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Three Times the Harm
Women and girls who exercise too hard and don’t eat enough risk the serious implications of the female athlete triad.

MCW researcher Dr. Anne Hoch
Photo by Ben Smidt

Betsy Hines had just suffered her 10th stress fracture in less than six years, forcing the 21-year-old Marquette University student to pull out of her Irish dancing competitions yet again. But Hines knew what the problem was. And she was finally ready to confront it.

Hines was suffering from the female athlete triad, a condition that affects women who don’t eat enough calories to support their level of activity. It’s commonly seen in women and girls who compete in sports that encourage a thin but athletic build – such as gymnastics, dancing and running. And Hines had all three components: a lack of menstruation, a loss of bone density (which can lead to fractures) and low energy availability due to diet.

The elements are related: If women exercise hard but don’t eat enough, their periods stop. That causes estrogen levels to drop, which can lead to developing osteoporosis when they should be building bone, says Dr. Anne Z. Hoch, director of the women’s sports medicine program at the Medical College of Wisconsin’s Sports Medicine Center.

Hoch devotes much of her research to the triad. More than 10 of her research projects have been dedicated to the subject, and last year, she received a $125,000 United Way grant to study it. And she consistently interacts with the athletes. In addition to her clinical practice at the Medical College, Hoch is team physician for Mount Mary College, Divine Savior Holy Angels High School, Milwaukee Lutheran High School and the U.S. National Speedskating Team. She’s also a consulting physician for the Milwaukee Ballet.

In 2007, Hoch and her colleagues found that when women suffer from the triad, their blood vessels lose the ability to dilate when stressed, an early sign of heart disease. “We really want to get the word out because this has such serious consequences,” Hoch says. Another study by Hoch and her colleagues, published last April in the Clinical Journal of Sports Medicine, looked at how 257 NCAA Division I schools, including Marquette, screen female athletes for the triad. Nearly two-thirds of the schools completed a full health history and exam only on freshman and transfer students. “Only 32 percent of the programs did exams annually,” Hoch says.

All women on Marquette teams complete annual questionnaires that check for signs of the triad, such as eating too little and missing periods, says Carolyn Smith, executive director of Marquette’s student health service and head team physician. Smith treats three to five triad patients a year but says it’s difficult to know how widespread the condition really is.

For Hines, the problem started at 15 when she got serious about dancing. She upped her practice time to 30 hours a week and cut her calories to just 1,000 a day. “For me, it was performance-
driven,” says Hines, now 26. “How do I win my next competition? How can I perform better as an athlete?” By the time she arrived at Marquette, she did not have a regular period and was nursing a stress fracture. Her family doctor had found significant bone loss, and Smith confirmed it. But it wasn’t until after the 10th fracture that Hines got serious.

Hines, who lives in Minneapolis, realizes she should have been eating 2,500 to 3,000 calories a day. She runs her physical therapy clinic’s dance medicine program and hopes other therapists “start to rethink some of the old training and coaching patterns.”Although her bone density has begun to stabilize and her periods have come back – though sporadically – she still fights the urge to train too much. “It would help if they could promote positive self-image and good nutrition, and not be afraid to take action if they see signs of the female athlete triad.”

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