Female Athlete Triad

By Matthew Paulus MS ATC LAT

What is the Female Athlete Triad?

The female athlete triad is a combination of interdependent symptoms including low energy availability, menstrual disturbances, and low bone mineral density that is seen more commonly in the female athletic population versus the general population. There is a higher prevalence of the female athlete triad in athletes who compete in sports that require weight modulation such as gymnastics, distance runners, and dancers compared to non-lean sports. Studies have shown that the female athlete triad effects anywhere between 15-60% of the female athletic population. While it is more common for an athlete to have one or two of the symptoms, there are severe long-term effects if any component is left untreated.

3 Components of the Female Athlete Triad:

1.Low Energy Availability

Occurs when nutritional intake is not equivalent to the energy expenditure of that athlete. This can be related to or separate from an eating disorder. It should be noted that an athlete does not need to be under-weight to be involved in the female athlete triad.

• Energy imbalances: Sometimes the athlete does not recognize the energy demands versus their energy intake. Decreasing caloric intake or restricting foods within the diet combined with excessive exercise are common with female athletes.

The largest difference between unintentional energy deficits and an eating disorder is the psychological component that is involved with disordered eating. The diagnosis for an eating disorder must meet a specific criterion and be diagnosed by a physician or mental health professional.

Common eating disorders that are in association with the female athlete triad include:

• Anorexia Nervosa: An eating disorder classified by distorted body image that creates an unjustified fear of gaining weight. Calorie restriction can occur in multiple ways including restricting food intake or excessive exercise.
• Bulimia: The act of binge eating into excess followed by purging. Purging episodes may include excessive exercise, fasting, vomiting, or the use of laxatives.

2. Menstrual Disturbance (Amenorrhea) 

Menstrual disturbance (Amenorrhea): Defined as the absence of menstruation or period, typically three months or more. In the female athlete triad, increased exercise or weight fluctuations can decrease the level of estrogen and cause irregularities in menses. These irregularities can cause imbalances in hormonal regulation and a multitude of complications within body systems. There are two types of amenorrhea, primary and secondary. Primary amenorrhea is the delay of menstruation during development. Secondary amenorrhea is the absence of menses after the first occurrence of menstruation and is more common with female athlete triad.

3.Low Bone Mineral Density

Bone mineral density is the measurement of an individual’s overall bone mass. For healthy women, bone mineral content with fully develop at puberty and into their mid-20’s with a decrease in bone mineral content following menopause. Healthy athletes typically have a higher bone density from participating in high-impact, sport related activity.  In the female athlete triad, these individuals will have a lower bone mineral density which decreases the ability for bones to remodel and can increase likelihood of injury. In some cases, this decreased bone mass can turn into osteopenia or osteoporosis which significantly increases the female’s risk of fractures.

Short- and Long-Term Effects of the Female Athlete Triad:

If managed early, most components of the female athlete triad can be reversed with adequate nutrition and activity modulation. Long-term effects can include:

• Cardiovascular disease
• Increased risk of fracture or stress fractures
• Decreased immune function
• Delayed healing ability
• Decreased accrual of overall bone density
• Endocrine dysfunction
• Development of depression, anxiety disorders, eating disorders.

Recognizing the Symptoms

It is important for coaches, athletic trainers, and loved ones to pay attention to changes in their players’ status. Some signs an athlete may be at risk for this condition include:

• Early or increased fatigue
• Loss or abnormality in period
• Loss of muscle mass
• Increase in injury or prolonged time for recovery
• Fasting or limiting food consumption
• Depression, reduced self-esteem, increased irritability

Treatments Available

Early recognition is the most effective form of treatment for female athlete triad. Once recognized, the individual will most likely benefit from a multi-disciplinary approach. The goal when treating the female athlete triad is to regulate the female’s menses along with restore bone mineral density. Having a diet that promotes intake of Vitamin D and calcium is a recommendation. In some cases, additional hormone replacement therapy may be a requirement. It may be helpful for the individual to seek additional guidance from a nutritionist or mental health professional.

By: Matthew Paulus MS ATC LAT

Related Articles: Does Milk Make Bones Stronger?, Exercise Fatigue, and Eating and Exercising

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