The Athletic Female Triad

In May, the American College of Sports Medicine published their position stand on the Female Athlete Triad (see ACSM, 1997). The Triad consists of disordered eating, amenorrhea, and osteoporosis and occurs in physically active girls and women as well as elite athletes. The components of the Triad are interrelated in cause, progression, and outcome. Alone or in combination, Triad disorders can reduce physical performance and have serious medical and psychological consequences.

Women and girls are subject to inner and societal pressures to reach and maintain unrealisticlly low levels of body weight and/or body fat. These forces contribute to the development of disordered eating behaviors which help to initiate the Triad. Other factors that are specific to athletes include: sport-related emphasis on body weight and body fat, perfectionism, lack of nutrition knowledge, drive to excel at any cost, impact of injury, and pressure to lose weight from parents, coaches, judges, and others.

Obtaining accurate prevalence data for athletic populations is difficult because athletes often deny disordered eating behaviors. Furthermore, those who chronically use disordered eating practices generally do not meet the strict DSM-IV diagnostic criteria for anorexia nervosa or bulimia nervosa. Many athletes erroneously believe that losing weight by any method enhances performance and that disordered eating behaviors are harmless. Inadequate caloric intake and disordered eating practices jeopardize health and performance due to muscle glycogen depletion, dehydration, loss of muscle mass, hypoglycemia, electrolyte disturbances, anemia, amenorrhea, and osteoporosis.

The amenorrhea component of the Triad is hypothalmic in origin and caused by decreased ovarian hormone production and a hypoestrogenemia similar to menopause. The hypothesis is that low energy availability disrupts the hypothalmic gonadotrophic releasing hormone pulse generator. Thus, menstrual disorders are caused by a failure to consume enough energy to compensate for the energy cost of exercise, rather than by exercise itself. To avoid alterations in their reproductive hormones and menstrual function, active women should consume enough calories to match their calorie expenditure.

Amenorrhea is the most discernible symptom of the Triad. Unfortunately, many women welcome the convenience of not menstruating and do not report the amenorrhea because they consider it to be benign. However, the low concentration of ovarian hormones in amenorrheic athletes is associated with reduced bone mass and an increased rate of bone loss.. All other causes of amenorrhea must be excluded and amenorrheic women should be encouraged to consume at least 1,500 mg of elemental calcium per day. Although reduced training, increased calorie intake, weight gain, and hormone replacement therapy may restore menses, bone mineral density may not return to normal levels. Poor nutrition and amenorrhea may reduce skeletal accretion during the critical years of bone formation in the adolescent athlete,, placing the athlete at risk for stress fractures and premature osteoporosis.

Sport medicine professionals should be aware of the interrelated development and the varied presentation of Triad components because the Triad is often not recognized, denied, and under reported. They should be able to recognize, diagnose, and treat or refer women who present with any Triad component. Athletes who have one Triad component should be checked for others. Screening can occur during the pre-participation examination and/or clinical evaluation for: menstrual change, weight change, disordered eating patterns, cardiac arrhythmia (including bradycardia), depression, or stress fracture.

All sports medicine professionals, trainers, coaches, and officials of sports governing bodies should learn how to prevent and recognize the symptoms and risks of the Triad. Those who work with active girls and women, including parents, should promote a training environment that is medically and psychologically sound – there shouldn’t be pressure to lose weight. Sports medicine professionals should have a fundamental knowledge of nutrition, and be able to recommend resources for nutrition, medical, and psychological evaluation and counseling. Active girls and women should learn about proper nutrition, safe training practices, and the warning signs and risks of the Triad.

American College of Sports Medicine Position Stand. The female athlete triad.

 

Medicine and Science in Sports and Exercise. 1997:29: i-ix.

 

Ellen Coleman, RD, MA, MPH
ellen@cruciblefitness.com