Female runners experience changes in menstrual function and bone mass – Female Athlete Triad

Female runners experience changes in menstrual function and bone mass – Female Athlete Triad
Female runners experience changes in menstrual function and bone mass


In this article, research is used to discuss the problems of menstrual function and bone mass in female runners. The word energy is used interchangeably to indicate food intake. When the research discusses reduced energy availability, it signifies less caloric intake than what is needed to sustain the athlete’s health. This could be unintentional – the athlete is burning more calories than they are taking in. Or it could be intentional and there is an underlying eating disorder. An eating disorder can be: starvation, fasting or restricted eating. It can be taking in excessive caffeine or diet pills, laxities, or purging after eating.

We work on joint problems, whether it is the high school runner or the osteoarthritis suffer in later years. In many of these patients, other problems exists. These problems can be those outline here or they can be obesity, cardiovascular or any other ailment affecting the aging population. To help a person heal, we can work on the spine and joints, but other professionals may need to be consulted on nutritional problems.

Female athletes actually had a better diet than their male counterparts

Before we get into the problems of caloric intake, let’s look at a study that found that female athletes actually had a better diet than their male counterparts:

In this June 2022 (5) study, the researchers aimed to “explore the gender-specific differences in dietary intake of female and male distance runners competing at greater than 10-km distances.  . . .211 endurance runners (121 females and 90 males) were selected as the final sample . . Participants were classified to race distance (10-km, half-marathon, marathon/ultra-marathon) and type of diet (omnivorous, vegetarian, vegan) subgroups. . .  Compared to male runners, female runners had a significantly greater intake in four food clusters, including “beans and seeds”, “fruit and vegetables”, “dairy alternatives”, and “water”. Males reported higher intakes of seven food clusters, including “meat”, “fish”, “eggs”, “oils”, “grains”, “alcohol”, and “processed foods”. Generally, it can be suggested that female runners have a tendency to consume healthier foods than males. The predominance of females with healthy dietary behavior can be potentially linked to the well-known differences between females and males in health attitudes and lifestyle patterns.

The problems of eating disorders in elite female athletes

A December 2021 paper (4) writes: “A considerable number of runners are at risk of suffering from some type of eating disorder. A significant relationship was observed between long-distance runners and the risk of eating disorders (anorexia nervosa, bulimia nervosa, and being a compulsive eater), and the association is stronger for the compulsive eater than for anorexia nervosa and bulimia nervosa. Lastly, childhood experiences (such as being obese/a healthy weight) were notorious for increasing the risk of eating disorders.”

Long distance runners in the Olympics

An April 2022 study examined the problems of eating disorders in elite female athletes. The study wrote: “In the 2021 Tokyo Olympics, female athletes reached a record high of 48.8% of all athletes, and women competed in various events. Underneath the success of women in sports, reproductive dysfunction and impaired bone health associated with female relative energy deficiency in sports (eating disorders) are considered problematic.” (1) Further they write: “Long-distance female runners aim to maintain low body weight or tend to lose weight prior to competition to optimize their time-based performance. Consequently, some long-distance runners experience eating disorders (ED) in the effort to obtain desired low body weights; about half (46%) were classified as “at risk” for developing an eating disorders in a study of collegiate endurance runners from seven US universities.”

40 female adolescent endurance runners

A July 2021 study (2) evaluated the three-year change in menstrual function and bone mass among 40 female adolescent endurance runners (average age about 16 years old) according to baseline disordered eating status. Three years after initial data collection, runners underwent follow-up measures including the Eating Disorder Examination Questionnaire and a survey evaluating menstrual function, running training, injury history, and prior sports participation.

  • Runners with a weight concern, shape concern or known pathologic behavior in the past 28 days were classified with disordered eating.
  • Runners with disordered eating at baseline reported fewer menstrual cycles/year, more years of amenorrhea, and a higher proportion of menstrual irregularity and failed to increase lumbar spine or total hip bone mineral density at the 3-year follow-up.
  • These finding support associations between disordered eating at baseline and future menstrual irregularities or reduced accrual of lumbar spine bone mass in female adolescent endurance runners.

Female Athlete Triad Cumulative Risk Assessment

A May 2022 study (3) explored if food limitation, menstrual function, measures of bone health, and a modified Female Athlete Triad Cumulative Risk Assessment (testing for food absorption and energy usage with or without eating disorders, menstrual dysfunction, and low bone mineral density) are associated with a history of multiple bone stress injuries.

  • 51 female runners (ages 18-36 years) with history of multiple bone stress injuries were assessed with a conclusion being suggested of: “women with a history of multiple bone stress injuries suffered more prior low-energy (low impact) fractures and have greater historical and current estimates of energy deficit (low food energy intake with or without diagnosed eating disorders) compared with control (subjects).”


1 Uchizawa A, Kondo E, Lakicevic N, Sagayama H. Differential Risks of the Duration and Degree of Weight Control on Bone Health and Menstruation in Female Athletes. Frontiers in Nutrition. 2022:766.
2 Barrack MT, Van Loan MD, Rauh M, Nichols JF. Disordered eating, development of menstrual irregularity, and reduced bone mass change after a 3-year follow-up in female adolescent endurance runners. International journal of sport nutrition and exercise metabolism. 2021 Jun 7;31(4):337-44.
3 Gehman S, Ackerman KE, Caksa S, Rudolph SE, Hughes JM, Garrahan M, Tenforde AS, Bouxsein ML, Popp KL. Restrictive Eating and Prior Low-Energy Fractures Are Associated With History of Multiple Bone Stress Injuries. International Journal of Sport Nutrition and Exercise Metabolism. 2022 May 6;1(aop):1-9.
4 Monserrat Hernández M, Arjona Garrido Á, Checa Olmos JC, Salguero García D. Relationship between Negative Running Addiction and Eating Disorder Patterns in Runners. Nutrients. 2021 Dec 1;13(12):4344.
5 Motevalli M, Wagner KH, Leitzmann C, Tanous D, Wirnitzer G, Knechtle B, Wirnitzer K. Female Endurance Runners Have a Healthier Diet than Males—Results from the NURMI Study (Step 2). Nutrients. 2022 Jan;14(13):2590.



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