Overcoming female athlete triad

shutterstock_246365317After dealing with an eating disorder during high school, Alicia* seemed to find her stride as a college student. She started running as a college freshman and competed with both the cross-country and track teams. “I was in a better place as part of the team. It was helpful to know that I had to eat to run.” Alicia realized that she needed to fuel her body to maintain a rigorous exercise regimen that included running 60 miles a week.

Then, a series of injuries struck Alicia. During her sophomore year, she tripped on some ice and broke her femur. After she recovered from the fracture and returned to running, Alicia began experiencing thigh pain that she thought was caused by a strained hamstring muscle.

However, Alicia’s pain was caused by a stress fracture in her pelvis. (A stress fracture is an incomplete break in the bone caused by overuse.) Alicia’s stress fracture worsened and later turned into a solid break.

“There were other injuries, including repeat muscle pulls, and I developed bradycardia (a slower-than- normal heart rate). I didn’t understand what was going on with my body and felt like I was overreacting.”

Overwhelmed by her injuries and unable to run with her teammates, Alicia experienced a relapse of her eating disorder after a prolonged period of stability. At the end of her junior year, she entered an eating disorder treatment program and was also referred to a sports medicine physician—Kate Ackerman, MD, MPH, co-director of Boston Children’s Hospital Female Athlete Program, who could provide care for her injuries.

“Dr. Ackerman really listened to me and was able to put all of the pieces together.” Ackerman ordered a bone density test, which confirmed that Alicia suffered from significant effects of female athlete triad. Female athlete triad is a complex syndrome characterized by energy deficiency (inadequate caloric intake typically caused by disordered eating or an eating disorder), menstrual irregularities and low bone mineral density.

Ackerman helped manage Alicia’s treatment, coordinating with her nutritionist, therapist, psychiatrist and physical therapist. “Having a unified team is really important in a situation like Alicia’s, where athletes might get mixed messages about how much exercise is safe,” says Ackerman.

She was allowed to exercise by all of her providers, but this was monitored closely to help her to keep from overdoing it. Exercise gave Alicia a sense of stability by doing something she loved in moderation. Her providers supported this by making sure she was fueling enough, regaining normal menses and staying consistent with her stretches and physical therapy exercises. They also worked closely with her to make sure that she was developing coping mechanisms for stress and a healthier relationship with food and exercise.

“Dr. Ackerman was really invested in my physical and emotional well-being and my recovery process and was always available to my other doctors,” says Alicia.

Importantly, Ackerman helped Alicia and her caregivers determine the appropriate amount of exercise and how to minimize injury risk.

“I learned to listen to my body,” says Alicia. She learned to eat intuitively, to take breaks from exercise to allow her body to heal when necessary and to watch her heart rate. Ackerman also referred Alicia to The Micheli Center for Sports Injury Prevention for a gait analysis, so she could improve her running form to further reduce her risk of injury.

After battling anorexia and suffering from the effects of the female athlete triad for more than five years, Alicia continues to recover. She’s now in nursing school and has learned to combine fitness with other interests. She runs 3-4 miles several times a week and sets aside time for friends and hobbies when she feels overwhelmed. Alicia attributes her recovery to several factors:

1. Having a supportive treatment team that believed in her and trusting them even when what they were telling her seemed counterintuitive.

2. Engaging in Dialectical Behavioral Therapy (DBT) and learning to use distress tolerance skills to cope with the anxiety that came along with following her meal plan and other painful feelings (DBT brings together acceptance and change to help people overcome negative behavior patterns. It combines individual therapy and group skills training.)

3. Staying motivated by keeping her personal and career goals in mind. Athletes with eating disorders often reject conventional approaches to treatment that may completely restrict activity. Alicia realized that Ackerman wanted to allow her to keep active but also keep her safe. She understood that Ackerman’s job was to make sure she was medically stable enough to engage in exercise, while enhancing her bone density and improving her approach to activity. Alicia knew she had to do her part to follow recommendations.

Learn more about the female athlete triad at Boston Children’s Female Athlete Conference.

*The patient’s name has been changed to respect her privacy.