The first time I met my 16-year-old patient, she hadn't had a period for 14 months. For the past year, she had felt moody, had difficulty concentrating, and had experienced "hot flashes" and "night sweats." This teenager was a competitive volleyball player with Olympic aspirations. She exercised every day and lost 20 pounds over the prior six months. She didn't eat very much, but at night she often dreamed about food. Luckily, she hadn't had any bone fractures … yet.

My patient was experiencing the Female Athlete Triad, a disorder that has three related parts: 

  1. Low energy availability from disordered eating
  2. Menstrual problems
  3. Low bone mineral density for the patient's age

Female athletes at any level—from recreational players to elite, highly competitive athletes—may have one or more parts of the triad. Research has found that up to one third of college-level and elite female athletes have disordered eating. The triad is more common in sports that emphasize thinness, such as gymnastics, ballet dancing, diving, and figure skating—where 42% of participants may have disordered eating. And one study found that 16% of elite female runners had all three parts of the triad. 

Here's a run-down on the triad:

Low energy availability is a result of disordered eating—eating too few calories for the amount of energy an athlete is “burning” in her sport. She may not mean to eat too little; she may not know how many calories a teenage female athlete requires. In fact, most female athletes need a minimum of 2,000 to 2,400 calories per day. Or she may intentionally cut back on her food to lose weight because she thinks it will help her compete better, or look better. She may have an eating disorder, such as anorexia (weight loss by severely limiting food) or bulimia (binge eating coupled with purging behaviors).

Menstrual problems occur when weight loss interrupts normal pathways and leads to decreased production of estrogen. A teenage girl with the Female Athlete Triad may have primary amenorrhea, meaning she has never had a menstrual period. Or she may not get them anymore, a condition known as secondary amenorrhea. Although it may be normal for a teen to miss a menstrual period in the first year or two, a missed period after having had monthly periods is often a red flag.

Reduced bone density is also related to a low estrogen level. Low estrogen can cause hot flashes and night sweats; it can also affect bones. Estrogen stimulates bone formation and protects the strength of the skeleton. When a teenage girl has low estrogen she may develop osteoporosis, weakening of the bones due to the loss of bone density and improper bone formation. So she is at increased risk for stress fractures and other injuries. And bone loss may not be completely reversible even with estrogen replacement, calcium, and vitamin D supplementation, or weight gain.

Be on the look-out for signs that an athlete is overdoing it:

  • Weight loss
  • Frequent injuries
  • Obsession with exercising every day
  • Problems with menstrual periods

P-R-E-V-E-N-T-I-O-N is my favorite “cheer.” Peak athletic performance does not necessarily require a low body weight. Before each high school sports season, every athlete should have a Pre-participation Physical Evaluation—a standardized exam form with screening questions aimed at identifying disordered eating and menstrual irregularities

If there's a problem, it's time for a team huddle. This team includes a physician, a nutritionist, and possibly a mental health professional.  Other important team members include the coach and athletic trainer. The goal is to restore weight and regular menstrual periods and help the young athlete enjoy her sport in a healthy way!

Teen athletes need to take a "time-out" to do these important things:

Help your teen stay in the game!

Rima Himelstein, M.D., is a Crozer-Keystone Health System pediatrician and adolescent medicine specialist.