Dancers constantly strive to perform with maximum energy—often with minimum weight gain. So it's no surprise if they sometimes run out of fuel. But if undereating occurs along with missed periods and low bone density, the combined effect can spell trouble. Known as the female athlete triad, it can lead to poor performance and bone injuries, like fractures.


Not consuming enough calories can leave your students with too little energy to support healthy bones. Unfortunately, the problem gets worse every year. "It's like a bone bank," says Dr. Elizabeth Matzkin, surgical director, women's musculoskeletal health, at Brigham and Women's Hospital in Boston. "If you're not building your bone density, that's a problem, because you're losing it after age 20 to 25."

In one of Matzkin's studies, having all three symptoms led to a 50 percent increase in injury risk. Female athletes who missed periods (amenorrhea) were three times as likely to suffer bone or joint damage. In the long-term, amenorrhea can cause bone diseases like early osteoporosis.

When a dancer comes to her with an injury, Matzkin says she considers the root cause. "When I see a stress fracture, I ask: 'Is it a real stress fracture?'" The underlying reason may be low energy availability leading to amenorrhea, then poor bone density and finally a fatigue break.

But the problem is not limited to underweight dancers. "That's the biggest misconception," says Matzkin. "You don't have to be anorexic or bulimic." Triad disorders can affect people of all body shapes, sizes and types.

Telltale Signs

So how can teachers recognize it? Awareness is essential, says Matzkin. "Talk to dancers about how important it is to eat well in order to dance strong." If students are underperforming, she suggests asking them or a parent about menstrual irregularities.

Amenorrhea is defined in two ways: skipping periods or not having started to menstruate at a normal age. Nobody likes to deal with having her period, but "it's a sign of health," says Matzkin.

Some dancers use oral contraceptives to replace lost estrogen and build bone mass. But it's important to achieve a regular cycle without them to know if you're balancing your energy needs.

"Dancers need to get enough energy to perform and not have their body take it away from somewhere else," says Matzkin. This doesn't always mean gaining weight. Teachers should refer students to a nutritionist for individual advice on adjusting their energy intake.

"Early prevention can often help avoid the consequences that are not reversible later in life," says Matzkin. The more you can recognize the triad, the better off your students will be down the road. "If it's detected, then it can be prevented," she adds.

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