2011 June | Female Athlete Triad Coalition

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I am an athletic trainer for a women’s sports team and would like to incorporate weight training and other off-field conditioning or cross-training to improve performance and decrease risk of injury. I have also been told weight training is good for bone health. However, I’m afraid I may end up overtraining my athletes or causing problems/injuries like those related to the Female Athlete Triad. Am I qualified to do this type of training?

As an athletic trainer you are certified and trained to prevent and treat injury. Only a trained professional that is certified in strength training and conditioning (National Strength and Conditioning Association’s Certified Strength and Conditioning Specialist or USA Weightlifting are great examples) should be training athletes in sport-specific strength training or conditioning (e.g. plyometrics or speed/agility drills). You are right; strength training has very positive effects on bone health. However, there are specific recommendations to how much and how often athletes should be conditioning off the competitive field and it varies greatly between sports. These types of certifications teach a strength coach proper technique in all areas of strength and conditioning, and about the unique balance between time spent engaging in athletic practice/competition and time spent conditioning off the field. Also, training information on how to tailor workouts to maximize performance in each sport would be valuable. It is a real concern that without being taught these skills in advance, you may over train/injure your athletes. It would be in your and your athletes’ best interests if someone that is certified as a strength coach would train them, or you could seek out a certification yourself. There is more information about the certifications mentioned at www.nsca-lift.org or http://weightlifting.teamusa.org/.

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My daughter has been missing her period for the past 3 months. I understand a period may be absent in skinnier girls who exercise too much. My daughter is not fat but is definitely not skinny. Also, I do not think she exercises enough to cause any worry. I am aware pregnancy is the top reason for a missed period but could there be another reason why my daughter is not getting her period?

Yes, there are other reasons why your daughter may not be getting her period. These reasons include polycystic ovarian syndrome or PCOS, and chronic diseases, such as thyroid disease, diabetes, or hyperprolactinemia (high levels of prolactin). However, you should first confirm she is not pregnant. Once pregnancy is ruled out, you should contact your primary care physician for an evaluation for your daughter to see if she has any of these conditions and find out the cause of her missing period.

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I am a coach for a high school girls track team. I would like to play a more active role in preventing the Female Athlete Triad amongst my athletes. What is the best approach for me to achieve this?

Since you are the person who interacts the most with your athletes (asides from immediate family members), a proactive approach may be to ensure your athletes are being screened for the Female Athlete Triad either using a pre-participation physical evaluation or a self-report questionnaire, or both. Athletes who are identified as having one or more components or appear to be at risk, should be referred to specialists who have experience diagnosing and treating this particular condition or any one of the components which may be affecting the athlete. If the athlete demonstrates signs of disordered eating, a multi-disciplinary team approach to evaluation and management has been show to be a good method for treating the athlete. The treatment team should consist of a physician, nutritionist, and mental health provider. Additional team members may include an athletic trainer and strength and conditioning coach. Due to potential conflicts of interest or straining of the coach-athlete interactions, coaches are discouraged from taking part in the treatment of an athlete with disordered eating attitudes and behavior.

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My coach says that it is ok to lose your period as long as you do not experience a stress fracture. I have never had any signs of a stress injury so should I ignore this problem?

A: No, you should not ignore this problem. Having low bone mass is not painful and you are not going to notice any signs or symptoms until the day you fracture. Losing your period is unhealthy. If you go more than 3 months without your period, you should consult your physician. You should not perceive weight loss and losing your period as normal outcomes of training, even if your coaches, athletic trainers, or team mates tell you not to worry. Going without a period for more than 3 months may have a negative impact on your bone and cardiovascular health.

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I am a cross-country runner and I have missed my period for the past 2 years, especially since I started training more. I am concerned my bones may be weak but how do I know if I am at a greater risk for a stress fracture?

A: Stress fractures are common injuries in young cross-country runners. Stress fractures can be particularly detrimental to an athlete’s present and future running career and pose significant risks for an individual’s general health. Risk factors for stress fractures include:

- Missing or losing your period for 3 months or longer

- Increased training volume and intensity

- Lower body weight

- Prior history of stress fracture

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Impact exercise is recommended to improve bone density. What specifically does impact exercise mean?

A: Any activities that involve jumping (volleyball, basketball, gymnastics) , running, hitting a ball (tennis, squash, baseball) are all considered impact exercises, while cycling and swimming are considered non-impact exercises. Although, non-impact exercises are good for heart and lung health, they are not the most effective way to improving bone health.

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As a female athlete, at which bone site am I most susceptible to fracture?

A: For different activities, there are different sites that are more susceptible to fracture than others. The skeleton adapts by increasing bone density when exposed to repeated stress. Sports or activities that involve more dynamic, high intensity loads (e.g. ball or power sports) tend to improve bone density greater than those that involve lower intensity loads, such as endurance running.

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I have not had my period for several months and was recently told by my doctor that I have poor bone health. Will I ever be able to improve my bone health to a normal level?

A: Having your period consistently is important for bone health. Therefore, regaining your period will help to improve your bone health, but it is currently unknown and furthermore, it is uncertain whether your bone mass will ever return to a normal level. There are many factors that affect your bone health such as the age that you first lost your period, for how long you’ve missed your periods, your family history and body size, and the quality of your diet. However, regaining your period is one of the first important steps you can take along with a proper diet to improve your bone health.

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Although I do not get my period, do I still need to worry about my bone health if I consume a lot of dairy foods?

A: It is recommended that female athletes with amenorrhea consume 1200-1500mg of calcium per day. If you are consuming dairy foods, such as milk, cheese, and yogurt, you are already doing a wonderful job at consuming calcium and Vitamin D. However, consuming adequate calcium only helps to stop further bone loss, not increase bone mass. Therefore, it is important not only to continue to consume foods high in calcium and Vitamin D, but to resume regular menstrual cycles and practice other healthy lifestyle choices, such as exercising and not smoking.

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If I lose my period does it necessarily mean that my bone health will be affected?

A: Amenorrhea is the loss of your period and is a key indicator of possible low bone mass or bone loss and implications for future poor bone health. There are many reasons by which one can lose their period [e.g. pregnancy, illness, etc.] and consulting a physician is the first step in the path to recovery. In athletes, it is common to see a case where you could be not taking in enough calories to support the amount of exercise you do each day. In this case, losing your period means estrogen levels are low and no longer support bone health. Be advised that a few sessions with a dietician may be helpful to understand how much you should be eating to sustain the exercise you do each day and regain your period.