The Female Athlete Triad

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For most girls and young women, sport participation can be a healthy and enjoyable experience, as well as a buffer against eating disorders. For some athletes, however, sport participation can involve disordered eating, amenorrhea, and osteoporosis—a syndrome of interrelated problems that has been called, “The Female Athlete Triad.” Although it was initially described about ten years ago, awareness of the Triad and its effects has been lacking by athletes, parents, sport personnel, and even healthcare professionals. The Triad can affect female athletes at all levels of competition, but it can also affect physically active girls and young women who are not competitive athletes. It usually begins with disordered eating.

The term “disordered eating” has been adopted to describe the first component of the Triad rather than “eating disorders,” in large part to include the full spectrum of unhealthy eating, from simple dieting to clinical eating disorders, but also because the other two components (amenorrhea and osteoporosis) can occur even when eating is disturbed at a subclinical level. Disordered eating often begins when female athletes restrict their eating in an effort to become thinner or leaner because of a prevailing notion in the sport world that a leaner body can enhance athletic performance. However, athletes in sports that emphasize thinness (i.e., distance running), are judged (i.e., gymnastics, figure skating, diving, etc.), have an appearance aspect (i.e., cheerleading), use revealing sport attire (i.e., swimming), or utilize weight classes (i.e., crew) are probably most at risk.

The second component of the Triad, amenorrhea (loss of menstration), is so common among female athletes that it has sometimes been viewed by athletes and sport personnel as “normal.” In fact, some athletes report that they prefer not having their menstrual periods because they “interfere with training.”

Amenorrhea in physically active females is the result of a complex interplay of eating and exercise. For many years, healthcare professionals assumed that amenorrhea in athletes resulted from exercise stress, low body weight, low body fat, and inadequate nutrition. Most of these factors now appear to play no role, and a series of recent investigations by Anne Loucks, Ph.D., at Ohio University, has suggested that “energy availability” may be the critical element. Dr. Loucks defines energy availability as dietary energy intake minus exercise energy expenditure, or the amount of dietary energy that remains after the energy cost of exercise has been spent. In essence, amenorrheic athletes, eat too little for their physical activity, either inadvertently or by design (i.e., dietary restriction). Dr. Loucks and her colleagues have found amenorrhea and other menstrual disorders can be prevented or reversed by increasing energy availability (through eating more and/or exercising less), without regard to stress, weight, or body composition.

We know that most anorexic patients, as well as many other eating disorder patients, engage in exercise that is excessive in terms of duration, frequency, and/or intensity. If energy availability is a critical factor in producing amenorrhea, it may in part explain why some (physically active) anorexic patients lose their menstrual cycle prior to weight loss and why some patients continue to have a menstrual cycle despite being at an extremely low weight. From the standpoint of the Triad, it could explain how an athlete, who does not have an eating disorder per se, but is engaging in disordered eating (i.e., consumption of too few calories based on level of training) could lose her menstrual cycle. Amenorrheic athletes should receive a medical evaluation to determine a possible need for hormone replacement. In terms of recovery, menstruation for many athletes tends to return with a decrease in exercise and/or increase in caloric intake. Until menstruation occurs, amenorrheic athletes should be encouraged to increase their calcium intake as directed by their healthcare providers.

In the third component of the Triad, osteoporosis, low levels of ovarian hormones associated with amenorrhea can result in loss of bone mass. The combination of menstrual dysfunction and inadequate nutrition (especially calcium) associated with disordered eating, may accelerate bone density loss. The primary risk to athletes is the increased risk of stress fractures during their competitive years. Although a variety of factors (i.e., duration of menstrual dysfunction, type of activity involved, genetics, extent of disordered eating, etc.) determines an individual’s skeletal health, any athlete with menstrual dysfunction should probably be assessed for loss of bone mass. Research findings on restoring bone mass following a return to normal menstruation are mixed. Some women have been found to be able to gain bone mineral density, though sometimes limited, while others have been able to maintain but not gain bone density.

As yet, we do not have sufficient prevalence studies to give us a clear picture of how many girls and young women may be affected by the Female Athlete Triad. However, given the prevalence of eating disorders in young women, the prevalence of amenorrhea in athletes, and the pressures to be thin or lean in athletics today, we must assume that many physically active girls and young women, even if they are not competitive athletes, are at least at risk. We can take solace in the fact that concerted efforts are being made to educate the public and healthcare professionals regarding the Female Athlete Triad. Most notable in this regard is the American College of Sports Medicine (ACSM), which is currently updating its original position stand on the Triad. Additionally, a national task force comprised of individuals from the sport and healthcare worlds was recently assembled with the charge of public and professional education, prevention, and research related to the Triad.

Our recommendations to female athletes, their parents, and their coaches include becoming better informed about the Female Athlete Triad. For more information, the reader is directed to the ACSM web site www.acsm.org to review its position stand. We would also strongly recommend a very informative new web site offered by the NCAA, which offers a wealth of excellent information on a variety of topics related to the health of the athlete, such as nutrition, body image, and athletic performance. Additionally, it contains recommendations for athletes, parents, and coaches for avoiding problems, while promoting physical and psychological well-being through sport participation. The web site is www.ncaa.org/nutritionandperformance.html. Finally, and most importantly, we, like the ACSM, recommend that any athlete who exhibits any component of the Triad should be medically evaluated for all three—early identification and treatment are the keys to limiting or preventing its effects. Just as we want to intervene with disordered eating before it progresses to an eating disorder, we want to intervene with any menstrual dysfunction and loss of bone mineral density to hopefully avoid amenorrhea and osteoporosis in the future.

By Roberta Trattner Sherman, PhD, and Ron A. Thompson, Ph.D.
Reprinted with permission from Eating Disorders Recovery Today
Winter 2003-2004 Volume 2, Number 2
©2003 Gürze Books

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