The Female Athlete Triad—A Slippery Slope

I’ll never forget the day I went to war with my body. I was considered a “multi” athlete in high school track and field, meaning I competed in a variety of events. It was the sectional meet of my senior year and I had already qualified for the state in javelin, discus, and high jump. The last event I was trying to qualify for was the pole vault. Prior to the competition the officials had each of the girls competing step onto a bathroom scale. When we stepped off the scale the officials wrote our weights on our arms in thick black marker. Many of us were puzzled. I had competed in previous sectional and state competitions prior and this was the first time I ever experienced a “weigh in.” The officials informed us that “for safety” our weights needed to be equal to or below the manufacturer’s pole rating. To this day I still don’t fully understand this rule as it is only enforced in some high school divisions, but not at the college or professional level. 

148. That was my weight written boldly on my arm for all to see. “Wow! You don’t look like you weigh THAT much,” said one of the girls I was competing against. I think she was trying to compliment me, but it absolutely crushed me inside. In an instant my mindset shifted from thinking about the competition to thinking I was the heaviest girl out there. I became aware of the girls around me and how my body was “bigger” than theirs. I wasn’t going to be able to use the 140lb pole I performed with all year and at the last minute I was able to borrow a 150lb pole from the boy’s team. I barely qualified for state, stick vaulting over the opening height on my third attempt. I couldn’t bend the pole to save my life. I chose to give up my spot at the state meet in the pole vault my senior year because I wasn’t comfortable on the 150lb pole. Instead of seeing this as a small road block from high school state rules and regulations, I saw this as a failure due to being “overweight.”  For the first time in my life I began looking at myself in the mirror and picking parts of my body to pieces. i felt if I was lighter I would be able to get my body easier over the bar in pole vault and in high jump. At the time I didn’t understand that a stronger and more powerful body was necessary in those jumping events.

I graduated from high school and accepted a track and field scholarship to college. Uniform style shifted majorly between high school and college track. Gone were the days of wearing boys cross country shorts, I now had an option between spandex shorts or briefs. Genetics blessed me with a strong frame and muscular legs, but at the time I didn’t see that. Since high school I had developed a view of myself that was extremely distorted. I can still see myself looking in the mirror and being horrified. The spandex were so tight around my “thunder thighs” and the briefs were even worse because they showed off even more of my “square” and muscular frame. I envied the girls competing around me who were long and thin, falsely believing that was the missing ingredient to my success. I remember intentionally not lifting as much as I could have in the weight room because I didn’t want to “bulk up.” I look back now and realize I missed out on personal records (PR’s) and medals because I wasn’t allowing my body to reach its full potential. 

What came next was a slippery slope.

The female athlete triad is a disorder characterized by low energy availability, amenorrhea (loss of menstruation), and decreased bone density. Females who participate in sports are at risk of developing one or all three parts of the triad. Having any component of the disorder is enough to compromise performance and health in general.  All girls who compete in sports are at risk, but those that compete in sports that are weight dependent tend to be more at risk. Even though the triad is traditionally thought to be more common in long distance runners, it is important to understand it can happen to anyone.

After four years of college track and field I went onto graduate school to pursue my Doctorate in Physical Therapy. I weighed 140lbs at the time and I was worried that without the organized and mandatory two-a-day college track practices I would gain weight. As a multi-field event athlete in college, I did not run more than a few times a week. It was only at practice and it was usually for warm up or short sprints to build power for my jumps and throws. When I began PT school I started running long distances (for the first time in my life) and performing excessive cardio with hopes to shed “a few pounds.” I downloaded a calorie counting app and decided I wanted to lose 10lbs because I thought that that would make me happier. I know now how ridiculous and dangerous this thought was. Even though the pressure from competing in track was over, I was still trying to find my self worth in a number on a scale. I obsessed over staying under 2000 calories a day because the app arbitrarily assigned me this number in order to lose 10lbs. The app didn’t know anything about my level of activity, it didn’t know what my genetic make-up was or how my body was made to perform, and it didn’t educate me on what foods I should have been eating to fuel my body. Macronutrients (carbs, fats, proteins) and micronutrients (vitamins and minerals) are essential nutrients in food for sustaining our bodies not only when we play sports, but also for sustaining LIFE. Macro’s and micro’s are outside of the scope of this article right now, but just realize they are required in order to be able to function.

The first few months of PT school I skipped going out to eat with my friends in order to stay home and track my calories. I missed out on good times and meals with friends and family because I was afraid I wouldn’t know what was in my food. My classmates in PT school told me my lunches looked like rabbit food, usually just a salad without dressing and some nuts. If I ate more than my allotted number of calories I would go to the gym right away and shame myself with cardio until the treadmill told me I burned the amount of calories I had just taken in. I started showing signs if disordered eating long before I was hit full on with the first component of the female athlete triad, low energy availability (EA).  Low EA can occur with an eating disorder in which an athlete is intentionally reducing their energy intake either through extreme calorie restriction, purging food through the oral cavity, and/or exercise purging. Low EA can also occur without an eating disorder in the case the athlete is unintentionally not eating enough to support the level of energy expended during exercise.1

Low EA has specifically been linked to depression, low self-esteem,  anxiety disorders, anemia, fatigue, increased risk of infection, and increased risk for illness.1,2 I attributed my fatigue and anxiety levels to be normal stress that anyone would have in their first year of professional school. This was totally incorrect. PT school wasn’t draining my energy, my poor diet and lack of recovery from exercise was.

Food creates energy in our bodies and our bodies physiologically require that energy for us to be able to live, breathe, and perform. A nutritious diet is vital for competitive athletes, depending on what distance you run or what events you do in track and field the percent of certain macro’s and micro’s you require may differ. For example, sprinters and long distance runners rely on different physiological systems and therefore require a different percent of daily carbohydrates, proteins, and fats. When people want to lose weight they often think about cutting carbs first. If you are an athlete, particularly a long distance runner, your body thrives on carbs. If you are starving your body of the nutrients it requires you are hindering yourself from achieving your best performance.  Energy systems are another topic that is outside the scope of this article, but understand that food is required for you to function. This is not a suggestion, this is SCIENCE. Think about trying to drive your car on an empty tank, it wouldn’t go anywhere! If you have questions about what a nutritious diet looks like for you, you should seek out a sports dietitian, someone who is specialized in customizing a nutritious diet for athletes.

Then I stopped having my period, another component of the triad. Amenorrhea is the absence of menstruation for greater than three months in a female who has previously had regular periods.1 Amenorrhea due to low EA is also known as “functional hypothalamic amenorrhea” which diminishes the level of estrogen in the female body. Estrogen is a vital hormone in females that has several important roles including, but not limited to reducing cardiovascular disease and reducing the breakdown of bone.1

It wasn’t long before I started developing the third component of the triad, decreased bone density. I was running a minimum of 3 miles every time I exercised and sometimes I would get on an elliptical or bike afterwards, exercising for 1-2 hours a day at least 6 days a week. I started having a sharp pain in my foot so I went to see a sports medicine physician who diagnosed me with a stress reaction (early stages of stress fracture). Despite advice from him to restrain from high impact activity and my knowledge of rehabilitating this injury, I continued to run because I was determined to break into the 120’s on the scale. As a first year physical therapy student I knew enough about the female athlete triad to answer a question on an exam, but I didn’t realize I had fully developed the syndrome. I knew I had disordered eating and exercise habits, but I didn’t fully comprehend that I was starving my body of nutrients, recovery, and necessary functions vital to live and thrive.

I hit rock bottom when I passed out before class one day and had to go to the hospital. Earlier that morning I skipped breakfast to go for a run around campus. I was studying in a lab before class when I  noticed I was having heart palpations. I stood up quickly out of fear and collapsed. I achieved my goal to weigh in the 120’s, but at the expense of my health. I was miserable. I had put myself through torture for an entire year because I wanted my body to be smaller, robbing it of full potential. When I looked at myself in the mirror I didn’t look fit, I looked worn down. My friends and family told me I looked sick and frail. I was killing myself all for a number on the bathroom scale.

When I went home for a short summer break I visited my family physician for treatment. He chalked my heart palpitations up to test anxiety and told me my stress reaction had likely become a stress fracture because I couldn’t even walk without pain. Fortunately my recovery was relatively quick; this isn’t always the case for girls who develop the triad. While at home, I began eating nutritional meals my mom cooked for me again. I had to stop weight bearing exercise because of my stress fracture. Within a month I weighed in the 140’s again. Weight gain is the strongest predictor of returning to normal menstrual function and sure enough I got my period back.2  

It took me 3 months before I was able to run on land again without pain in my foot. A physical therapist recommended I use a couch to 5k program to ease back into running. At the end of the program I actually set a new 5k PR, something I never thought I would do as a jumper and thrower. A PR that I was incapable of running my first year of PT school because I was destroying my body.

If you are a competitive cross country athlete, track and field athlete, or even a recreational runner and you think you may have one of the components of the female athlete triad PLEASE reach out for help. Disordered eating is one of the first behaviors that females demonstrate before developing components of the triad. Talk to your doctor, your athletic trainer, your physical therapist, or someone you feel comfortable with that will get you to the right help. Caring for athletes with the female athlete triad is a multidisciplinary approach. Coaches, parents, and medical professionals PLEASE be looking out for signs and symptoms in these girls (and guys, yes they can experience components of this disorder as well). As a physical therapist I don’t see patients for this diagnosis, I see the behaviors while I am treating something musculoskeletal in nature. If not properly treated appropriately the female athlete triad syndrome can have lasting effects on the skeletal and reproductive system for life.

Five years later I am a practicing Doctor of Physical Therapy. I completed a sports residency after PT school because I wanted to work with athletes of all ages. I wanted to share my story here on the TrackProbs blog with the hope that this message would inspire someone to get help or choose a different path, even if it is just one person. I hope that through sharing my experience, someone else doesn’t have to go through what I went through. Skinnier does not mean stronger. A number on the scale does not equate to new PR’s. Setting a goal to have a “thigh gap” won’t get you a scholarship to college. As female athletes, our bodies need to be strong, powerful, and have the ability to endure until we cross the finish line and/or go for our last attempt. If you are starving your body of the fuel and the recovery it REQUIRES, you will never see your full potential.

Now that I don’t have track practice and I am a recovering cardio addict, I CrossFit for exercise. CrossFit reminds me of track and field because we run, jump, and throw (medicine balls). I get to work out with people who encourage me just like my track team did and compete with myself for PR’s every day. I fuel my body with the appropriate nutrients I need to be able to perform CrossFit and run during the week. CrossFit helped me see what I missed when I was in college, my performances are not defined by a number on the scale. I want to lift heavier. I want to be faster. I want to be stronger. The other day someone told me, “You went beast mode on that workout.” This was so much more gratifying than any comment about my weight. I no longer place my self worth on a bathroom scale number or compare my body to other girls, their stories and goals are different than mine. I look forward to turning 30 and getting a second chance for new PR’s at masters level track and field now that the war on my body is over. #strongerbetterme

REFERENCES

  1. Stickler L, Hoogenboom BJ, Smith L. THE FEMALE ATHLETE TRIAD‐WHAT EVERY PHYSICAL THERAPIST SHOULD KNOW. International Journal of Sports Physical Therapy. 2015;10(4):563-571.
  2. Mountjoy M, Sundgot-Borgen J, Burke L, Carter S, Constantini N, Constance L, Meyer N, Sherman R, Steffen K, Budgett R, and Ljungqvist A. The IOC consensus statement; beyond the female athlete triad–relative energy deficiency in sport (RED-S). British Journal of Sports Medicine. 2014;48:491-497.
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