The Female Athlete Triad Coalition recognizes the importance of an informative and verifiable resource with regard to Triad-related research. The Female Athlete Triad Coalition has provided female athletes and physically active women with the opportunity to find valuable answers to their personal inquiries in an approachable and accessible manner. The expert responses to your questions provided below are from knowledgeable and qualified Triad Coalition researchers. Click each heading to toggle through the FAQs.

Training Issues

Do I need to change my training to recover from the Triad?

An athlete does not need to reduce her training to avoid Triad or to resume normal menstrual cycles if she is amenorrheic (not menstruating). Many assume that the athlete must reduce exercise in order to avoid Triad, but the fact is that most athletes can effectively address Triad-related health problems with adequate nutrition. That said, if training can be reduced by adding one day of rest per week, resumption of normal menstruation will likely occur more quickly.

Body Weight

Do I need to gain body weight in order to resume normal menstrual cycles?

Even small increases in body weight may be all that is necessary to resume menstrual cycles. Studies are ongoing to determine just how many calories are needed for normal menses to resume, but so far, it appears that even small increases in body weight (1-3 kg) may be all that is required to resume normal menstrual cycles by reversing the negative energy deficiency that caused the problem.

Menstrual Issues

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.

 

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?

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.

 

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?

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

 

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?

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.

 

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?

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.

 

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

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.

 

Should I go on the Pill to combat the Triad?

Going on the Pill is not the best answer to fix Triad-related bone loss. Amenorrheic athletes are frequently prescribed hormonal contraceptives to prevent or slow bone loss, but this does not address the underlying problem — it only addresses the symptoms. The problem is energy, and energy should be part of fixing the problem. Contraceptives may normalize menstrual periods and provide estrogen, but they will not necessarily improve bone health. Athletes on birth control pills often believe they have addressed their Triad-related problems, and therefore are probably not being counseled to improve dietary habits. As a result, they may continue to travel down the energy deficiency path, which contributes to further bone loss. In fact, long-acting, progesterone-only contraceptives like Depo-Provera have been shown to cause bone loss, and the packaging for these drugs now includes a warning to this effect. Nevertheless, this particular drug remains popular among athletes who feel normal menstruation impairs their performance.

 

Do I need to gain body weight in order to resume normal menstrual cycles?

Even small increases in body weight may be all that is necessary to resume menstrual cycles. Studies are ongoing to determine just how many calories are needed for normal menses to resume, but so far, it appears that even small increases in body weight (1-3 kg) may be all that is required to resume normal menstrual cycles by reversing the negative energy deficiency that caused the problem.

 

Is it bad to not have normal menstrual cycles?

Losing your menstrual cycle is not healthy. Failing to menstruate for more than six months is unhealthy and should be evaluated by a physician. Athletes often view weight loss and losing their menstrual cycles as synonymous with improved athletic performance, and so they must be warned of the serious health risks of not menstruating — particularly, bone loss. Armed with the latest information and research, the athlete herself may be the first and best line of defense against this condition.

Recovery from the Triad

Should I go on the Pill to combat the Triad?

Going on the Pill is not the best answer to fix Triad-related bone loss. Amenorrheic athletes are frequently prescribed hormonal contraceptives to prevent or slow bone loss, but this does not address the underlying problem — it only addresses the symptoms. The problem is energy, and energy should be part of fixing the problem. Contraceptives may normalize menstrual periods and provide estrogen, but they will not necessarily improve bone health. Athletes on birth control pills often believe they have addressed their Triad-related problems, and therefore are probably not being counseled to improve dietary habits. As a result, they may continue to travel down the energy deficiency path, which contributes to further bone loss. In fact, long-acting, progesterone-only contraceptives like Depo-Provera have been shown to cause bone loss, and the packaging for these drugs now includes a warning to this effect. Nevertheless, this particular drug remains popular among athletes who feel normal menstruation impairs their performance.

Bone Health and Stress Fractures

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?

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.

 

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?

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

 

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

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.

 

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

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.

 

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?

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.

 

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?

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.

 

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

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.

 

I was recently diagnosed with a stress fracture and my doctor sent me to get a bone density scan. My bone density came up normal. Why would I sustain a stress fracture if I do not have a low bone density and my bones are not fragile?

A bone density scan or a dual energy absorptiometry (DXA) scan is typically used to diagnose osteoporosis, i.e. the disease of porous bone. DXA scans are typically performed at the hip and the spine, because these are the most common sites of osteoporotic fractures. Your DXA scan may show up normal, particularly if you have been doing weight-bearing exercises, such as running, basketball, or volleyball. Why? Let’s take the example of running. When you run, the bones in your legs are submitted to loading and this has a positive effect on the bone density in your hips. Running would not have such a beneficial effect on the bone density in your spine because this site is not directly loaded when you run. Depending on the sports you may practice (e.g. sports that involve the upper body) and a range of other factors (genes, hormones, diet…), the bone density in your spine may also show up normal.Having a low bone density is considered a risk factor for any type of fracture, which is probably why your doctor wanted to have you complete a DXA scan. However, having a normal bone density does not guarantee that you will not sustain a stress fracture. A stress fracture usually occurs when a bone is no longer able to repair itself from small cracks that are created by repetitive loading when you exercise. These little cracks are normal as long as the bone has enough time to repair them. If these cracks accumulate, then they may form a bigger crack that can evolve into a stress fracture. This may occur in the face of a sudden increase in training and other stressors. It is also important to remember that having a normal bone density at the hip and spine is good news! This means that you are less likely to have osteoporosis later in life compared to someone your age that already has low bone density. You may want to discuss with your doctor what other factors may have caused the stress fracture. This can be hard to identify but it is worth trying to avoid the recurrence of the fracture.