Female triad, which is also known as the female athlete triad, is generally defined as a triumvirate of three interrelated conditions: disordered eating, amenorrhea (lack of menstrual periods), and osteoporosis, or low bone mass. Young female athletes at risk for the triad include those participating in activities in which a lean figure is valued, such as gymnastics.
Disordered eating encompasses poor nutritional choices, skipping meals, and, in extreme cases, eating disorders. Food is the source of the calories that provide energy, and calories are expended as energy during daily exercise and training. When an athlete fails to eat enough to compensate for the calories used during exercise, she loses weight, which can be unhealthy.
For the athletes at risk of the female triad, the imbalance of calories consumed and calories used during exercise and other activities creates an energy deficit. The deficit, also called low energy availability, disrupts the hormonal balance, and this places the athlete at a higher risk of amenorrhea. Amenorrhea causes a major reduction in estradiol, the primary form of the female hormone estrogen. The hormonal imbalance puts the athlete at risk of rapid bone loss, bone fractures, and premature osteoporosis.
Physically active teenage girls and college-age women, especially those who are athletes, are most at risk for the female triad. Factors contributing to this risk include the desire to achieve and maintain the thinness that is portrayed in media as the ideal image. The pressure and risk increases for female athletes who want a low body weight for a sport or activity, those who compete in sports with weight classifications, and athletes in competitions where appearance (aesthetics) contributes to their scores.
The triad affects cross-country runners and dancers concerned about low body weight and athletes who participate in sports with weight categories, such as judo, wrestling, and tae kwon do. Gymnasts, ballet dancers, and figure skaters are among the athletes concerned about aesthetics.
Exact figures on the prevalence of the female triad are somewhat difficult to obtain due to a lack of reporting from athletes and the tendency of those with the syndrome to mask its symptoms and effects. According to some studies, among women who participate in athletics that focus on leanness or aesthetics, as many as 69% may have amenorrhea. Research has also found that up to 70% of elite athletes in sports with weight classes exhibit some degree of disordered eating. The prevalence of osteoporosis in female athletes ranges from 0% to 13%, with rates of osteopenia (bone mass density that is lower than normal but not low enough to be considered osteoporosis) much higher, at 22% to 50%. The prevalence of all three components of the triad among female athletes has been reported as 4.3%.
The athlete at risk for the triad may appear healthy because of her lean figure and the amount of activity that she does. The condition may not be obvious because those with disordered eating or an eating disorder generally hide their eating habits from others. In addition, some athletes and coaches may not realize that it is abnormal for intense physical activity to cause amenorrhea. As a result, the first indication of the condition might be when the athlete sustains a fracture due to the loss of bone density. Other symptoms may include weight loss, fatigue, and difficulty concentrating. As noted above, an athlete does not need to exhibit symptoms of all three of the triad components to be at risk for complications of the syndrome.
Possible signs of disordered eating could include the lack of body fat, continual dieting, poor eating habits, and training excessively. Symptoms of eating disorders include fatigue, brittle hair and nails, chest and abdominal pain, low blood pressure and heart rate, and heart irregularities.
It is important to note that disordered eating does not necessarily indicate a full-blown eating disorder. All eating disorders involve disordered eating, but the reverse is not always the case. The difference is one of severity, frequency, and the consequences to the individual. The female athlete triad may involve either disordered eating or a diagnosed eating disorder.
The more common eating disorders include the following:
Poor diet, inadequate caloric intake, and excessive training can lead to problems with the menstrual cycle. Periods may be irregular or not occur at all.
The spectrum of irregular menstrual conditions includes:
Menstrual irregularities lead to low estrogen levels and other hormonal abnormalities, which can affect bone mass and lead to osteopenia or osteoporosis. In addition, just when girls and young women should be eating nutritionally to build strong bones, some athletes do not take in enough calcium. The recommended dietary allowance (RDA) of calcium is 1,200 mg per day for teenage girls and young women with normal menstrual cycles. For those with irregular or absent cycles it is 1,500 mg per day plus 400 mg of vitamin D.
The diagnosis of each component of the triad includes an evaluation during which a medical history is taken. The Female Triad Coalition recommends the evaluation be performed by a multidisciplinary healthcare team, including a physician, a sports dietician, and, if called for, a mental health professional. Evaluation could include the following:
The American College of Sports Medicine (ACSM), is among the organizations that advocate prevention as the best treatment for the triad. As with diagnosis, a team approach for treatment is recommended, involving a physician, a nutritionist, and, potentially, a psychologist. The support of friends, coaches, and family is also extremely important.
The primary treatment goal is to restore the balance between the energy consumed and energy used for exercise. This involves adjusting the diet so the patient takes in more calories. Treatment could also involve reducing the amount of exercise the athlete does. If a diagnosed eating disorder is present, specific treatment for that disorder may be indicated, such as psychological counseling or the prescription of antidepressants.
Health professionals and the patient usually set a weight-gain goal. The diet should include calcium-rich foods such as milk, yogurt, cheese, and broccoli. It may be necessary for the athlete to take calcium and vitamin D supplements.
HRT may be prescribed to prevent osteoporosis. However, this treatment is usually prescribed for amenorrhea or after menopause has ends.
The scope and length of the triad components will determine the condition's long-term effect on an athlete. In general, the prognosis is good. Few athletes are hospitalized with or die from the syndrome. However, some issues may persist. In some cases, disrupted menstrual cycles could affect fertility. In addition, it is not yet clear whether suffering from osteopenia or osteoporosis early in life will affect mortality or lead to more pronounced osteoporosis in the later years.
Preventive measures include educating athletes, parents, coaches, and trainers about the triad and the need for adequate nutrition. Emphasis should be placed on nutritional requirements and the importance of calcium for bone health. Athletes should be advised to keep track of their periods and seek medical care when the cycle is irregular.
In addition, it is recommended that athletes be assessed for the triad during preparticipation physicals and/or during the their annual physical exam. The ACSM has also advised sports administrators to consider rule changes to discourage unhealthy weight loss habits.
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Nazem, Taraneh Gharib, and Kathryn E. Ackerman. “The Female Athlete Triad.” Sports Health 4, no. 4 (July 2012): 302–11.
American College of Sports Medicine. “The Female Athlete Triad.” ACSM.org . https://www.acsm.org/docs/brochures/the-female-athlete-triad.pdf (accessed February 22, 2017).
De Souza, Mary Jane, et al. “2014 Female Athlete Triad Coalition Consensus Statement on Treatment and Return to Play of the Female Triad Athlete.” British Journal of Sports Medicine. http://www.femaleathletetriad.org/wp-content/uploads/2014/02/De-Souza-et-al.-2014_FAT-Consensus-Paper.pdf (accessed February 22, 2017).
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American College of Sports Medicine, 401 West Michigan Street, Indianapolis, IN, 46202, (317) 6379200, Fax: (317) 634-7817, http://www.acsm.org/ .
American Council on Exercise, 4851 Paramount Drive, San Diego, CA, 92123-1449, (858) 576-6500, Fax: (858) 576-6564, (888) 825-3636 ext. 782, firstname.lastname@example.org, http://www.acefitness.org/ .