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If you’ve trained for a marathon or half marathon, you’re well acquainted with the dangers of shin splints, pulled muscles, and joint injuries.

And you probably take deliberate care to avoid them.

But it may surprise you to learn female distance runners face a little-known health risk that can have serious, even permanent, consequences.

I’m talking about Female Athlete Triad (FAT).

A recent article in the Journal Of Women’s Health Physical Therapy defines the condition by its three components: “low energy availability, menstrual dysfunction, and low bone density”. Those components form a chain reaction of problems that build on each other. Unchecked, each one can lead to long-term health issues from hormonal imbalance to lowered metabolism and immunities, to osteoporosis. But it’s easily ignored by those who suffer from it, and misdiagnosed by their doctors.

Low energy availability often triggers the chain reaction; but how many people, including doctors, would describe a woman who fits a 5am training run into her busy schedule as ‘low energy’? Reread the description. ‘Low energy’ and ‘low available energy’ aren’t the same thing. According to researchers, low available energy is “the amount of dietary energy remaining for other body functions… after exercise training”. You can look, and even feel, fantastic; but if your training regimen or diet is too demanding, your body will slow or shut down other systems to conserve energy.

Often, the reproductive system is the first to go offline; and that process usually starts with menstrual irregularities. Sadly, many female athletes believe the myth that irregular or missed periods are just part of the game. Of course, there are a number of other reasons a runner’s period might be irregular, from pregnancy to perimenopause to a perfectly healthy personal cycle. But if you’re skipping periods, it’s important to find out why. Regardless of the cause, untreated menstrual dysfunction can lead to the third part of the triad, low bone density, setting you up for osteoporosis and other problems.

What’s a distance runner to do?

Start by examining your diet. Endurance training and low calorie or fad eating plans do NOT go together, ladies! Whether or not it’s intentional (and 80% of the distance runners in one FAT study expressed weight loss goals), running on fumes is the fastest route to Female Athlete Triad. And although you don’t have to give up your quest for a medal, you may need to adjust your training regimen, too.

If you’re skipping periods or have hormonal issues, it’s definitely time to schedule an appointment with your doctor. Be ready to talk with them about your symptoms and overall risk for Female Athlete Triad. This is especially important if you’re taking contraceptives for previously reported irregular periods. This commonly prescribed quick fix for athletic women can mask the other components while also contributing to them.

If you aren’t sure how to begin the conversation, take this article with you. Better yet, start treating yourself like the serious athlete you are and surround yourself with the team of professionals you deserve. In addition to a medical doctor, consider at least one session with a dietitian, as well as a women’s health physical therapist like someone at Femina Physical Therapy. In addition to our trusted referral network of specialists, we’re happy to discuss Female Athlete Triad and your entire training regimen with you. Physical therapy isn’t just for injuries; you’d be surprised by all the ways we can help you stay in the race toward optimal health and fitness.


Rothschild C., Schellhase, K. 2020. Considerations For The Adult Female Endurance Runner: A Survey Analysis. Journal Of Women’s Health Physical Therapy 44:1 3-8.

What Our Patients Have to Say


Testimonial by T.H.

I started seeing Heather in October 2014. For more than two years, I had been suffering from painful urinary tract infection type symptoms after my bartholins gland surgery which included constant burning and urinary frequency sensation that led to more and more painful intercourse. I had made multiple visits to internist, obgyn and urologist's offices, went through a range of treatment with UTI and bladder frequency medication that included antibiotics, vesicare, estrogen cream, but nothing worked.

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Testimonial by R.M., Age 40

I can’t speak highly enough of the theapists at Femina Physical Therapy and how much they have helped me grow, discover, and love my body. I had had painful sex for my entire life, and didn’t know that there was anything that could be done about it. It was at the point where my husband and I were not having sex for MONTHs, because it was just too frustrating, and I hated feeling like I was the ONLY woman out there who had this problem, especially at my age. I finally brought it up to my doctor because I was turning 40 and my husband and I were barely having enough sex to conceive. And she brought up pelvic floor, PT. I didn’t even know this was a “thing”.

Read more: Testimonial by R.M., Age 40

Testimonial by M.M.

My husband and I were married for 5 years and unable to have intercourse, but I never knew why. After numerous awful experiences at doctor’s offices (where many doctors told me I “just needed to relax”), a surgery that didn’t fix the problem, and a year of owning dilators that didn’t get me anywhere, someone finally referred me to Heather for Physical Therapy. I finally had answers and information from someone who knew exactly what I was dealing with!

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Testimonial by S.P., Age 26

I would like to start off by thanking Heather Jeffcoat for educating me and curing me of Vaginismus. I had been married for almost three years before I was referred to Heather. I never knew about Vaginismus until almost three years into my marriage. I knew something was wrong when I went on my honeymoon and came back a Virgin. I had always imagined how magical my first night would be but boy was I wrong.

Read more: Testimonial by S.P., Age 26

Testimonial by Rosanna R., age 35

Heather has affected my life in the MOST POSITIVE way and I am forever grateful. My husband refers to her as the "sex doctor" so you can only imagine how happy he is with my therapy outcome.

After the birth of my son I suffered from "Vaginismus", however, at the time I just thought I was broken. My "broken vagina" affected me physically but it was an emotional struggle as well. Many women in my life also suffered with pain from sex after their babies were born so I knew I wasn't alone. They told me they "just got used to it" but I couldn't see myself living that way.

Sex wasn't just painful, it was literally impossible - IT DIDNT FIT!

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Testimonial by M.M.

A personal journey and testimonial from one of my patients:

My husband and I were married for 5 years before we were able to have intercourse due to my vaginismus. There was nothing traumatic in my past but for some reason, even though I wanted sex, I mentally avoided "that area" of my body and didn't even admit to myself that there was a problem for a long time, even though I was never able to put tampons in. Once I finally opened my eyes up to the fact that I had a problem, I had a surgery that was supposed to fix the issue.

Read more: Testimonial by M.M.

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