High amounts of stress over prolonged periods of time can wreak havoc on our bodies. Besides the commonly talked about issues that come with a high stress life – increased blood pressure, heart attacks, depression, etc. – stress can affect both sexes on a hormonal level as well. For female athletes, intense physical and psychological stress may be a catalyst in the development of the female athlete triad.
Female Athlete Triad
The female athlete triad is a three-part, interrelated pattern of dysfunction that can evolve when the athlete is under high amounts of physical and/or psychological stress, causing a change in eating patterns, menstruation, and finally bone mineral density.
It is important to note that this pattern can happen to any physically active woman who faces physical stress, it doesn’t exclusively apply to an athlete. I would even suspect, and consider, the fact that this pattern could happen in a woman who is not physical active at all but rather faces high amounts of psychological and emotional stress, forcing any one of these three catalysts to begin the process.
Physical and Psychological Stress
As strength coaches and trainers (and even women or female athletes who train themselves) it is important to be aware of the athlete’s stress level and its impact on their training and sports program. Female athletes, especially in the high school and collegiate settings, typically face a high amount of psychological/emotional stress. This comes not only in the form of course work and exams but can also be tied to social stress – making new friends, being away from home (for the collegiate athlete), relationship stress, body image stress, etc.
The last example, body image stress, can kick off the female athlete triad as extreme changes to diet and nutritional intake commonly follow a negative self image. When nutritional intake is poor, energy imbalance may create a platform for amenorrhea (cessation of normal menstruation). As well, high amounts of stress can alter hormones which can also have negative implications on normal menstruation. A decrease in nutrients, such as vitamin D and calcium, and alterations in hormones, especially estrogen, can eventually create a loss of bone mineral density.
This example clearly shows the interrelatedness of the female athlete triad and if we had started the example with more of a physical stressor (intense training, competition, and eventual overtraining) the same type of interrelated connection would easily be seen.
According to Powers and Howley (Exercise Physiology: Theory and Application to Fitness and Performance, pg. 467) 4% of all female athletes will meet the criteria of the triad and 26% will have two of the components in the triad. Additionally, 3% of nonathletic women (ages 13-29) display all three aspects of the triad. Given the prevalence of this issue, we should first evaluate some of the potential signs of the female athlete triad.
Signs of the Female Athlete Triad (Morgenthal AP [PDF])
* Fatigue
* Anemia
* Depression
* Abnormal or cessation of menstruation
* Stress fracture
* Decreased ability to concentrate
* Cold intolerance
* Hypothermia
* Cold and discolored hands and feet
* Enlargement of the parotid glands
* Sore throat
* Erosion of dental enamel from frequent vomiting
* Abdominal pain and bloating
* Constipation
* Dry skin
* Face and extremity edema
* Lightheadedness
* Bradycardia
* Chest pain
What to do
Now that we have identified what the problem is (the components of the triad) and how it can be initiated (high amounts of physical/psychological stress) we can lay out a game plan with practical information for addressing the problem.
First, it is important to emphasize that due to the intense psychological component of eating disorders, coaches, trainers, and nutritionists should seek out help from a qualified psychologist who works with these individuals to ensure they get the appropriate information and are well attended to on that front.
From the training side of things, picking up on some of the warnings signs of the female athlete triad is the first step to ensuring that you address the situation promptly. In fact, having good communication and rapport with your athlete(s) will hopefully allow you to pick up on a potential problem before it even gets this far. Once you have identified a potential risk, it can be helpful to have or consult with a qualified psychologist on the safest and most appropriate way of addressing the issue with the athlete. Sometimes, very direct questions will be met with a lot of denial and resistance. You want to ensure that you handle the situation with care and respect for what the athlete is going through.
Work with a qualified sports nutritionist who can talk to the athletes and teach them about the importance of healthy eating and answer any questions they may potentially have about diets, weight loss, and certain strategies for decreasing body fat. We all know there is so much information out there and a lot of it is not only poor but potentially dangerous. Additionally, in the high school setting, a meeting with parents may be arranged, as they are the ones typically seeing the athlete on a more frequent basis than you do. You can present this information as well as some of the potential red flags of the female athlete triad so that the parents are well-informed and know what to look for.
Finally, analyzing the training and competition schedules as well as how these schedules work in conjunction with the school schedule can be a proactive approach on the coach’s part. Knowing when mid-terms and exams are, from a strength coach standpoint, will allow you to plan training accordingly, and back off the intensity/volume/frequency a little bit as the athletes at this time are facing high amounts of psychological stress and usually sleeping less, as they are increasing their time studying, both of which will lead to a decreased ability to recover from the training stress. Furthermore, manipulating the training program around periods of frequent competition (as well as paying special attention to year round training in three sport athletes) can be helpful in preventing overtraining and ensuring that the athletes have appropriate time to recover both physically and psychologically from the demands of game day.
The female athlete triad is a very serious issue and should be dealt with appropriately. Have good communication with your athletes and recognize when there is problem. These are key steps to ensuring the the issue is addressed before it develops into something far more serious. Having a well-planned training program and educating the athletes on appropriate nutritional strategies can be helpful in preventing the female athlete triad and assisting the athlete in establishing healthy habits that they can carry with them through life beyond their sport.
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About the Author:
Patrick Ward holds a Masters Degree in Exercise Science. He is a Certified Strength and Conditioning Specialist (CSCS) through the National Strength and Conditioning Association (NSCA) and a USA Weightlifting-Certified Club Coach. In addition, Patrick is a licensed massage therapist focusing on Neuromuscular therapy and Active Release Techniques (ART). I have been working in the field of strength and conditioning field for over 8 years. I am also a licensed massage therapist in the State of Arizona, specializing in clinical, therapeutic, orthopedic and sports massage. I am certified in Neuromuscular Therapy (NMT), Active Release Techniques (ART) for the Upper Extremity and Functional Movement Screen (FMS). My professional experience working with a diverse clientele includes training and massage therapy for optimal health, injury or post-surgery rehabilitation, injury prevention and optimal athletic performance. I have served as a strength and conditioning consultant for various athletes of all ages and status. Prior to starting Optimum Sports Performance, I was a top-level fitness and human performance coach in New York City, where I also presented seminars and clinics for other fitness professionals. Patrick currently lives in Chandler, Arizona and is the owner of Optimum Sports Performance and the Co-founder of Reality Based Fitness. He can be reached at patrick@optimumsportsperformance.com. Visit website: optimumsportsperformance.com
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