Keeping Your Hormones Happy During Exercise
Though the Olympic closing ceremonies are now a distant memory, the accomplishments of Jessie Diggins, Lindsey Vonn and Julia Mancuso remain in my thoughts. As a college athlete and lifelong sports enthusiast, I appreciate how much hard work it takes to achieve these athletic milestones. And as a doctor, I also understand what a toll this road to greatness can take on the body. While it’s true that exercise has mostly positive effects on one’s health, intense long-term training can also have some downsides. Most female athletes are aware of the effect that serious conditioning can have on their menstrual cycles. But while missing your period due to athletic endeavors sometimes feels like an indication of hard work when you’re in your 20s, this can be a sign of hormonal imbalances that can signal a body out of homeostasis or optimal function.
Amenorrhea, or an absence of a monthly period, is now considered to be one indication that a female athlete should be assessed for what is known as female athlete triad. Triad because it is found in women who, in addition to having amenorrhea, also have inadequate nutrient intake and are at risk of developing osteoporosis. Essentially female athlete triad—sometimes referred to as FAT—is seen in women who are expending more calories and nutrients than they are taking in and are consequently nutritionally depleted. This diagnosis may or may not overlap with an eating disorder. Women with this symptom picture may not realize that they are not getting sufficient nutrition for the amount of exercise they are doing. In fact, awareness of this condition has been deficient until recently so education for college athletes around the long-term effects of this condition may have been lacking.
By long-term effects, I am referring mostly to the bone health piece of the triad. While training and competing, women may have adequate or above normal bone density but, because of the incomplete nutrient intake, FAT may result in a more accelerated bone loss once this athlete reaches menopause. The other complicating factor is that we do not routinely test bone mineral density until a woman reaches menopause and the methods for doing so are not direct measures (ie T-scores which measure the standard deviations below the mean to predict fracture risks for postmenopausal women). Because of the concern for the bone health of young athletes, the International Society for Clinical Densitometry (ISCD) developed a new method for assessing the bone health of pre-menopausal women, namely the Z-score. The Z-score compares a person’s age and sex to the average mean bone density. We are now better able to determine if a female athlete is considered to have low bone mineral density and be at risk for stress or other fractures or if they have osteoporosis. While menstruating athletes gain 2-4% bone mass annually, female athletes not getting their period lose 2% of their bone mineral density per year which sets them up for a much higher fracture risk if playing high impact sports. Although DXA scans are not commonly run due to the cost, 22-50% of female athletes have been found to be osteopenic compared to 12% of their less athletic peers.
By long-term effects, I am referring mostly to the bone health piece of the triad.
It All Starts with the Hormones
As I mentioned, the first sign that an athlete may be at risk for or have developed female athlete triad is an absence of a regular period. In fact, even a shortened or less frequent period can be suggestive of this condition. When the body senses that it’s not getting the nutrients that it needs, the hypothalamic hormone (released up in the brain) that controls two of the hormones (LH and FSH) responsible for regulating the menstrual cycle decreases; thereby decreasing the levels of LH and FSH released from the pituitary gland. These low hormone levels eventually result in low levels of estrogen which in turn contributes to an irregular or absent period and detrimental effects on bone health. An additional hormone, leptin, also seems to play a role. This hormone comes from our fat cells and studies indicate that a certain amount of body fat - and therefore leptin - is also necessary to support optimal hormone levels and menstrual cycle regularity.
Up to 62% of female athletes exhibit what is referred to as disordered eating
It’s All About Energy
Your body cannot produce the hormones needed to create a healthy and regular menstrual cycle without adequate nutrition. And if you aren’t getting the nutrients you need, you probably also aren’t going to have as much energy as you could. It can be hard to imagine young athletes pushing themselves to achieve amazing athletic accomplishments while being calorically deprived, but it happens all the time. By some estimates, up to 62% of female athletes exhibit what is referred to as disordered eating. Depending on the demands of the particular sport a girl is involved in and the messages young women internalize about what their body should look like or how much they should eat, female athletes may modify or restrict their food intake aiming to reach a certain weight or physique. But while this “disordered” eating may be conscious and deliberate, for some female athlete triad sufferers, it is not. They may not realize that the food they are taking in is not meeting the demands of what they are doing physically. There has been a recent suggestion to change the name of female athlete triad to relative energy deficiency in sport or RED-S; a name that more clearly explains the importance of the nutritional component to optimizing the health of a young athlete.
"Fight Like a Girl"
It may be that the lack of attention given to this condition is entwined with societal undervaluing of female athleticism and strength. Women and girls need to better understand what contributes to health and strength in their days of competition and beyond. Any sign of the female athlete triad should warrant the attention it deserves - a full work up with a trusted provider; work with a nutritionist; possibly support from a therapist; and maybe all of the above. Whatever healthcare support is necessary to rectify the energy deficiency and the sequelae that can result from it. A nutrient rich diet and basic supplementation to support bone health, including Calcium and Vitamin D, should be considered. But every female athlete is unique in their health profile and their motivations for working hard in sports and elsewhere and thus consulting with a naturopathic doctor to address the mind-body connection and a holistic approach to long-term health would be my advice for any young athlete looking to push her body to its limits while keeping all her internal systems strong.
Gottschlich LM, Young CC, et al. Female Athlete Triad. Medscape. 2017; accessed March 21, 2018
Melin A, et al. The LEAF questionnaire: a screening tool for the identification of female athletes at risk for the female athlete triad. British Journal of Sports Medicine. 2014; 48(10): 1136