The Female Athlete Triad

First described in the early 1990’s, the female athlete triad refers to disordered eating, amenorrhea, and osteoporosis. No one yet knows how commonly the triad occurs, but there is concern that it may go largely unrecognized by athletes, coaches, trainers, and health care professionals. A panel of experts representing the American College of Sports Medicine recently called for increased awareness of this disorder. There is concern that the triad will not only hurt performance now but health later on in an individual’s life.

The first part, disordered eating, is the precipitating event for the triad. Rather than restrict this description to a narrower focus of "eating disorders", the term, "disordered eating" refers to a broader array of abnormal eating behavior. At the severe end of the spectrum are those athletes who fulfill the diagnostic criteria for anorexia nervosa or bulimia nervosa. At the other end are those who may inadvertently be taking in fewer calories than they need. They may appear to be eating a healthy diet – one that would be adequate for a sedentary individual – but their caloric needs are higher. Regardless of how it develops it is thought that the mismatch of energy creates an "energy drain" on the endocrine system, which in turn leads to the second and third parts of the triad.

Amenorrhea – cessation of periods for 3 or more consecutive cycles – is a result of inadequate estrogen production by the ovaries. Although some athletes may not be bothered by the absence of periods it is an easily recognizable warning sign that something is not right. There are many causes of amenorrhea, including pregnancy, so an athlete should seek qualified medical care. Once amenorrhea develops the athlete should not ignore it or attempt to minimize its significance.

The final part of the triad, osteoporosis is a consequence of inadequate estrogen. It is well documented that inadequate estrogen is not good for bones. In one of the original descriptions (1) of the triad osteoporosis was termed, "premature bone loss or inadequate bone formation". Although this is different from the World Health Organization’s more stringent definition of osteoporosis, the point is that failure to build bone at a normal rate or losing bone density at a young age is not healthy. This may lead to short and/or long term problems. In the immediate time horizon, poor bone formation spells trouble for an athlete in the form of stress fractures. Furthermore, during the young adult years a woman reaches maximum bone mineral density. After age 30 a woman can expect to lose an average of 0.5% of bone density per year: a rate that accelerates to 2% after menopause. Thus it is vital to maximize bone density when younger. There is concern that the triad poses significant risk of osteoporosis later in life.

The female athlete triad is a constantly evolving topic. It changes as more studies and information become available. The best chance to minimize damage from this disorder is early recognition followed by appropriate medical care. A team approach consisting of nutritionist, physician, and counseler/psychologist, who are all skilled in the management of this disorder, represents the best treatment option.
1.) The female athlete triad: disordered eating, amenorrhea, osteoporosis. Yeager et al. Med Sci Sport Exer 1993. 25;775
2.) Disordered eating and the female athlete triad. Sanborn et al. Clin Sport Med. 2000 April 19(2);199
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