With all the focus on couch potatoes, let’s start by emphasizing that exercise is good for children and adolescents, and it’s good news that girls are more actively participating in sports than ever before. However, parents, coaches, and others involved in girls’ athletic activities need to be aware of research suggesting possible health problems that can arise.
These health concerns are called the “female athlete triad.” Studies have found three interrelated disorders found in female athletes:
1. Low energy availability occurs when you exercise more than you eat;
2. Abnormal menstrual periods;
3. Low bone density. [1,2] Low estrogen can make bones more fragile and increase the chance of fractures.
Eating disorders tend to be a problem for girls in several different sports, especially swimming, diving, gymnastics, dancing, and figure skating. Girls may be encouraged by their coaches or teammates to lose weight to improve their appearance or their performance. Binge eating followed by intentional vomiting or the use of laxatives are two of the most commonly used dangerous weight loss strategies. Compulsive exercise is an additional form of purging. Despite the use of purging strategies to improve performance, they can impair performance and increase the risk of injury. 
When athletic activity results in less body fat, it can delay puberty in girls, and increase the risk of menstrual problems. If breast development has not begun by age 13, and menstruation has not occurred by age 16, a medical exam should be considered. Also, female athletes who start their periods before the age of 16, but then stop menstruating for more than 6 months should see their doctors. This could be a result of weight changes, low energy intake, or an eating disorder, but a medical exam should be conducted to rule out a serious condition. These problems can affect a girl’s self-esteem, and may also have implications for osteoporosis or other health problems.
The underlying causes of illness must be addressed. Low energy is corrected through either increasing calories, decreasing physical activity, or both. To treat menstruation dysfunction, changes in diet and exercise are the first step – before hormone therapy is considered. Osteoporosis can be treated through Vitamin C pills and calcium or bisphosphonates, depending on the severity of the bone density. However, improving diet should be part of treatment. Treatment options for any of the above problems should be considered with the guidance of a physician who is independent of the sports activity.
In 2014, the British Journal of Sports Medicine published a consensus statement that successful treatment of the “female athlete triad” is based on an integrative approach that includes the involvement of a primary care physician or sports medicine physician, a sports dietitian, and a mental health practitioner. Parents and coaches should also be concerned about these health issues. Exercise and sports should be encouraged in girls, but adults should encourage a reasonable approach to diet and nutrition, and discourage excessive exercise. Menstrual problems should not be considered “normal” for athletes and efforts should be made to encourage weight gain and modify exercise if menstrual problems persist.
All articles are reviewed and approved by Dr. Diana Zuckerman and other senior staff.
1. Hoch et al. Prevalence of the female athlete triad in high school athletes and sedentary students. Clinical Journal of Sports Medicine. 2009;19:421-428.
2. Raj MA, Rogol AD. Female Athlete Triad. [Updated 2018 Apr 26]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2018 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK430787/
3. American Academy of Pediatrics Committee on Sports Medicine and Fitness. Medical concerns in the female athlete. Pediatrics 2000:106; 610-613.
4. Peacock A, Alvi NS, Mushtaq T. Period problems: Disorders of menstruation in adolescents.Archives of Disease in Childhood. June 2010.