The Female Athlete Triad

Since we were little we have been subliminally bombarded with the perfect body image, more so for women than for men.  As endurance athletes some information presented to us lays out that the less we weigh the faster we will run, it’s partially true but there are other factors that come into play such as oxygen capacity and many others.  Today I want to go into why this topic is important to me and why I think it is a good learning tool to teach our daughters or any female athlete that we coach or have in any part of our lives.

A common disorder in many high school and collegiate female athletes is what’s commonly known as the female athlete triad. Females struggle with body perception way more than men and thus are more likely to suffer from eating disorders such as anorexia or bulimia. As I’ve noted in another article about disordered eating this isn’t just disorders like anorexia but encompasses a wide range of varying adaptations people make with what they do to fuel their bodies.  What women don’t understand is that low energy availability can lead to amenorrhea and osteoporosis either of these alone or in combination can pose significant risks to physically active females. Some of these consequences can potentially be irreversible and emphasizes the critical need for prevention.

The complication with the triad is that the outcome can be detrimental to the female later in life. The cost of the eating disorder ends in a low caloric intake, thus the body fat percentage dips below 12%, a normal body fat for females should be above 18% so anything under that should be a root for concern. The female athlete may see an enhancement to performance due to weight drop which can add to the continuation of the disordered eating. The female will be able to maintain decent performance for up to a year or a little over before a decrease in performance will take over because of muscle loss and lack of fuel for the activity level.  The lack of calories isn’t just bad for performance but when a woman’s body fat drops below 12% the body has problems manufacturing hormones that are needed for a normal estrus cycle and thus the female begins to have cessation of a menstrual cycle for more than three months, what is known as Amenorrhea.  Amenorrhea can also come from excessive exercise and not eating enough calories leading in a decrease of estrogen production. Without estrogen release, the menstrual cycle is disrupted and can result in her periods becoming irregular or even stop all together.

There are two types of amenorrhea:  A female who has her period and then stops menstruating for ninety days or more is said to have secondary amenorrhea. Primary amenorrhea is characterized by delayed menarche (onset of a menstrual cycle), which can delay secondary sexual characteristics.  Secondary amenorrhea or oligomenorrhea is mostly seen in athletic women.  When menstral dysfunction is found doctors will do a medical, menstrual, reproductive, family history and ask questions specifically related to disordered eating. [Joy et al] Laboratory testing for secondary amenorrhea can be seen in Table 1 below, it is important to rule out pregnancy and polycystic ovary syndrome as a cause for lack of mensus.


Table from Joy et al Am Fam Physician. 2009 Mar 15;79(6):489-95.

Production of estrogen is needed to restrain bone resorption and promote bone formation. Low energy availability such as any type of disordered eating can impair bone health, especially when athletes exercise for prolonged periods of time without increasing their dietary intake. Energy availability can change daily but the effect on menstrual status might not manifest for months and the effect on bone density may not be detectable for at least a year.

Lack of energy availability can cause a reduction of physiological mechanisms that reduce the energy needed for cellular maintenance, thermoregulation, growth and reproduction. Even if an athlete is diagnosed amenorrheic; if they have a stable body weight it can suggest that energy balance can be restored even when energy availability is low. Energy availability can be reduced in many ways, one is by increasing exercise so that more energy is needed more than the amount put in or you can reduce energy intake more than you use it. Even if an athlete does not have a clinical eating disorder, those that don’t meet all the criteria for them are classified as having an eating disorder not otherwise specified (ED-NOS).

Disordered eating is found in 25-31% of elite female athletes, while in the normal population it only accounts for 9%. The percentage of amenorrhea increases as a female athlete adds more mileage to the training routine, but this is not true for all women, just those that have disordered eating. The athletes with a greater risk of low energy availability are those who restrict dietary intake, exercise for prolonged periods, those that are vegetarian or those that limit the types of food they will eat.

The health consequences of the female triad from sustained lower energy availability can extend beyond a physical manifestation, it can also present as psychological problems such as low self-esteem, depression and anxiety disorders. Females can also start to present complications in the cardiovascular, endocrine, reproductive, skeletal, gastrointestinal, renal and central nervous systems.  Amenorrheic women are often infertile due to the absence of ovarian follicular development, ovulation and luteal function.  Even though in some cases women can recover and begin ovulation after their menses is restored.  Athletes that suffer from luteal deficiency may be at risk for infertility due to poor follicular development or failure of implantation thus have a higher chance of miscarriage. In animal experiments a reduction of dietary intake by more than 30% caused infertility and skeletal demineralization.

As the number of missed menstrual cycles goes up the bone density can start to decline and the female athlete may start to have more stress fractures, female athletes with menstrual irregularities have a 2-4 times greater chance of stress fracture than a female with a regular menstrual cycle.

Screening for any part of the triad can be challenging because the health consequences are not always readily apparent but if an athlete presents one part of the triad they should be screened for the other two to cover all bases.  Patient history of dietary practices, weight fluctuations, eating behaviors and exercise expenditure should be obtained. In many athletes with disordered eating they may present a fear of weight gain, menstrual dysfunction and disturbed body image. Any athlete that presents disordered eating should be referred to a mental health professional for further evaluation.

If an athlete with disordered eating or an eating disorder is determined they undergo initial laboratory assessment that includes: electrolytes, chemistry profile, complete blood count with differential, erythrocyte sedimentation rate, thyroid function tests, and urinalysis. There is often a wide range of normal values even in the severely undernourished and health care professionals should be careful about normal results. For evaluation of secondary amenorrhea it would include a pregnancy test, gonadotropin measurement, follicle stimulating hormone (FSH), luteinizing hormone and to rule out ovarian failure while also check the ratio of LH/FSH to check for polycystic ovary syndrome. If menses isn’t restored a reproductive medical specialist may be useful to look at females that have lacked menses for 3-6 months.

Noticing and recognizing this triad or any part of it early in a females’ athletic career is vital to not only her current but her future health.  Society teaches us from a young age that skinny and frail is sexy, but that is not case, it is unhealthy. Teaching our daughters from a young age to feel comfortable in their skin and not harp over food can help them successfully avoid being in this triad.  We also have to recognize that there will still be some that will manifest this triad and we need to do our best to support them through all the endeavors. Those of us that work with young female athletes should be able to reconize some of the symptoms so that our athletes can remain healthy and reap the benefits of regular exercise.

August 8, 2013. Uncategorized. 2 comments.