Female Athlete Triad is a serious health problem that involves disordered eating, low bone mass, and amenorrhea (cessation of the menstrual cycle) in female athletes. The condition is most common in elite sports and sports that emphasize leanness, such as cross country running, gymnastics, and figure skating. In the past 25 years, much has been learned about symptoms, risk factors, causes, and treatment strategies for Female Athlete Triad. Studies involving different types of athletes have provided valuable information that has helped many physically active women avoid the health problems of this condition.
A new modelFemale Athlete Triad was first identified 25 years ago. Recently, the emergence of a new model for understanding Female Athlete Triad has greatly advanced understanding of the condition in the sport community. Originally, the three components of Triad included disordered eating, low bone mass, and amenorrhea. These components are known to be interrelated, as energy deficiency associated with disordered eating plays a causal role in the development of menstrual disturbances, and both energy deficiency and a low estrogen environment associated with amenorrhea play a role in initiating bone loss. In the new Triad model, these interrelationships are reaffirmed; however, each component of Female Athlete Triad is represented as being on a continuum of severity from health to disease. At the “healthy” end of the continuums are optimal energy availability, the presence of normal ovulatory menstrual cycles, and optimal bone health. At the “unhealthy” end of the continuums are the clinical outcomes associated with each Triad component, including energy deficiency, with or without disordered eating; abnormal menstrual cycles, referred to as functional hypothalamic amenorrhea; and bone loss, the most severe cases of which are called osteoporosis.
Another point the new model of Female Athlete Triad highlights is that many athletes may not present with the extreme ends of the continuum, but rather may display intermediate, or “subclinical,” presentations of one or more of the conditions, and, most importantly, that progression along the three continuums can occur at different rates. For example, an athlete may show signs of restrictive eating, but not meet the clinical criteria for an eating disorder. She may also display subtle menstrual disturbances, such as a change in menstrual cycle length, anovulation, or luteal phase defects, but not yet have developed amenorrhea. Likewise, she may be losing bone, but may not yet have dropped below her age-matched normal range for bone density.
While the conditions represented by each continuum can occur independent of the other two conditions, it is more likely that, because of the clear associations between the three conditions, it is likely that an athlete suffering from one element of Triad is also suffering from the others.
What causes Female Athlete Triad?
The significance of energy deficiency as a cause of Female Athlete Triad–related menstrual disruptions and bone loss is now more apparent than ever.
Research has determined that one of the primary causes of Triad-related health problems like menstrual abnormalities and bone loss is a chronic energy deficiency. The amount the athlete eats is simply not enough to meet the caloric (energy) demands of their daily exercise training. In other words, energy deficiency occurs when there is a negative imbalance between food intake and energy expenditure through exercise — it doesn’t matter if the imbalance is due to an intentional caloric restriction or an increase in exercise. Because an athlete’s energy supply can be purposely manipulated (unlike bone density and menstrual regularity), it warrants a special comment. It is clear that in many cases of Female Athlete Triad, there is some form of disordered eating behavior that contributes to the energy deficiency. The disordered eating can present in a variety of ways; the athlete’s constant drive to be thin or achieve an inappropriately low body weight can lead to poor body image or purposeful restriction of calories. These behaviors cause a chronic energy deficiency.
It is also noteworthy to remember that some athletes can experience an energy deficiency even if they’re not consciously restricting their food intake at all. These individuals simply do not eat enough food to fuel their exercise energy expenditure. A busy class schedule, travel, stress, and other factors can hinder female athletes from maintaining an adequate diet for training. Thus, some athletes who do not present with disordered eating symptoms or behaviors are often overlooked in discussions of Female Athlete Triad.
Recent studies have attempted to define a threshold of energy below which the body attempts to suppress menstrual function, but no firm conclusion has been reached. Some research suggests that if an athlete eats “normally” (the average amount for her body weight), she should be able to perform the equivalent of running up to eight miles per day without compromising menstrual function. However, other studies have shown menstrual irregularities in recreationally active women who run only 7.5 miles per week, which most people would not consider intense training. In those studies, the women’s diets did show some evidence of restriction, which further reinforces the idea that nutrition plays a key role in triggering Triad-related problems; on the other hand, this means good nutrition is key in preventing the condition.
For good reason, then, most educational efforts aimed at preventing Female Athlete Triad focus on nutrition and disordered eating. A comprehensive approach should include not only clinically recognized eating disorders, such as anorexia nervosa and bulimia nervosa, but also subclinical disordered eating behaviors, such as caloric restriction. The subclinical category includes many athletes who fail to meet the criteria for an eating disorder, but display a preoccupation with body weight and a poor body image.
What should I do about Female Athlete Triad?
An important goal of Triad education is to improve the identification of not only athletes with full-blown Triad in the fitness community, but also of those who may be moving in an unhealthy direction across the three Triad continuums. Sports medicine professionals, parents, coaches, trainers, and the athletes themselves should be aware that even moderate restriction of food intake (with or without weight loss) or subtle menstrual cycle changes can be early indicators of the progression to serious Triad complications. A low threshold for intervention should be standard, and if an athlete exhibits one aspect of the condition, the other two should be investigated. This strategy might mean, for instance, a bone density test and nutrition counseling for an athlete who is experiencing irregular menstruation.
Obviously, the best times to catch potential Triad-related problems are during the pre-participation exam and yearly check-ups. Health care providers can visit
www.femaleathletetriad.org to view the standard protocol for the pre-participation exam. Female athletes should be asked about their eating habits and their menstrual regularity as part of basic screening, and people with a history of stress fractures may warrant special attention. These recommendations extend to all female athletes — not just those in sports that emphasize leanness.
It’s also important to remember that many health care providers are not familiar with Triad, and might be dismissive of its signs and symptoms (though considerable progress has been made in this area). It is therefore important to visit a physician that is familiar with and up to date on Triad.
Finally, it’s important to remember that not all Triad-related symptoms are caused by an energy deficit or dietary problem. Amenorrhea might also be caused by an anatomic defect, premature ovarian failure, a prolactin-secreting tumor, polycystic ovarian syndrome (PCOS), or pregnancy. Low bone mass, too, can have other causes. A physician’s evaluation and testing can determine whether another health problem is present. If not, an examination of the balance of calories taken in versus those expended throughout the day could point to energy deficiency.
Take-home messages
There are several key messages to remember about Female Athlete Triad.
- Losing your menstrual cycle is not healthy. Failing to menstruate for more than six months is unhealthy and should be evaluated by a physician. Athletes often view weight loss and losing their menstrual cycles as synonymous with improved athletic performance, and so they must be warned of the serious health risks of not menstruating — particularly, bone loss. Armed with the latest information and research, the athlete herself may be the first and best line of defense against this condition
- An athlete does not need to reduce her training to avoid Triad or to resume normal menstrual cycles if she is amenorrheic (not menstruating). Many assume that the athlete must reduce exercise in order to avoid Triad, but the fact is that most athletes can effectively address Triad-related health problems with adequate nutrition. That said, if training can be reduced by adding one day of rest per week, resumption of normal menstruation will likely occur more quickly
- Even small increases in body weight may be all that is necessary to resume menstrual cycles. Studies are ongoing to determine just how many calories are needed for normal menses to resume, but so far, it appears that even small increases in body weight may be all that is required to resume normal menstrual cycles by reversing the negative energy deficiency that caused the problem
- Going on the Pill is not the best answer to fix Triad-related bone loss. Amenorrheic athletes are frequently prescribed hormonal contraceptives to prevent or slow bone loss, but this does not address the underlying problem — it only addresses the symptoms. The problem is energy, and energy should be part of fixing the problem. Contraceptives may normalize menstrual periods and provide estrogen, but they will not necessarily improve bone health. Athletes on birth control pills often believe they have addressed their Triad-related problems, and therefore are probably not being counseled to improve dietary habits. As a result, they may continue to travel down the energy deficiency path, which contributes to further bone loss. In fact, long-acting, progesterone-only contraceptives like Depo-Provera have been shown to cause bone loss, and the packaging for these drugs now includes a warning to this effect. Nevertheless, this particular drug remains popular among athletes who feel normal menstruation impairs their performance
Further information can be obtained from the Female Athlete Triad Coalition, an international consortium that is dedicated to Triad prevention, advocacy, education, and research. Please visit
www.femaleathletetriad.org for more information.
Dr. Mary Jane De Souza and Dr. Nancy Williams have conducted over 25 years of research on the effects of exercise on the menstrual cycle, and have published numerous papers on Female Athlete Triad. Dr. Williams is currently the president of the Female Athlete Triad Coalition. Their contact information is as follows:
Mary Jane De Souza, Ph.D.
Professor, Department of Kinesiology
Co-Director, Women’s Health and Exercise Laboratory
Penn State University
University Park, PA 16802
Email: mjd34@psu.edu
Nancy I. Williams, Sc.D.
Associate Professor, Department of Kinesiology
Co-Director, Women’s Health and Exercise Laboratory
Penn State University
University Park, PA 16802
Email: niw1@psu.edu
References:
De Souza, MJ, S West, S. Jamal, G Hawker, C Gundberg, and NI Williams. The Presence of Both an Energy Deficiency and Estrogen Deficiency Exacerbate Alterations of Bone Metabolism in Exercising Women. Bone. 2008 Apr 8. [Epub ahead of print]
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