Female Athlete Triad

The female athlete triad is a combination of three interrelated conditions that are associated with athletic training: disordered eating, amenorrhea (suppression of the menstrual cycle), and osteoporosis (weakening of the bones).

“Today's "healthy" look is thin, according to society's current definition. Unfortunately, unhealthy behaviors are associated with this very slender appearance. The most touted body image is unattainable by most: slim, androgynous hips combined with voluptuous breasts. The supermodels with their personal trainers and, in some cases, enhanced breasts are the idols of today's teenagers.” (1)

Disordered Eating

The first part, disordered eating, is the precipitating event for the triad. An illness that takes many forms and includes a broad spectrum of eating disorders.

Among female athletes, the prevalence of disordered eating behavior is between 15% and 62%. (2,3) Disordered eating can cause many problems including dehydration, muscle fatigue and weakness, an erratic heartbeat, kidney damage and other serious conditions.

Disordered eating includes anorexia nervosa and bulimia nervosa but is not limited to these disorders. Anorexia nervosa can be either moderate to severe restriction of food intake to a more serious case of occasional bingeing or purging. Regular bingeing and purging is termed bulimia nervosa. Another popular dilemma is the misuse of diet pills, diuretics or laxatives and excessive exercise which keeps your body from getting enough nutrition. You may not get enough calcium, which can lead to bone loss. Another concern is hormone imbalances that lead to more bone loss through menstrual dysfunction.

Amenorrhea

Primary amenorrhea is when a girl has reached 16 without the onset of menses, or if she has gone 2 years following thelarche (development of secondary sex characteristics) without menarche. Secondary amenorrhea exists when a women with previously normal menstrual cycles has fewer than six to nine periods annually Amenorrhea is often associated with decreased serum estrogen levels. Lack of protective estrogen leads to decreased bone mass and may raise cardiac risk. (4)

Missing three or more periods in a row is cause for concern. With normal menstruation your body has estrogen, a hormone that helps to keep bones strong. When a female is deficient in estrogen, she may lose bone density and strength (premature osteoporosis). If this happens during youth, it may also cause serious problems later in life when the natural process of bone mineral loss begins after menopause. With lowered estrogen levels, the female athlete can experience bone loss similar to that seen in menopause but unfortunately, the lost bone is never replaced.

Amenorrhea can put a female at an increased risk for stress fractures from low bone mass due to this hormone imbalance. On top of this, hormonal imbalances make it difficult to get pregnant if there is a desire to have a baby.

Osteaoporisis

Low estrogen levels and poor nutrition can lead to osteoporosis. Osteoporosis is a weakening of the bones due to the loss of bone density and improper bone formation. This condition can ruin a female athlete's career because it may lead to stress fractures and other injuries due to weakened bones. Because of poor nutrition, a woman’s body may not be able to repair the injuries efficiently. A woman can also develop health problems related to osteoporosis at an earlier age than usual.

An additional problem that needs to be understood concerns the methods of determining body fat. Although underwater weighing is considered the gold standard, the body fat value will be falsely high with underwater weighing when bone density is decreased. This occurs because the standard equations do not take into account the increased porosity of osteoporotic bone. (1)

Treatment

All female athletes are at risk for the female athlete triad or any of its components. No particular sport is known for having a larger portion of its participants with the triad, but some generalizations can be made. Gymnastics, track and field, dance, and cheerleading have a higher percentage of women with the female athlete triad, as opposed to softball or weight lifting. (5)

The optimal time to screen athletes for the female athlete triad is during the preparticipation sports physical examination. The physician might also screen for the triad during acute visits for fractures, weight change, disordered eating, amenorrhea, bradycardia, arrhythmia and depression, and also during visits for routine Papanicolaou smears.(6)

REFERENCES

1. Angela D. Smith, MD (THE PHYSICIAN AND SPORTSMEDICINE - VOL 24 - NO. 7 - JULY 96)
2. Dummer GM, Rosen LW, Heusner WW, et al: Pathogenic weight-control behaviors of young competitive swimmers. Phys Sportsmed 1987;15(5):75-86
3. Rosen LW, Hough DO: Pathogenic weight-control behaviors of female college gymnasts. Phys Sportsmed 1988;16(9):141-146
4. The Writing Group for the PEPI Trial: Effects of estrogen or estrogen/progestin regimens on heart disease risk factors in postmenopausal women: the Postmenopausal Estrogen/Progestin Interventions (PEPI) Trial. JAMA 1995;273(3):199-208
5. Boone Barrow, MD, Consulting Staff, Department of Family Medicine. eMedicine - Female Athlete Triad : Article by Laura M Gottschlich
6. Otis CL, Drinkwater B, Johnson M, Loucks A, Wilmore J. American College of Sports Medicine position stand. The female athlete triad. Med Sci Sports Exerc 1997;29:i-ix.