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Amenorrhea, or absence of menstruation, is the second component of the triad. When disordered eating and intense physical activity drain the body of enough energy to support a pregnancy, the body shuts down the reproductive system. The ovaries become dormant, and occasionally they remain permanently damaged even after normal menses resume.
In the 1970s, after Title IX opened the door to women’s college sports, amenorrhea was thought to be a normal adaptation to exercise. Some coaches even believed that it was the mark of adequate training, and women were only considered “fit when it quit.” Today, doctors understand that when stress causes even a few months without a period, it can adversely affect a woman’s health and set her up for life-long problems, including infertility and osteoporosis. As an athlete’s estrogen level decreases, her body becomes less able to absorb calcium from food. Instead, calcium begins to be leached directly from the bones, lowering bone density and weakening the skeletal system. A study performed by Katherine Beals and Melinda Manore revealed that female athletes who had irregular periods were far more likely to sustain bone and muscle injuries than their peers who had normal menses. These injuries include stress fractures, which are incomplete breaks across part of the bone, usually at a site of bone remodeling.
Stress fractures can be symptomatic of osteoporosis, the third element of the female athlete triad. As osteoporosis worsens, the bones reach a state where even mild stresses such as running or walking can cause fractures. A groundbreaking study performed by Dr. Barbara Drinkwater in the early 1980s found that women in their twenties with amenorrhea had the bone density of women who were in their fifties or even seventies. Still, nearly 50 percent of female distance runners have amenorrhea, compared to only 2-4 percent of the normal population.
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