Young Female Athletes Part Two: Female Athlete Triad

Adolescent Female Athlete month continues here at Julie Wiebe, PT! I am thrilled to have my friend and colleague Julie Granger of Prism Wellness Center bring her wealth of knowledge and experience working with this population in a 3-blog series!! These are excerpts from her recently published e-book Young Female Athlete’s Playbook .  It is an excellent resource that I have already passed on to my schools PE teacher, fellow moms of  high level tween athletes and recommended to colleagues. Soak in the info here and then dig deeper by taking advantage of the discount code she has generously offered to my blog followers (more info at the end of the blog)! If you missed Part one….check it out here. Julie covered the impact of growth spurts on skeletal and neuromuscular development. Now we are moving on to understanding how menarche, pelvic health and sports performance are interconnected, particularly as it relates to the Female Athlete Triad. Check it out! 

Menarche, Pelvic Health, Performance and the Female Athlete Triad by Julie Granger, PT

It is well worth mentioning that more than just skeletal and neuromuscular changes happen during the “magic window.” Girls are also reaching menarche, or the start of their periods, and laying the groundwork for pelvic and abdominal health in pre-adolescence and beyond. And guess what? Injuries, pelvic & abdominal health, menstrual function and sports performance are all related.

So what happens if menstruation is irregular? You better believe this is a problem related to injury risk. Jill Thein-Nissenbaum & colleagues have reported that there is a relationship between menstrual irregularity and injury risk in high school female athletes, particularly in athletes in aesthetic sports (cheer, dance, or pom squads).[i] In those tested, 19.7% of athletes reported menstrual irregularity and 63.7% reported injuries. They also found that athletes with menstrual irregularity are 3 times more likely to sustain an injury in 7+ days of time loss from sport (severe injury) than those w/normal menses. So they sit out of their sport, and it’s doubtful anyone is doing much about addressing the possible root cause of energy deficiency. 

This brings up an underlying problem that occurs in our highly active girls called the Female Athlete Triad. The Triad is a cluster of symptoms, or a syndrome that occurs in active females due to a relative deficiency in energy. Energy is defined as what is left over after all normal bodily functions, sports participation, and what is used in school or in one’s job. Girls who are growing are also at risk for low energy because their bodies require more energy to perform necessary functions for normal development. A relative energy deficit, therefore, can lead to impaired bone health, increased risk for fracture, and abnormal, irregular, or absent menstrual cycles. Sometimes girls are at a relative energy deficiency because they are burning more calories than they are taking in. Sometimes this is intentional and can be classified as disordered eating, and other times it is not. Either way, it is important that the amount of energy being used is always less than the amount of energy taken if we want our young athletes to be successful and healthy.

A newer term, Relative Energy Deficiency in Sport, was coined in 2014 which classifies this phenomenon related to other body systems that may be affected not only in female but also male athletes. These may include the areas of the Triad mentioned before in addition protein synthesis, cardiovascular function, psychological function, anemia, endocrine function, and overall sport and athletic performance. It is our job as providers, parents, coaches, and mentors of young female (and male!) athletes to ensure that we are monitoring their energy intake and expenditure and not setting our young athletes up for long-term health dysfunction. And to me, one of the easiest ways to monitor this, at least in females, is to keep tabs on her menstrual function.

Education about the relationship between menstrual health, sports participation, abdominal and pelvic health MUST occur BEFORE girls hit their growth spurts. Girls often mistakenly believe that if you haven’t gotten your period, that you must be a better athlete because you’re training harder or you’re dieting and losing weight. Girls are under pressure not only from the media and friends, but also from coaches for certain body types and eating behaviors. The endless cycle (pun intended) gets reinforced and girls don’t know where to turn.

There are simple and useful resources like period and health/diet tracking apps. In addition, it would be amazing if girls, parents, and coaches would understand the relationship between natural hormonal energy levels during different parts of the menstrual cycle and their relationship to sports performance. For example, how cool would it be if athletes, parents, and coaches knew that there is an energy spike during ovulation and energy crash just prior to the start of menstruation? What if athletes, parents, and coaches were aware that due to natural, normal hormonal fluctuations that she is at greater risk for injury just prior to the start of her menstrual cycle?[ii] Wouldn’t it be amazing if they would plan training, recovery, and competition around these natural cyclic patterns in the female cycle?

Many girls and adults are really in the dark about these factors. How much better would it be if girls and adults were aware of how menstrual function affected sports performance, energy availability, and injury risk?

Moving forward: what do we do about all of this?

Given that girls are at higher risk for certain injuries and may suffer more than boys following other injuries and illnesses, we hold a great responsibility to keep them safe, moving, healthy and happy as they progress in through childhood and adolescence.

So what is the solution? There probably is not a panacea for this, but I truly believe it begins with simply starting the conversation.

For any girl, puberty and adolescence can be either a perfect opportunity or a perfect storm. She may get hurt or sick. With all that could go wrong, it could all become a grim picture. Alternatively, we could look at it is an AMAZING OPPORTUNITY to steer our girls on the most inspirational, empowered paths into adolescence and adulthood. Her success during this amazing time of opportunity depends on who is serving her, teaching her, and leading her, and it starts at her pediatric/adolescent well visits, with school nurses, coaches, parents, athletic trainers, health coaches, dieticians, physical therapists, at her pre-participation exams, and in her health education in school.

Wanna start a conversation of your own? Get educated! Julie Granger has created an awesome resource to help you learn more about supporting girls in sports. Check out the Young Female Athlete’s Playbook, which is now online and ready for download! For being a valued reader here at Julie Wiebe, PT, you can use the coupon code GIRL20 for an additional 20% off all products in a one-time PRISM Wellness Center Store purchase!

You can also connect with Julie Granger on her website/blog, facebook and instagram (@prismwellnesscenter) to check out daily updates pertaining to women & girls’ health, or request to join her private Facebook community, PRISM STRONGirls to keep the conversation going!


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[i] Thein-Nissenbaum J, Rauh M, Carr K, Loud K, McGuire J. Menstrual irregularity and musculoskeletal injury in female high school athletes. Journal of Athletic Training. 2012; 47(1): 74-82.

[ii] Drummond J. “Adrenal Fatigue in Active Women: Impacts on Fertility, Sports Performance, and Strategies for Prevention and Recovery.” Lecture notes. Women in Women’s Health Live Conference. The Integrative Women’s Health Institute, New York, 2016.

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