Female athlete triad

The female athlete triad is a disorder that girls or women can develop who play sports or exercise intensely. Female athlete triad consists of three related conditions that affect one another. The female athlete triad includes:

1. Disordered eating: Abnormal eating habits (i.e., crash diets, binge eating) or excessive exercise keeps the body from getting enough nutrition.
2. Amenorrhea (a woman or adolescent girl is not having menstrual periods): Poor nutrition, low calorie intake, high-energy demands, physical and emotional stress, or low percentage of body fat can lead to hormonal changes that stop menstrual periods (amenorrhea).
3. Premature osteoporosis (low bone density for age). Lack of menstrual periods disrupts your body’s bone-building processes and weakens the skeleton, making bones more likely to break.

A female athlete can have one, two, or all three parts of the triad.

Female athletes in any sport, regardless of competition level, can potentially develop the triad. However, females participating in endurance sports such as track and field, swimming, and rowing or those requiring subjective judging like gymnastics and figure skating are most at risk ¹.

Fashion trends and advertising often encourage women to try to reach unhealthy weight levels. Some female athletes suffer low self-esteem or depression, and may focus on weight loss because they think they are heavier than they actually are. Others feel pressure to lose weight from athletic coaches or parents.

Triad Factor 1: Disordered Eating

Most girls with female athlete triad try to lose weight as a way to improve their athletic performance. The disordered eating that accompanies female athlete triad can range from not eating enough calories to keep up with energy demands to avoiding certain types of food the athlete thinks are “bad” (such as foods containing fat) to serious eating disorders like anorexia nervosa or bulimia nervosa.

Triad Factor 2: Amenorrhea

Exercising intensely and not eating enough calories can lead to decreases in the hormones that help regulate the menstrual cycle. As a result, a girl’s periods may become irregular or stop altogether. Of course, it’s normal for teens to occasionally miss periods, especially in the first year. A missed period does not automatically mean female athlete triad. It could mean something else is going on, like pregnancy or a medical condition. If you are having sex and miss your period, talk to your doctor.

Some girls who participate intensively in sports may never even get their first period because they’ve been training so hard. Others may have had periods, but once they increase their training and change their eating habits, their periods may stop.

Triad Factor 3: Osteoporosis

Estrogen is lower in girls with female athlete triad. Low estrogen levels and poor nutrition, especially low calcium intake, can lead to osteoporosis, the third aspect of the triad. Osteoporosis is a weakening of the bones due to the loss of bone density and improper bone formation. This condition can ruin a female athlete’s career because it may lead to stress fractures and other injuries.

Usually, the teen years are a time when girls should be building up their bone mass to their highest levels — called peak bone mass. Not getting enough calcium now can also have a lasting effect on how strong a woman’s bones are later in life.

Female athlete triad causes

The main cause of the female athlete triad is a lack of energy intake. This can be due to an energy imbalance (you use more energy than you consume). A substantial percentage of energy intake is provided through carbohydrates, and to a lesser extent, proteins and fats. Females who are very active may have this problem. Many female athletes, either deliberately or inadvertently, fail to maintain adequate energy intake. The female athlete triad also may be due to an eating disorder, such as anorexia.

When females intentionally create this energy deficit, it is described as an eating disorder. Females athletes are 5 to 10 times more likely than male athletes to have an eating disorder. The prevalence of clinical eating disorders, such as anorexia nervosa or bulimia nervosa, among female elite athletes ranges from 16% to 47%. A substantial percentage of females with eating disorders also have a concomitant personality disorder, substance abuse disorder, or obsessive-compulsive disorder, and the rates of suicide are greater for these women than for healthy females of the same age.

To maintain optimal energy availability, increased energy expenditure should ideally justify increased nutritional intake. There exists a direct correlation between carbohydrate availability and reproductive and skeletal health ².

Girls and women may be at risk for the female athlete triad if they:

• are a competitive athlete
• play sports that require them to maintain a certain weight or to check their weight often
• exercise more than what is healthy
• are obsessed with being thin
• have body image issues
• are depressed
• are pushed by their coach or parents to win at all costs.

Female athlete triad pathophysiology

Low energy availability

Energy availability the energy acquired through oral nutrition less the energy expended during exercise and baseline daily metabolic requirements. Energy availability, whether through increased expenditure or decreased oral intake, is the main factor in the triad. Disordered eating may be intentional or unintentional. Eating disorders such as anorexia nervosa or bulimia nervosa are intentional causes. However, many female athletes without the diagnosis of an eating disorder may exhibit disordered eating habits. Most of the time, this will occur unknowingly, and the athlete will not take in enough energy. The extensive continuum of disordered eating ranges from healthy dieting to fasting, skipping meals, using diet pills or laxatives, and binging and purging A direct correlation exists between carbohydrate availability and reproductive and skeletal health. Low energy availability secondary to disordered eating results in menstrual dysfunction and low mineral density.

Altered bone mineral density

Bone tissue is dynamic and constantly being remodeled by osteoclasts (which resorb old bone) and osteoblasts (which form new bone). This is done under the control of polypeptides, steroid hormones, thyroid hormones, cytokines, and growth factors. Secondary to hypothalamic dysfunction, female athletes function at a low estrogen state. Estrogen’s principal role in bone is to directly act on osteoblasts, and it has an indirect effect on osteoclasts to prevent bone resorption Athletes should have a 5% to 15% higher bone mineral density than age-matched nonathlete. Altered bone mineral density will increase bone fragility and increase the risk of fractures. The incidence of stress fractures is greater in amenorrheic athletes, and bone density has been shown to negatively correlate with the number of missed menstrual cycles since menarche.

Menstrual dysfunction (amenorrhea or oligomenorrhea)

Menstrual abnormalities result from altered hypothalamic function. Menstrual dysfunction in the female athlete directly correlates to decreased estrogen. It may be primary or secondary amenorrhea. Primary amenorrhea is defined as no menstruation by 14 years of age without the development of secondary sexual characteristics or by 16 years, even if the female has undergone other normal changes that occur during puberty. The persistent absence of menstrual cycles beginning sometime after menarche is called secondary amenorrhea.

Female athlete triad prevention

There are things you can do to prevent the female athlete triad, especially if you are at risk.

• Eat a nutrient-rich, well-balanced diet.
• Exercise in moderate amounts.
• Get plenty of rest.
• Find ways to reduce stress.
• Talk to a doctor or counselor to get help.

Female athlete triad symptoms

Signs and symptoms of the female athlete triad include:

• fatigue
• weight loss
• bone loss
• absent or abnormal periods
• stress fractures
• fasting or limiting food intake
• binge eating
• self-induced vomiting
• extreme exercise.

Disordered eating

Eating a balanced diet is especially important during teenage years when our bodies are building the bone we will need through life.

Although they usually do not realize or admit that they are ill, people with disordered eating have serious and complex disturbances in eating behaviors. They are preoccupied with body shape and weight and have poor nutritional habits.

Disordered eating can take many forms. Some people starve themselves (anorexia nervosa) or engage in cycles of overeating and purging (bulimia).

Others severely restrict the amount of food they eat, fast for prolonged periods of time or misuse diet pills, diuretics, or laxatives. People with disordered eating may also exercise excessively to keep their weight down.

Females are more likely than males to have disordered eating. The illness can cause many problems, including dehydration, muscle fatigue and weakness, an erratic heartbeat, kidney damage, and other serious conditions. Not taking in enough calcium can lead to bone loss. It is especially bad to lose bone when you are a child or teenager because that is when your body should be building bone. Hormone imbalances can lead to more bone loss through menstrual dysfunction.

Menstrual dysfunction

Missing three or more periods in a row is cause for concern. With normal menstruation, the body produces estrogen, a hormone that helps to keep bones strong. Without a menstrual cycle (amenorrhea), the level of estrogen may be lowered, causing a loss of bone density and strength (premature osteoporosis).

If this happens during youth, it may become a serious problem later in life when the natural process of bone mineral loss begins after menopause. Amenorrhea may also cause stress fractures. Normal menstruation is necessary for pregnancy.

Premature Osteoporosis (Low Bone Density for Age)

Bone tissue wears away, making your skeleton fragile. Low bone mass puts you at increased risk for fractures.

Female athlete triad diagnosis

Contact a doctor if you or someone you know may have the female athlete triad. The doctor will ask questions about your periods, eating habits, and exercise routine. They also will do a physical exam. Your doctor may ask you if you take certain medicines, such as diet pills, laxatives, or birth control pills.

All female athletes need a thorough history in addition to the routine history, with a focus on the components of the athlete’s nutritional, musculoskeletal, menstrual, endocrine/metabolic, psychosocial, performance, and medication history.

• Nutritional history – Nutritional intake and eating patterns, quantity of protein, carbohydrate, vitamins, and minerals consumed.
• Menstrual history – The age at menarche, average length of menses, average time between menstrual periods, menstrual changes with increased training, and number of cycles annually. Pregnancy should be excluded in the case of amenorrhea.
• Endocrine/metabolic history – Any personal and family history of thyroid disorders, pituitary disorders, and diabetes should be sought. Obtain signs and symptoms of polycystic ovarian syndrome,
• Psychosocial history – Discuss eating patterns. The Eating Disorder Inventory (EDI) may be used. Document any alcohol, tobacco, or drug use. Ask about social support, depression, anxiety, and any history of physical, emotional, or sexual abuse.
• Performance history – Ask about changes in strength or performance.
• Medication history – Review all medications, dietary supplements, and herbal agents. Obtain information about oral contraceptives separately as patients often do not consider this a medication. Ask about any anabolic steroid use. Determine if the patient uses emetics, diet pills, stool softeners, or laxatives.

The physical examination should screen for pathologies that could cause metabolic and hormonal abnormalities. Thyroid should be palpated for evidence of enlargement or irregularity. Pay particular attention to the teeth, noting tooth decay from repeated vomiting and subsequent hard brushing, and parotid glands for evidence of hypertrophy, as with bulimia nervosa. Perform visual field testing to assess for pituitary macroadenoma; if large enough, it may press on the optic chiasm and cause bitemporal non-homonomous hemianopsia. A thorough skin exam should also be performed.

A pelvic examination should be performed when appropriate, particularly when a patient presents with delayed or disordered menarche.

Laboratory testing

A trainer or team physician should conduct a baseline urinary acetoacetate measurement. Normally menstruating athletes can self-measure or have a trainer perform monthly measurements of urinary acetoacetate in times of increased training. The goal is to completely remove urinary ketones before and after a meal as well as before and after training.

• Beta-HCG can be performed in the presence of amenorrhea to rule out pregnancy
• A complete metabolic panel to assess electrolyte levels, renal function, and hepatic function and a complete blood cell (CBC) count to evaluate for anemia
• A thyroid panel to assess for thyroid dysfunction
• Secondary lab tests involve testosterone (free and bound), luteinizing hormone, follicle stimulating hormone, estradiol, and prolactin levels

Imaging

Pelvic ultrasound can be useful for determining the etiology of primary amenorrhea (eg, the presence of ovaries, uterus). If an abnormal pituitary function is suspected, thin-section magnetic resonance imaging (MRI) of the head through the sella turcica should be performed. Electrocardiography may show bradycardia, which is common in athletes, and a resting heart rate of fewer than 50 beats per minute should be explored with a baseline ECG.

If evidence from the patient’s history or physical examination suggests the presence of a stress fracture, plain radiography should be the initial test of choice. A 3-phase bone scan should be performed if the radiographs are negative. Dual radiograph absorptiometry can be used in athletes with multiple stress fractures.

A dual-energy x-ray absorptiometry scan can also be used to assess for osteopenia or osteoporosis.

Female athlete triad treatment

The female athlete triad is a disorder that should be taken seriously. Most cases require treatment. Treatment for female athlete triad often requires help from a team of medical professionals including your doctor (pediatrician, gynecologist, family physician), your athletic trainer, a nutritionist, and a psychological counselor. A doctor will talk to you about healthy eating habits and lifestyle choices. You may need to change your diet. A nutritionist can help create an eating plan that provides enough vitamins and nutrients. You also may need to change your exercise routine.

If your periods do not return to normal, you may need more treatment. Your doctor may prescribe birth control pills to help regulate your cycle. Hormone medicines that include estrogen or progesterone may help as well. These can balance your energy and improve bone strength.

Initial treatment involves correction of the underlying cause. Most of the time this is a low energy state whether through an increased caloric intake, decreased physical activity, or both. Consulting a nutritionist or sports dietician is important ³.

For menstrual dysfunction, the female athlete should be referred to an obstetrician-gynecologist who can evaluate and treat the patient. Treatments for menstrual dysfunction in the female athlete are initially limited to hormone replacement therapy with cyclic estrogen and progesterone.

Female athletes with osteopenia or osteoporosis may be treated with oral vitamin D and calcium or bisphosphonates depending on the severity of the bone mineral density loss and risk factors for fractures.

Those females diagnosed with a mental health disorder such as depression, anxiety, or an eating disorder should be referred to a psychiatrist and/or psychologist for evaluation and treatment.

Living with female athlete triad

Women who have the female athlete triad can develop other health problems. Amenorrhea is a condition that occurs when you miss a period for 3 months or more in a row. Osteoporosis is a disease that makes your bones thin and weak. It can occur when your body doesn’t get the nutrients it needs to help bones grow. It can increase your risk of fractures, breaks, and other injuries. Your organs also can sustain damage due to a lack of nutrients.

Without treatment, the female athlete triad can cause long-term health problems. When combined with a low body weight, it can even lead to death.

Female athlete triad prognosis

For many athletes with female athlete triad, the long-term prognosis is good. Few athletes with the female athlete triad are admitted to the hospital for inpatient treatment, and few die from their disease. However, significant long-term morbidity may affect these women later in life.

The diagnosis of the female athlete triad was established in the early 1990s, although this set of symptoms had been noted for years before it was named ⁴. However, no long-term data on future problems are available. The first generation of athletes in whom this condition was diagnosed is still years away from menopause. Thus, it is unclear whether osteopenia/osteoporosis occurring at a younger age affects mortality or leads to more advanced osteoporosis later in life or to an increased risk of significant fractures (eg, hip fractures) ⁵.

For mild to moderate cases of the female athlete triad, some improvement in bone health is thought to occur. The lost bone mass density is unlikely to be replaced in its entirety, and the bone mass that should have been accumulated during this important time in bone development may or may not be fully regained ⁶. Unfortunately, no long-term, double-blind, controlled studies are available (or even performable).

As more information about the female athlete triad and its complications is gathered, everyone involved may better understand the significant morbidity that can occur years or decades after the disease is diagnosed and treated.

References

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