Viewpoints presented in this blog reflect opinions of the author and do not necessarily reflect positions or policies of ACSM.

Gatorade Sports Science Institute (GSSI) and Dr. Mary Jane De Souza recently hosted an industry-presented webinar entitled: The Female Athlete Triad & Sports Nutrition Strategies for Recovery. Watch a free recorded version of the webinar here.

Key Points: 

1. Recovery of the Triad is dependent on nutritional therapy to reverse energy deficiency and low EA.

2. Recovery of bone is dependent on increased body weight, fat mass and menses.

3. Must consider energy status and estrogen for recovery and to make recommendations for return to health. If estrogen therapy is considered, transdermal is the best for women who fail one year of nutritional therapy and with worsening bone health.

Several questions were asked by attendees during the webinar and the answers are below.


Q: What is a normal time frame from chronic low EA to menstrual dysfunction? (when do the first symptoms appear?)

Depending on your current menstrual status, where you are in your cycle, and the magnitude of energy deficiency, it may take weeks to months for menstrual disturbances to be observed. 

Q: Does use of a birth control pill have an impact on energy availability?

Oral contraceptives may be associated with changes in appetite or eating behaviors, but aside from that they do not directly alter energy availability.

Q: Is there a clear relation between menstrual dysfunction and reproductive ability? and if so, will it always be reversible (when menstrual function is back to normal will an athlete have a normal reproduction capacity)?

Anovulation, oligomenorrhea and amenorrhea can impact reproductive ability. We expect reproductive ability to resume once the menstrual irregularity is resolved and cycles become ovulatory again; however, there have not been any studies yet that have looked at fertility itself with respect to the Triad.

Q: kcal/kg/FFM/day - How can this be used in the field where body comp is not known?  vs kcal/kg/bw?

Correcting for body mass rather than fat free mass would likely result in an underestimation of EA.  There are several commercially available tools, such as Bio-electric Impedance Analysis (BIA) devices, that are available to estimate fat free mass that would be recommended in field assessments of EA.

Q: How long should a menstrual cycle be absent before you are considered to have amenorrhea?

Current Endocrine Society Clinical Practice Guidelines define functional hypothalamic amenorrhea as an absence of menses for 3 months or more.

Q: I'm wondering how to identify menstruating and amenorrhea? Compare with themselves, or 28 days?

Eumenorrheic menstrual cycles occur at regular intervals and last approximately 26-34 days.  Oligomenorrhea is characterized by long and irregular menstrual cycles, often longer than 36 days.  Amenorrhea is the absence of menses for 3 months or longer.

Q: At the beginning of the presentation, you mentioned that this can also affect men. In addition to bone health, does this also affect hormones in males?

There is some evidence that metabolic and reproductive hormones may be suppressed in men who have low energy availability or chronic energy deficiency.

Q: Can females who menstruate regularly on the pill still have menstrual dysfunction (if they were not using the pill to regulate hormones) and is this just as dangerous for reproductive function?

Use of oral contraceptives suppresses ovulation and menstrual function, as they are intended to prevent pregnancy and, since you have monthly bleeding, make it seem like you are having regular menstrual cycles. Bleeding while on the pill is not menstrual bleeding it is breakthrough bleeding stimulated by the pills.  The pill is not “dangerous” for reproductive function.  In a small number of women, when you stop the pill you may experience post-pill amenorrhea.  

Q: Did you have a specific recommendation for the increased calorie group? I.e. a certain food or specific source of energy?

For the REFUEL study, the intervention was only focused on increasing the total number of calories by 20-30% of baseline energy expenditure needs. An interesting topic for future research would be to determine if specific macronutrients are needed or if increased calories of any macronutrient composition are adequate to have positive benefits.

Q: Having your athlete be on a birth control pill for regular menses will this prevent bone loss?

OCs are processed by the liver, which leads to decreased hepatic IGF-1 production, contributing to potential negative impacts on bone health.  OC’s are not the best strategy to prevent bone loss.  Contraception in the form of a patch or vaginal ring to avoid first-pass effects on hepatic IGF-1 production likely will yield better outcomes on bone.

Q: Specifically, around the question of 45 kcal/kg/FFM/day? How do we determine this?

EA is calculated as energy intake (kcal) – exercise energy expenditure (kcal) / fat free mass (kg).

Simple assessments of energy availability can utilize diet logs for energy intake, exercise logs or the Compendium of Physical Activity for energy expenditure, and bioelectrical impedance or skinfolds for fat free mass.

Q: In the study, when the calories were increased in the oligo/amenorrhoeic, was the quality of the calories taken into consideration, e.g., calories from fat vs carbohydrate, etc.?

For the REFUEL study, macronutrient composition was not considered.  This intervention was only focused on increasing the total number of calories.

Q. Does phytoestrogen supplementation can alleviate negative impact of subclinical/clinical MD on bone health?

There is some data in postmenopausal women that phytoestrogens may help with bone problems to a small extent.

Q: Do you look at hemoglobin to look at energy levels? Regular menses can affect.

To date, not much research is present to determine the impact of iron status on Triad-related conditions. We do have one study that shows the ovulatory eumenorrheic women do have a higher prevalence of iron depletion compared to amenorrhoeic women, the two groups do not differ in serum ferritin levels, hemoglobin, hematocrit, or total body iron. More research is necessary to investigate whether iron impacts bone health in this population.

Q: Intermittent fasting seems to be the new hot topic. What is your take on athletes taking part in intermittent fasting?

Some studies have begun to look at within-day fluctuations in energy availability.  It is possible that diet patterning which produces severe energy deficits throughout the day, even if 24-hour diet goals are met, may result in negative health outcomes.

Q: Does the recommendation also apply to those who have hypothyroidism? Hyperthyroidism?

We excluded women with thyroid conditions from our study.

Q: Can any of this be correlated to menopause?  Have there been any studies following this information?

It would be interesting to see how the bone health of previously amenorrhoeic athletes is when they get to be menopausal- but no, we do not have any data to date on this issue.

Q: Even in college athletes you would consider waiting a year before starting hormone replacement knowing they may lose a year of participation?

Because the root of Triad is inadequate energy, the recommended first course of action is to start nutritional therapy for one year to increase energy levels. This should start to recover menstrual status after a few months. If the athlete fails to complete nutritional therapy for a year (i.e. does not consume enough calories to resume normal menses), the physician working with the athlete could then consider hormone therapy, preferably in the form of patch or vaginal ring to avoid first-pass effects on hepatic IGF-1 production.

Q: Is it possible to have amenorrhea or oligomenorrhea without possibility of bone damage?

Not likely. The extent of bone loss with amenorrhea/oligomenorrhea would be dependent on the length of time without regular menses. Estrogen production is extremely important for inhibiting the osteoclasts responsible for bone resorption, and therefore the longer you are without normal estrogen levels (i.e. when you are not menstruating regularly), the more active these cells are at breaking down bone. If energy status is improved relatively early on, this could help prevent the progression of bone loss.

Q: What about postmenopausal athletes and bone recovery with nutrition support - is it possible without pharmacy?

Because estrogen levels are drastically reduced with menopause, bone health is at risk during this time.  Along with proper nutrition and adequate food consumption, the Food and Nutrition Board (FNB) recommends that post-menopausal women supplement with calcium and vitamin D to the recommended daily value of 1200 mg of Calcium and 600-800 IU Vitamin D. But be advised that pharmacological therapy may be necessary for postmenopausal bone loss. 

Q: What impact does age have?  Comparing a 20-year-old to a 40-year-old, with other factors being similar?

Women who are of greater gynecological age (farther from having their first period) seem to be more robust against menstrual disturbances.  Younger women may also still be accruing bone density so it is especially important for them to maximize their peak bone mineral density, whereas older women may only need to maintain their bone mass.

Q: What type of supplement/vitamins do you recommend for low density athletes?

Calcium and vitamin D are important contributors to bone health. The FNB at the Institute of Medicine recommends adults to take between 1000-1200mg calcium and 600-800 IU vitamin D daily.

Q: What are your recommendations for vitamin D supplementation?

The recommended daily allowance established by the FNB at the Institute of Medicine of the National Academies recommends 600 IU daily for people ages 13-50 and 600-800 IU daily for people ages 51 and older. 

Q: What about psychological therapy?

A mental health practitioner should be included in the multi-disciplinary team for Triad treatment, especially when disordered eating behaviors or clinical eating disorders are present.

Q: Can you explain the physiology as to why OA athletes would have a 27% increase in fractures versus an Anorexic athlete?

The 27% increase was specific to stress fractures.

Q: Is it possible that despite a decrease in BMD, bone structure can be maintained so that the bone remains functional and strong with low risk of stress fractures?

One possibility of why jockeys don’t have stress fractures is due to it being a non-loading activity, many of the fractures encountered in this population are of the traumatic type from falls.  We don’t yet know whether bone geometry can be recovered or if it can be maintained despite decreases in BMD.

Q: My question is regarding my personal experience with the F.A.T. I have been recovered from an eating disorder and amenorrhea for one year, but my bone health has not changed. I am still in the osteopenia category. I do have a history of stress fractures in my pelvis. My question is, at the age of 22, if there hope that I can reverse some of the bone loss? Should I consider pharmacological approach with my doctor?

Remember that bone health takes the longest to recover when you are along the spectrum of the Triad, and may also be impacted by the length of time for which you were dealing with the eating disorder and amenorrhea. While there is no current research to suggest that bone loss can be fully reversed, increasing your energy intake and achieving menstrual regularity is the first big step towards improvement. If you aren’t already taking calcium and vitamin D, please consult with your physician to include this in your recovery plan before seeking other pharmacological interventions.

Q: Does bone loss occur in perimenopausal and postmenopausal women on low energy diets?

Because estrogen levels are drastically reduced during the menopausal transition, this leads to decrements of 1-2% of bone mineral density per year. Along with proper nutrition and adequate food consumption, the Food and Nutrition Board (FNB) recommends that post-menopausal women supplement with calcium and vitamin D to the recommended daily value of 1200 mg of calcium and 600-800 IU Vitamin D. 

Q: Does age of athletes (adolescent vs women in their 30's) have any impact on treatment and resolution of symptoms?

Yes, you must check skeletal maturity issues in young athletes.

Q: Did the participants in your study track intake using an online tool e.g. MyFitnessPal or SparkPeople or keep a hand journal?

We utilize hand journals, but online tools can also be useful especially to individuals tracking their own intake.

Q: The menstrual cycle is a great indicator of the FAT in women - is there an equivalent for men and the MAT?

The Male Athlete Triad is likely more difficult to diagnose for that reason.  One symptom that may be readily observed is a decrease in libido.

Q: Women who take part in sports normally should have periods monthly, thus, my question on periods. Let us suppose we are talking about professional long-distance runners. We are aware of the deficits in performance that periods may have on women. Hence, what diets are the most appropriate for women to maintain their training regime and ensure they perform on race day?

There is NO data available to show that menstrual bleeding is detrimental to performance. We NEVER recommend trying to induce amenorrhea.

Q: Is it possible to recover BMD in mater athletes after menopause?

Women should work towards maintaining their bone mineral density as they go through menopause. Along with proper nutrition and adequate food consumption, the Food and Nutrition Board (FNB) recommends that post-menopausal women supplement with calcium and vitamin D to the recommended daily value of 1200 mg of calcium and 600-800 IU Vitamin D.  If losing bone, they should discuss strategies with their Dr.

Q: Transdermal estrogen is associated with increased risk of DVT, isn't it?

There is an increased risk dependent on the type of progestin the preparation.

Q: When you mentioned a 200 approx. increase in calories, for how long do you recommend maintaining this amount before trying to increase a little extra if no effects are seeing?

 If you start small say 200kcals, you can increase kcals after two to four weeks to get a better chance of recovery.

Q: Why in the REFUEL study the increase in energy intake was increased by 20-30% of EEE and not aimed at 45 kcal/FFM/day?

Because that volume of calories would have likely been too high to ask the women to eat and we would likely have been unsuccessful.

Q: Could you address the average kcal per kg to resume menses from your study? You mentioned the highest amount was ~445 kcals, but how many kcals per kg was this?

We are in the process of analyzing the data- watch for our publications.

Q: When calculating EA, what is your recommendation on how to estimate energy intake and exercise energy expenditure?

Energy intake can be assessed by 3-day diet logs or online diet recording tools.  Exercise energy expenditure can be assessed using exercise logs matched with heart rate monitors or using the Compendium of Physical Activity.

Q: Which type of sports are most likely to result in effecting menstrual cycle disturbances?

Menstrual dysfunction is more commonly observed in leanness sports which emphasize a low body weight for competitive or aesthetic purposes, as in endurance, weight-class, or anti-gravity activities.

Q: What do you think about doing screening DEXA scan for BMD and body composition on all incoming collegiate female athletes?

A screening DXA would be a valuable piece of information for these athletes to have, particularly because most do not realize that their eating behaviors/ inadequate consumption have detrimental consequences on bone health. This would also help identify those in need of dietary intervention early in their collegiate career. This would also provide useful information to the athletes regarding their health.

Author: 

Dr. Mary Jane De Souza, Professor of Kinesiology and Physiology at Penn State University.  Dr. De Souza is a preeminent researcher in the area of the physiological basis of exercise and how it modulates reproductive function and bone health through alterations in energy balance.  Dr. De Souza’s specific research “niche” has been defined by a series of studies demonstrating significant associations of menstrual disturbances, metabolic adaptation, and bone health.  Among her many recognitions, Dr. De Souza is a recipient of the prestigious Citation Award from the American College of Sport Medicine for her lifetime achievement in research, and the Honor Award from the New England Chapter of the American College of Sports Medicine.