Every woman’s body – inside and out – is as unique as her fingerprint. Some of us are good at squats (that would NOT be me) and some of us live for box jumps. Have you ever looked at the athlete next to you and think “Yeah, I’m in good shape -I’ve got this” only to realize that that athlete next to you, who is old enough to be your mom, just rowed circles around you; but you think to yourself, “Well, at least I’m good at pull-ups!”

I have been doing CrossFit for only 2 years, but one thing I have learned to appreciate is that each and every athlete has an “athletic cache” which includes her unique strengths and weaknesses as well as her unique response to physical and nutritional challenges. Finding that magical combination of exercise, nutrition and emotional and mental well-being that takes us off our plateaus into that better version of ourselves is the Holy Grail of our personal fitness goals.

Sometimes that journey is a bumpy one. We have all felt defeated after a tough WOD and felt crappy doing a nutritional challenge. However, other times when we ARE successfully seeing change in our performance and body composition, some unexpected – and sometimes concerning – changes are happening inside of our bodies. Here, we begin to talk about these changes and raise awareness of them so they can be managed.

The Female Athlete Triad1

The Female Athlete Triad was originally defined in an American College of Sports Medicine position statement published in 19972 and has since evolved to be recognized as 3 components that each exist on a spectrum from optimal health to disease: menstrual function, bone mineral density (BMD) and energy availability (EA). An athlete may experience one, two or all three of these components. Younger athletes (< age 32), especially adolescents, are particularly vulnerable because these early years are when peak bone mineral density is being established. Interference with this process can put an athlete at risk of osteoporosis and stress fractures. Menstrual cycle irregularity can also affect child bearing because ovulation is directly related to a regular menstrual cycle. When cycles become irregular, ovulation occurs less frequently and conception can become more difficult.

When the components of the triad occur on the “disease” end of the spectrum and persist for long periods of time, there is evidence that the risk of cardiovascular disease is increased. Imagine all the work that goes into your best 2K row time could actually be putting your heart at risk if done to excess! In more extreme cases where menstrual cycles are absent for an extended timeframe, the risk of pre-cancerous changes in the uterus is also increased. Fortunately, with awareness and health care providers knowledgeable in the unique challenges of female athletes, the female athlete triad can be very effectively managed.

Energy availability (EA) is defined as daily dietary energy intake minus daily exercise expenditure corrected for lean body mass; or more simply put, “energy in” minus “energy out”. When dietary intake is insufficient to keep up with energy expenditure, the body may reach a threshold where one or more components of the female athlete triad become apparent. This imbalance can occur from overt eating disorders like anorexia nervosa or bulimia, however very commonly can occur simply with insufficient caloric intake or an imbalance of macronutrients (“macros”) in one’s diet. What is challenging is that there is no “one size fits all”. Two gymnasts could train the same way, be on the same nutritional program with the same body mass index with dramatically different effects on their individual physiologies. The “nutritional prescription” to balance “energy in” and “energy out” for a specific athlete and her training program is often achieved with educated trial and error by the athlete herself or with the help of a sports nutritionist, CrossFit Coach and/or health care providers specializing in the special needs of athletes. Achieving this balance is critically important for staying on the “optimal health” end of the spectrum.

The physiologic changes associated with the female athlete triad can affect any athlete from the beginner to the elite level. A formerly obese woman who has become healthier and fitter losing body fat and gaining muscle mass can experience these changes the same way as an elite athlete trying to take her performance to the next level. But with increased awareness about the unique challenges that female athletes of all levels face, the better we can navigate the bumps that we may encounter in our fitness journey.

About the author:
Carla M. DiGirolamo, MD, PhD is a Board Certified Reproductive Endocrinologist taking new patients at Boston IVF, Waltham, MA and is credentialed as a Level 1 CrossFit Trainer, Les Mills certified group fitness instructor and is a member of CrossFit Health – a worldwide organization of physicians who CrossFit created by CrossFit Founder, Greg Glassman in his quest to cure the world of chronic disease. In addition to helping patients build their families, Dr. DiGirolamo’s special interest is managing the unique reproductive/endocrine challenges of female athletes.

  1. Weiss Kelly, AK et al.; Pediatrics 2016; 138(2) e-pub
  2. Otis, CL et al.; Med Sci Sports Exerc. 1997;29(5):i-ix