The Female Athlete Triad – What You Need to Know

The female athlete triad was recognized in 1992 when an association between disordered eating, amenorrhea, and osteoporosis was seen in activities that emphasized a lean physique. It affects energy availability, menstrual function and bone mineral density. The three corners of the triad are interrelated through their psychological and physiological mechanisms. About 15-62% of female athletes competing at the collegiate or elite levels suffer from the female athlete triad. (1)

Low energy availability appears to be the factor that impairs reproductive and skeletal health in the Triad, and it may be inadvertent, intentional, or psychopathological. (2). In extreme cases the triad may result in irreversible bone loss and death, an early detection is hence imperative.

There is no doubt that the benefits of exercise far outweigh the risks, participating in physical activities and sports for girls and women should always be encouraged. A point to remember, while studying the Female Athlete Triad is that exercise itself doesn’t cause bone mineral loss or irregular periods but it’s the mismatch between the energy requirements and the food that leads to the consequences of the female athlete triad.

Understanding the Triad

Irregular periods or amenorrhoea: It is an implication of anorexia- an eating disorder where an individual obsesses about weight and what they eat. Exercise-induced amenohhorrea is usually caused by the energy-drain resulting due to excessive exercising with insufficient amount of calorie intake and poor dietary choices. This can result in low estrogen production eventually leading to amenorrhoea. Excessive exercise may also increase the levels of cortisol in the body which hampers the production of hormones in the hypothalamus causing low estrogen secretion leading to the same outcome. (3)

Osteoporosis: The low amounts of estrogen in females is what leads to the loss of minerals in the bones. A weaker skeletal system affects the performance of an athlete by making them more prone to injuries and stress fractures.

Research shows that supplementation with calcium in such athletes can reverse bone-mineral loss and help to improve performance. (3)

Low energy availability: Anorexia leads to athletes consuming lower calories than required which leads to a deficit in important macro and micronutrients. Most of these athletes experience a breakdown of protein and body fat which leads to major loss in body mass. The lower energy negatively impacts performance and leaves the athlete undernourished.

Other implications of the Triad:

Women with the triad may also have a decreased immune function and an impaired skeletal muscle oxidative metabolism. They mostly likely suffer fractures specifically of the tibia.

Identifying the Triad

Some physical signs of anorexia like- unexpected weight loss, thin appearance, abnormal blood counts, fatigues, insomnia, excessive hair fall or thinning of hair coupled with irregular or absence of periods- amenorrhoea can be cl. Stress fractures along with these symptoms indicate osteoporosis.

How to handle it?

Prevention and early recognition of the symptoms are crucial for timely intervention. Typically, one would want to visit a health-care personnel who has a deep understanding of disordered eating behavior and eating disorders in particular to the sport, who will be better able to handle the demands of those sports.

Nutritional counseling: Seek counseling for your daily nutrition and plan a diet to replenish energy-dense food to revive your metabolism is recommended.

Parents, Coach, Physicians: Individuals closely connected to the athlete will have a major role to play in recognizing the patterns of eating disorders and excessive training. Being vigilant and keeping a check on their weight and nutrition is important to notice early signs of the Triad.

Risk group:

Women who restrict dietary energy intake, who exercise for prolonged periods, who are vegetarian, and who limit the types of food they will eat. Studies show that reducing dietary intake by 30% can influence can lead to irregularity in the menstrual cycle. Basically, athletes involved in ‘lean sports’ are at a higher risk.

References:

1. Hobart, J. A., & Smucker, D. R. (2000). The female athlete triad. American family physician, 61(11), 3357-3364.
2. STAND, P. (2007). The female athlete triad. Med Sci Sports Exerc, 39(10), 1867-1882.
3. The Female Athlete Triad , By Terry Zeigler EdD, ATC, https://www.sportsmd.com/womens-health/female-athlete-triad/