of physicians and physical therapists—and less than 10 percent of coaches—could identify the three triad components.

The Condition That's Quietly Sidelining Female Athletes

For many, the female athlete triad has stood in the way of lasting success in sports, but researchers are finally starting to understand the condition better—and help women avoid the long-term consequences

The day before the 2010 Dextro Energy Triathlon in Hamburg, Germany, pro triathlete Jenna Parker broke out in hives for no apparent reason. Because of anti-doping rules, she couldn’t take the necessary medication, so even though she was “completely covered in the rash [from the neck down],” she raced anyway. After all, Parker wasn’t injured, and she needed a good result to make the U.S. world championship team.

When the then-26-year-old showed up in London to race another event a week later, the itchy welts still covered her body. Parker’s race was unremarkable: She finished 40th, her lowest-place finish in almost four years. When she crossed the finish line, Parker collapsed and began crying uncontrollably. “I was completely broken, mentally and physically,” she says. Her doctor shut her down for the remainder of the season and told Parker to pretend she wasn’t an athlete, chill out, and eat cartons of ice cream.

It turned out the hives were her body’s attempt to send an emergency flare. The endless hours of training and the mathematical calculations she’d been using to keep her weight in check had taken a toll. Parker had become what she calls a “functional anorexic.” “What I’ve been told is the hives were my body’s way of saying, ‘You’re killing yourself and you won’t listen. Because you won’t listen, we’re going to do drastic things so you have to listen,’” she says.

The previous year, after a swift rise up the professional triathlon ranks during college, the Harvard University graduate had wanted to take her performance to the next level. Parker found a new coach in Australia. Her training load doubled, jumping from 18 hours a week to 35, and she learned just how far she could push herself physically and mentally. That year was one of Parker’s most successful years as an athlete. She placed second at U.S. nationals and won the Pan American Cup. (Parker was featured in Outside’s October 2010 “XX Factor” issue as Jenna Shoemaker. She changed her name to Parker in 2010 for personal reasons.)

“For a long time, the message [to female athletes] has been ‘train harder.’’

Despite her athletic success, Parker thought about her weight even more. It was the first time a coach regularly weighed her, even measuring her skin folds. “If you weren’t close to your numbers and he didn’t believe you were fit enough, he wouldn’t let you race,” she recalls. When Parker returned to training camp in early 2010, having gained a few pounds in the off-season, her coach told her she had to slim down or she’d be out of the group.

Parker did the math. She calculated her metabolic rate plus calories burned during workouts, then counted every calorie she ate. In six weeks, she lost 18 pounds from her 5'7" frame, getting down to 118. She also lost her period. “I couldn’t control how fast I got better at triathlon,” says Parker. “But if I lost the weight and got my skin folds down, he couldn’t kick me out of the group. It was the thing I could control.”

The same traits that appear to give athletes a competitive advantage—a lean build for fast times and a desire to work tirelessly and win—can sometimes put their health at risk. “For a long time, the message [to female athletes] has been ‘train harder.’ It was encouraged by coaches and everyone around them,” says Dr. Kate Ackerman, director of the Female Athlete Program at Boston Children’s Hospital. “But this was negative for their bodies, and hence the term female athlete triad emerged in the 1990s.”

While Parker was never officially diagnosed with the triad, she had all the signs. In 1997, the American College of Sports Medicine described the triad as three distinct conditions: disordered eating, amenorrhea (the absence of a period), and osteoporosis. But the more researchers studied female athletes, the more they realized there were many nuances to the triad, and women didn’t need to have a full-blown clinical diagnosis of the three conditions to be concerned. For example, while Parker didn’t experience stress fractures, the damage she inflicted on her body was serious enough that her body reacted with hives—an extreme, uncommon red flag.

The triad typically manifests itself in three different ways: low energy (with or without disordered eating), loss of a period, and lower bone density. Each of these components exists on spectrum from healthy to disordered, so depending on her eating and exercise habits, a woman can move between the two ends of the range for each component, and she doesn’t have to have all three to be diagnosed, says Dr. Aurelia Nattiv, a professor at UCLA in family medicine and sports medicine and a team physician for UCLA athletics. The presence of just one element is a call for concern, since the triad can contribute to long-term health issues like stress fractures, infertility, and impaired cardiovascular health. Some women may also be diagnosed with osteopenia or osteoporosis at an early age.

While some athletes resort to restricting food and training nonstop in pursuit of athletic gains and experience a short, enticing period of improved performance, the negative effects eventually catch up to them.

Researchers estimate that as many as 60 percent of exercising women may experience one triad component and up to 27 percent may experience two components. The number of women presenting all three is roughly 16 percent. Women who participate in sports like the triathlon (where leanness is seen as a competitive advantage) or dance (where athletes must wear revealing uniforms) are at greater risk, but the triad can show up in any sport. A recent study of female college athletes found that those in gymnastics, lacrosse, cross-country, swimming and diving, sailing, and volleyball were at moderate or high risk for the condition. And it’s not just a problem for professional or collegiate athletes—experts say that recreational athletes are also at risk.

Yet the triad lurks largely on the sidelines. There’s a stigma surrounding eating disorders and menstrual health. Plus, women are often treated in silos: An orthopedic surgeon may tend to an athlete’s stress fractures, while a nutritionist helps with her diet and a gynecologist evaluates her menstrual cycle. Few doctors will be presented with the full picture and put the pieces together. A study of 240 health care providers found that less than half of physicians and physical therapists—and less than 10 percent of coaches—could identify the three triad components. Only 9 percent of doctors felt comfortable treating it. “Many physicians are confused, especially if this isn’t their area of expertise,” says Nattiv. As a result, researchers think the prevalence of the triad may be even higher due to inconsistent reporting and, likely, underreporting.

Doctors and coaches of former college runner Sara Scinto never connected the dots between her symptoms. Scinto says her problems started in high school, when she started training harder, lost her period, and restricted food in an attempt to look like her faster teammates. Then, during her freshman year at Ohio Wesleyan University, she was sidelined from cross-country and track by a stress fracture. Over four years, Scinto endured six bone stress injuries, as fractures bounced from one shin to the other and then to her femur. “The approach was always injury prevention. Go to the trainer. Be aware of what’s soreness and what may be an injury. I don’t remember them ever talking about the female athlete triad or anything related to it,” says Scinto, now 23. “It destroyed my collegiate career. I had one good season.”

Sport aren’t to blame for the triad’s long-term health concerns, says Dr. Adam Tenforde, assistant professor of physical medicine and rehabilitation at Harvard Medical School. It’s physical activity coupled with harmful or extreme behaviors—like the belief that thinner runners are faster, or a team culture of abnormal eating behavior and inadequate rest and recovery—that may put an athlete at risk. “There’s a cascade of physiological responses to nutrition or inadequate nutrition,” says Tenforde.

Experts point to low energy availability as the underlying force behind the triad, sparking a domino effect that leads to the other symptoms. When an athlete’s nutritional intake doesn’t meet the body’s needs, whether due to reduced dietary intake—intentional or not—or increased exercise, the body shuttles resources to systems that are essential to survival, suppresses energy-intensive processes like menstruation and growth, and alters hormone levels.

That leads to a cascade of other problems. For example, when a woman doesn’t get her period due to energy deficiency, she doesn’t experience the monthly estrogen surge that’s critical for building bone, especially in adolescence and early adulthood. “You end up with decreased bone density, putting you at an increased risk for stress fractures, osteopenia, or osteoporosis in your twenties and thirties,” says Julie Granger, DPT, founder of Prism Wellness Center in Atlanta. “Females stop accumulating bone at age 20. From 20 on, all we can do is maintain what we’ve got.”

Many people, from recreational athletes to professionals, may find themselves caught in a cycle of underfueling their bodies. But there is a path back to health.

Recently, researchers have noted other symptoms beyond the triad that are connected to low energy availability and could affect long-term health. These include conditions related to immunity, cardiovascular health, protein synthesis, and mood disorders. In 2014, the International Olympic Committee proposed the term “relative energy deficiency in sport” (RED-S) to acknowledge these other symptoms and to include men who might suffer from a similar set of linked conditions.

While some athletes resort to restricting food and training nonstop in pursuit of athletic gains and experience a short, enticing period of improved performance, the negative effects eventually catch up to them. The reality is that when they properly fuel and rest their bodies, they perform better. A 2014 study of female junior elite swimmers, for example, found that those who had normal ovulatory function and ate enough to support their bodies swam faster, while those who experienced low energy availability and menstrual dysfunction saw a decrease in performance.

Many people, from recreational athletes to professionals, may find themselves caught in a cycle of underfueling their bodies. But there is a path back to health. “Just because you have this problem or had it in the past, it’s not doomsday,” says Granger.

Parker and Scinto both say their bodies are still trying to figure out what’s normal for them, but they’ve come out the other side. For Scinto, leaving the competitive running environment and talking to others who’ve had similar experiences helped. She’s now studying nutrition at Tufts University. Parker found coaches who supported her well-being and wanted her to eat well and get her period. She competed at the 2012 Olympic trials and retired in 2013. Now, for fun, she takes part in—and often wins—surf lifesaving competitions. (The events combine elements of lifeguarding, like an open-water swim, paddle, and beach run.) Both women say they need to be vigilant when training to ensure they aren’t pushing too hard or too far.

The continuing challenge—for female athletes and their doctors—is how to determine when women can return to their sport and at what level. In 2014, Nattiv and her colleagues developed evidence-based guidelines to help medical professionals screen, diagnose, and treat women for the triad and offer guidance for when it’s appropriate for an athlete to resume her sport. They recommend seeking out a multidisciplinary team that includes a physician and dietitian. If there’s an underlying body image issue, the team should also include a mental health professional. Researchers are working to better pinpoint the factors so that at-risk women are identified earlier, avoiding the long-term consequences of the triad and giving them the opportunity to continue competing at a high level.

“I learned a lot in the buildup to the breakdown, as well in the struggle to get myself back afterward,” says Parker. She wants girls to consider the long-term consequences versus the short-term gains, find coaches who support them, and recognize that they can be healthy and also crush at their sport.

Illustration by Katherine Lam

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Lead Illustration: Katherine Lam