By Katherine Dempsey

Tina has only gotten her period once during college.

The 21-year-old runner at a Big Ten university remembers seldom menstruating in high school or in college. Diagnosed with anorexia during her freshman year of high school, Tina – whose real name has been changed to protect privacy – spent several weeks out of school for treatment and to escape from the academic pressure that she says sparked her eating disorder.

Tina didn’t participate in track her freshman year of high school, and she says she remembers weighing less than 90 pounds at her lowest weight. With running, the anorexia also related to a her focus on eating right to run well and that turned into limiting the kinds of foods she ate.

Throughout college, Tina has run cross-country and track and avoided extra pounds earlier in college in order to run faster. Although that fear of weight gain has decreased a bit, she says the idea of putting on pounds is still on her mind. Throughout college, she’s paid close attention to the nutritional value of her food. Tina also describes herself as a perfectionist – another factor contributing to the fear of weight gain.

Despite weighing more than when she had anorexia, Tina says a researcher told her that her food intake didn’t replace the calories she burned while running and that she was dealing with syndrome called the Female Athlete Triad, although no physician has formally diagnosed her with the syndrome. From December 2013 to December 2014, Tina participated in a 12-month study that added calories to her diet, and she managed to menstruate once over that time.

She says she has boosted her caloric intake compared with the pre-study time and is more comfortable with indulging in treats, but she continues to keep a strict eye on the quality of her diet. She’s concerned about osteoporosis in the coming years, a problem that can result from the Triad. “Bone health is the biggest scare,” she said, adding that she’s also concerned about infertility.

A Calorie Problem

The Female Athlete Triad can affect both female athletes and women who exercise and who don’t consume calories sufficient for the energy they burn, said researcher Mary Jane De Souza, professor of kinesiology and physiology at Penn State and member of the Female Athlete Triad Coalition. The Triad is formally defined as “low energy availability with or without disordered eating, menstrual dysfunction and low bone mineral density,” according to the 2014 consensus statement from the Female Athlete Triad Coalition. Although the three components run along a spectrum, the Triad can result in problems like osteoporosis, stress fractures and infertility on the severe end.

The Female Athlete Triad Coalition is seeking to collaborate with the NCAA to create a way to better gauge how many athletes are dealing with eating disorders, disordered eating, menstrual dysfunction and low bone mineral density, said Dr. Elizabeth Joy, the Coalition’s president. The goal is to better determine how common the individual Triad components are in each college sport, said the family medicine and sports medicine physician who is medical director for clinical outcomes research at Intermountain Healthcare in Utah.

The concept of the Triad seems to be evolving, too. In 2014, a consensus statement from a panel of experts assembled by the International Olympic Committee was published in the British Journal of Sports Medicine. The statement presented a syndrome called “Relative Energy Deficiency in Sport” (RED-S), which essentially covers more issues than the Triad. RED-S can affect men, too, the document reports.

“The clinical phenomenon is not a ‘triad’ of the three entities of energy availability, menstrual function and bone health, but rather a syndrome that affects many aspects of physiological function, health and athletic performance,” the statement reports.

Some 90 to 95 percent of her Triad patients show disordered eating or eating disorders, Joy said.

It’s likely that athletes are more at risk of low energy availability if they participate in sports where it helps to be lean, such as long-distance running, Joy said. Gymnastics and other activities with an “aesthetic” factor are also more vulnerable, she said. A study published in 2002 reported eating disorders in 31 percent of 94 Australian female elite athletes participating in “thin-build” sports (ballet, gymnastics, light-weight rowing, long distance running, diving and swimming).

But, the Triad can affect any female athlete, Joy noted, and she has even treated soccer, basketball and volleyball players. She attributed the problem to the burden of improving body composition (fat mass and fat-free mass) in order to perform well, which in turn affects eating and exercise. People are preoccupied with the flawless female body, she added.  Athletes also use a lot of energy when they train; plus, athletes at very competitive tiers can be perfectionists, which is a risk factor for “disordered eating” and eating disorders. “It really does set athletes up for this condition,” she said.

Anne Loucks, a physiologist at Ohio University in Athens and member of the Female Athlete Triad Coalition, said it’s also biologically possible for appetite to be suppressed, leading to unintentional failure to eat enough. Endurance athletes often deal with appetite suppression due to working out and eating a lot of carbohydrates relative to protein and fat intake, Loucks said.

What Happens To the Body

Athletes can deal with low energy availability because they significantly cut back on how many calories they eat, said Loucks. Or, they may just significantly boost how much they exercise. Alternatively, they may decrease calorie consumption by a medium amount and do a medium amount of exercise at the same time. She studies how exercise and nutrition affect the reproductive system and bones. “Low stored energy” – essentially, low body mass index – can also bring on low energy availability, Joy said.

Energy availability is “energy intake [kilocalories] minus exercise energy expenditure [kilocalories] divided by kilograms of fat-free mass (FFM) or lean body mass,” the statement says. It goes “with or without disordered eating,” according to the paper. Low energy availability is what kicks off the overall Triad syndrome, but women don’t necessarily need to deal with all of the Triad’s three parts – they can deal with just one component, or more than one component, said De Souza, lead author of the statement.

When people eat food, they “compartmentalize” it and it’s “burned up” and distributed to five “compartments”: metabolism maintenance, growth, thermal regulation, reproduction and locomotion, De Souza said. If a person’s eating insufficient calories, the body takes away calories from growth first, she said, which affects how strong and dense the bones are. Reduced amounts of specific hormones inhibit bone tissue repair and growth, Loucks said. Tissue depletion weakens the bone, which makes it more likely to break. Stifled growth can affect adolescents’ developing bones, she said.  And, low energy availability plays a role in the brain’s shutdown of “reproductive capacity,” Joy said. That action in turn decreases the amount of estrogen in the blood, which women need in order to construct and preserve bone mineral density, said Joy, who is also an adjunct professor at the University of Utah School of Medicine.

Genetics can influence how much energy availability affects menstruation and how much an inadequate amount of estrogen influences bone mineral density, Joy added. And besides conscious limitation of eating, disordered eating might result from biological effects on certain gut hormones in women who exercise, De Souza said.

Diagnosis and Treatment 

Mark Hutchinson, head physician for athletic teams at the University of Illinois at Chicago and the treasurer of the Female Athlete Triad Coalition, said he sometimes observes student-athletes – such as gymnasts – affected by the Triad. A stress fracture often sends them his way. Other times, an athletic trainer alerts him to check out a particular athlete. That alert can be based on observations from the trainer and the athlete’s teammates (for instance, if a person’s dropped significant pounds). Athletes go through a screening before the season starts, which asks about past stress fractures, diet and menstruation. If something from the screening looks questionable, Hutchinson can investigate more about the Triad when that particular athlete visits Hutchinson with a medical issue – say, a cough.

The Female Athlete Triad Coalition consensus statement says that after screening takes place, an athlete should be assessed for diagnosis by a “multidisciplinary healthcare team,” which should contain a physician, sports dietitian, and mental health professional in the case of a clinical eating disorder or disordered eating. An exercise physiologist and athletic trainer can also be part of the group, it notes.

Jennifer Tymkew, a staff athletic trainer at Northwestern University who takes care of women’s basketball and women’s golf student-athletes, said she’s with the athletes a lot, so she’s able to look for hints of Triad components – for example, abnormal fatigue, repetitive stress injuries, or food-related problems, she said.

Joy said that at times athletes can perform very well even though they aren’t eating enough, though eating more would probably enhance their performance. But even if they’re performing well, they can ultimately get stress fractures – basically the Triad’s “end product,” she said. She said she’s even observed cases where stress fractures force athletes to bring their careers to a close.

And, the Triad can mean bad news for the future. Some of Joy’s patients, athletes in their twenties and thirties, still deal with menstrual and disordered eating problems, she said. They still deal with low energy availability and they’re infertile. She’s also worked with women who dealt with the Triad earlier in life and now habitually suffer from fractures due to low bone density.

De Souza pointed out that Triad diagnosis necessitates just one component. Hutchinson said someone is diagnosed with one of its components, with other components chipping in more discreetly. Dr. Danielle Bass, a primary care sports medicine specialist at the Chicago Center for Orthopedics at Weiss Memorial Hospital, said someone technically requires every Triad component to be diagnosed. But if an athlete displays one or two components, she still gives a Triad diagnosis.

When Hutchinson thinks a UIC athlete might be dealing with the Triad, he can give the person a clinical diagnosis, but an athletic trainer, residents in training, or primary care physician can also spot symptoms of the Triad. The diagnosis is then verified via extra tests – for example, the athlete might undergo a bone density scan to verify one part of the diagnosis.

Hutchinson said it’s good to get a nutritionist, psychologist and primary care physician involved with treatment. As an orthopedic surgeon, Hutchinson himself treats any stress fractures. All in all, it’s a group strategy.

Sometimes Hutchinson pulls athletes from participation until they fulfill requirements like seeing a psychologist a certain number of times or gaining a certain amount of weight. But, he only disqualifies athletes in very serious instances. That doesn’t classify as a “friendly threat,” he said. “They’re here to play. They’re here to perform.”