Female Athlete Triad & Femoral Stress Fx Recovery time

Triathlon Forum
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Hello ladies! New to the forum and came across it in a quest for information and answers. I want to share my experience to help others as well as get feedback from other women who have had similar experiences.

I’m an endurance athlete (ultra runner) who runs around 50-80 miles per week, cycles about 100 miles a week and recently (due to injuries) started swimming a little bit…so not a triathlete yet but hoping to become one in the near future. 3 weeks ago I had surgery to fix a femoral neck stress fracture that wasn’t healing after 2 months off from training. I’ve had over 10 stress fractures as well as full fractures (4 of them requiring surgery) in the last 10 years. I train between 12-20 hours per week, which includes heavy weight lifting, running and cycling.

After the last fracture on my femur, my ortho finally realized something was wrong when no accident or heavy training Ioad led me to fracture one of the strongest bones in the human body. He has recently diagnosed me with osteomalacia and female athlete triad. I apparently have been in a calorie deficiency for several years, despite the fact that I am not underweight (I’m 5’7" and weight between 125-135 lbs depending on training phase). I am strong and work hard in the gym to keep my bones dense. I also eat very healthy with 90% of my diet being whole foods.

I’ve had amenhorrea on an off for the last 7 years and completely for the last 4. Despite the fact that my hormones look normal and all blood work looks normal, my bones keep breaking no matter how much I try to take care of them. I’ve had low vitamin D for a while, but in the last year it finally crept up to the low end of normal (about 28-29). I take Vitamin D, calcium, Vitamin C, Vitamin K and Magnesium every day religiously. My Bone Scan also looks normal (which i don’t understand how).

I’m sharing this for a couple of reasons: I want to help other female athletes who may, like me, think that not having a period is normal. As a competitive runner my entire life, amenhorrea was just part of heavy training. Nobody explains that without estrogen (which comes with a period) your bones are left without protection and very vulnerable. Also, training hard requires more calories, no way around it. We just have to eat more to sustain that level of activity. I never really measured how much I ate, but upon further examination with my nutritionist, on a day that I would run 30 miles, burning well over 3,000 calories, I’d probably consume less calories than those used during my run on the entire day. Do that consistently, and your body starts to eat itself.

If you have nutritional deficiency, don’t get a period when you should or are suffering from stress fractures, please do yourself a favor and look into the female athlete triad and talk to your doctor about it. It can be a serious condition and it is completely preventable.

Also, anyone had femoral surgery before? My doctor said 4 weeks before I can get in the pool, 2 months before I can get on the bike and I could POSSIBLY start running in 6 months but full recovery would take up to a year. This timeline seems a little excessive compared to all my other fractures,did anyone have the same experience as far as how long it took for it to heal? Anything that helped you get moving, healing faster or just stay sane during these months of low activity?

Thank you!

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pardon, i’m not a woman, i’m the site owner here and a moderator. i’m posting just to alert you of the thread and subsequent discussion here on the mary cain article/video that’s on the main triathlon forum. yours is one theme underlying that thread. i’m not a doctor, just a longtime observer, but what i have observed over some decades as a coach/advisor/mentor of women who race at a high level - esp in ultras - is that there is a strong weight, and that weight is the right weight. lighter isn’t faster if it’s means you’re weaker, and one sign you’ve crossed that line is when you become amenhorreic.

this is - again - simply my observation. just as it was my observation a couple of decades ago that hard charging endurance sport (mostly by men) engaged in for 30 or 40 years seems to yield a higher than normal incidence of cardiac arrhythmias post-age-45 or 50, there seems to me to be an association between amenhorreia and stress fractures (and perhaps other medical perils) in women. so, you’re onto something i think. the interesting question is how and why you become amenhorreic if you’re not underweight. maybe other stresses. don’t know. and with that i’ve exhausted all the knowledge i have on this topic, which may be no knowledge at all, and i’ll bow out and let you ladies discuss.

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yes! absolutely agree. My entire life I aimed to stay at my “race weight” which for most people would be underweight. I think in my early years this may have cause long lasting damage. But what good is it to be light when you are not strong? Ultra running does require less muscle mass (than sprinters for ex) and it naturally falls off as we increase training miles, which is why I have made it a point to work hard in the gym to preserve as much muscle as possible. Amenhorrea in young athletes has been so normalized that having a period is often times looked at as a sign of not training hard enough. I feel it’s important to have this conversation to help females understand that it is NOT normal to lose the period and it can do a lot of damage to your body and running career.

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Ultra, hi,

First, welcome to the Women’s! Second, I’m not at a level where this is a concern for me, but I wanted to offer gratitude for bring the conversation over here. I’m really glad that we are thinking about the implications of amenorrhea. It’s so very important.

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there seems to me to be an association between amenhorreia and stress fractures (and perhaps other medical perils) in women. so, you’re onto something i think. the interesting question is how and why you become amenhorreic if you’re not underweight. maybe other stresses. don’t know. and with that i’ve exhausted all the knowledge i have on this topic, which may be no knowledge at all, and i’ll bow out and let you ladies discuss.

This is NOT my academic area but I’ve done some research on this for personal reasons. Some of the research literature suggests amenhorrea can be the result of enough of an energy imbalance over time, even at a normal weight. Other researchers have suggested inadequate dietary fat as a contributing factor, as apparently dietary fat is linked with hormones. The latest term is “REDS” (relative energy deficiency syndrome) rather than female athlete triad (FAT), as males can suffer from this too, and one can have these issues without the eating disorder part of the FAT.

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Hi! welcome.

My Bone Scan also looks normal (which i don’t understand how).

Do you mean DEXA scan?

I can’t answer your questions about surgery, unfortunately. You might try the main forum just to cast a wider net.

I can say, for the sake of sharing stories, that I spent high school suffering from anorexia and amenhorrea. I was diagnosed with osteoporosis at age 17. Fortunately, over the year I went from age 17 to 18, I was able to gain 20 pounds to reach a bare minimum normal weight. I then spent college suffering from a series of stress fractures that were the result of (a) bone density not having caught up yet, despite the healthy weight and (b) running too much. My headspace was “I worked my tail off to gain this weight and now that I am at a healthy weight I will run as much as I like because I am healthy and my body can handle it” despite repeated messages (in the form of repeated fractures) that it couldn’t.

It took me until age… 26 ish to finally stop having stress fractures. The 50 mpw that broke bones for me in college is something I can totally do now and have no issues. I am now 32; I had a DEXA scan last January and my bone density has improved 9.8% since age 18. So, there’s a lot of hope for people who go from years of a 16-ish BMI to a healthy weight and maintain it. I’m 5’6.5"; I weighed 115 pounds when I graduate from high school, gained a couple more in college, and have spent the better part of a decade at 120-125 lbs. I suspect that is the key contributor to the increased bone density and lack of fractures.

It sounds like the best thing you can do for yourself now to speed healing is to eat a lot so your body pulls itself out of thinking it doesn’t have enough energy to make hormones. You could also ask for an NTX study, which measures calcium excretion. Depending on where you live, maybe one of those sun lamps? Do those help with vitamin D? Also, look into a supplement called Bone Support by Twin Labs - not sure if that exists any longer, but that’s what I took when I had fractures. It’s basically a calcium supplement but an elite runner friend swore by it so that’s what I did.

keep us updated.

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pardon, i’m not a woman, i’m the site owner here and a moderator. i’m posting just to alert you of the thread and subsequent discussion here on the mary cain article/video that’s on the main triathlon forum. yours is one theme underlying that thread. i’m not a doctor, just a longtime observer, but what i have observed over some decades as a coach/advisor/mentor of women who race at a high level - esp in ultras - is that there is a strong weight, and that weight is the right weight. lighter isn’t faster if it’s means you’re weaker, and one sign you’ve crossed that line is when you become amenhorreic.

Allie Keiffer (sp?) has also been really outspoken about lighter not necessarily being faster. Shalane Flanagan’s cookbooks have, in the same vein, argued for eating enough to stay healthy. There’s something called the ‘lane 6 project’ too (I think that’s the right # lane).

In short, Mary Cain’s message is important, AND it joins other high-profile people who have been talking about this for a bit.

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if you have some time on your hands, look at some of the academic literature about this on pubmed. There was also a conference in Boston this summer about eating disorders and athletes (Allie Keifer (sp) gave a keynote) - that conference program would give you some starting places for what the current research is saying, and also the names of who the experts are in the field. Depending on location you might be able to see one of them, or get your MD to send your file, or whatever.

Cliff Rosen is one of the nation’s leading researchers in osteoporosis; presumably he’s knowledgeable about osteomalacia. I took a class from him in grad school; at that time (8 yrs ago) he practiced in Bangor, ME. I think he’s also a runner; he consulted on my issues and certainly seemed knowledgeable about the whole un-fun package of endurance athletics and amenhorrea and bone issues.

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thought of something else:
https://www.instagram.com/becomingbarbara/
I follow her IG, and she had a hip fx and surgery a bit over a year ago, I think. She and I have communicated over email; she’s really nice and would talk to you I’m sure.

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Hey! Thanks for posting and bringing this topic to conversation. I wanted to share my experience in hoping it’ll help! I had amenorrhea for the past 6 years from not consuming enough calories while being a collegiate soccer player and competitive triathlete. I had normal bone density from a DEXA scan, no hormonal imbalances, but I was Vitamin D deficient and low in calcium. I never had a bone injury/stress fracture during those six years and was not “super lean” (5’1" and 110ish lbs) Last year I decided it was time to address my amenorrhea and I worked with a RD to start fueling properly. I managed to gain 20 lbs while training 16-20 hours per week AND snagging a PR in the 70.3 distance. Definitely goes to show that smaller is not faster.

However, this past February (about 6 months of having a regular cycle) I too was diagnosed with a femoral neck stress fracture. I thought I was “out of the woods” so to speak since I had gotten my period back and gained weight. Even though I did not have bone density loss from those 6 years of amenorrhea, I think it still negatively affected my bone health. And like you, I think Vitamin D plays a pretty big role in this as well. It is interesting to hear from someone who had a normal bone density scan as well, I was definitely surprised that mine was normal!

To provide some context in terms of recovery time, I’ve been told that recovering from this stress fracture is much slower than others. I actually only had a stress “reaction” and no fracture was present in the MRI (Done on February 25) and as of today (April 29th) I am still on crutches and not cleared yet for any swimming/biking/walking. I am hoping to be cleared to slowly return to biking on May 9th!

I would love to connect more to hear about your training/recovery. Its tough and slow and frustrating but it always helps to hear from others going through the same thing!

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Hi - I just saw this post and someone else sent me a PM about tips for recovering from a FN SF. Here’s my response from May 9th. Maybe it will be a little helpful for others. At least provide a bit of hope. It’s a tough injury but you can get through it and still be competitive afterward.

Hi - sorry to learn you have a stress fracture. I had a femoral neck SF in June 2015 from overtraining and a BMI that was a bit low. I was also 45 years old. So a perfect storm. The best thing you can do is listen to the doctors and let it heal. Mine was bad and I didn’t run for about 6 months and it took that long just to start off with 30 seconds of jogging followed by 2 minutes of walking (repeating for 10 -15 minutes or something along that line). Luckily bones heal so you just have to wait it out. Some soft tissue injuries linger on for years.

I was on crutches for the rest of the summer and wasn’t off them until beginning of September. I did a lot of laying around on the sofa. When the doctor allowed me to get back in the pool I was careful pushing off the walls. I also got on my bike trainer and the Alter G when the doctor gave me the green light for those which was later in the fall. The rule of thumb was I couldn’t do anything that would cause it any pain. By the end of December my third MRI showed over 90% healing and I was able to start the run/walk protocol in January with the help of my coach.

Just be patient and you’ll be back at it. I was able to do a local sprint the following May, a 70.3 in June and a full IM in August (all 2016). The femoral neck is a place where healing can take longer due to less blood flow to that area. And the closer to the torso the longer it takes to heal. So it can feel frustrating!

If you have other questions, feel free to contact me. I respond quicker to my email: jholsten@gmail.com.

After 10 years of marathons and Ironmans I’m sort of retired from serious training. Between a new remote home that’s off the grid, turning 50, possible menopause and covid closing the pools, I am not sure what my future race plans are. I’ll defer IM Wales to 2021 but not sure I’ll do it at this point. So I haven’t been on ST that much. Instead of reading about training, I’m trying to figure out how to garden :slight_smile:

Best of luck!

Joyce Holsten in Vermont