Female Athlete's Triad
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The female athlete's triad is a combination of three different medical disorders (osteoporosis, disordered eating, and amenorrhea) that commonly affects female athletes [1] [2] [3]. These conditions alone or in combination can pose significant health risks and even death.[1]. Adolescents and young girls are more susceptible to this disorder. Usually, these female athletes become driven to excel in their sport. This could involve pressure from coaches, parents, society, and peers to obtain a certain physique. Female athletes may strive to lose body weight or fat and can thereby developing disordered eating habits. This is an unhealthy condition in which prolonged exercise is not accompanied by an increase in dietary intake, ultimately leading to menstrual dysfunction and osteoporosis [2].
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[edit] History
Female participation in organized sports has risen in the past decades. The most dramatic increase occurred with the passing of the Educational Assistance Act of 1972. This entitled schools to provide equal athletic opportunities and funding to girls, which increased female athlete participation over 600%. The health benefits seen in women are significant, but the rise in involvement has caused several medical disorders to become more prevalent. This lead The American College of Sports Medicine to coin the term “the female athlete triad” in 1992 [1].
[edit] Signs and Symptoms
In general, there are many health consequences associated with the female athlete triad. Psychological problems include low self-esteem, depression, and anxiety disorders, which are all commonly seen with eating disorders [1]. Emotional signs include mood changes and a decreased ability to concentrate [3]. Major bodily systems including the cardiovascular, endocrine, reproductive, skeletal, digestive, and central nervous systems experience medical complications [1]. Women who are most at risk are those who restrict their dietary intake, who exercise for prolonged periods, and who are vegetarian (because their diet can lack some nutrients) [2]. Adolescents should be gaining lean body mass; therefore, weight loss is a vital sign of the Triad. Other physical signs include dry skin, hair loss, increased rate of injury with slow healing times, and stress fractures.
Long-term consequences are nutrient deficiencies, because healthy eating patterns are never established. This can cause fluid and electrolyte imbalance, which leads to growth and mental impairment. Loss of reproductive function and serious medical conditions such as dehydration and starvation can leave a lasting impression. In severe cases, death can occur [3].
[edit] Disordered Eating
Disordered eating is not the same as an eating disorder. Disordered eating can be mild to severe [1] and is noticeable through irregular eating patterns. This can include severely limiting food intake, constantly weighing/measuring foods, eating secretly, refusing to eat in front of others, food and weight obsession, and laxative abuse [3]. In severe cases, disordered eating can develop into a specific eating disorder, such as anorexia nervosa or bulimia nervosa. In general, athletes have a heightened body understanding which makes them more susceptible to body image concerns. Women who participate in individualized sports that emphasize a low body weight or a certain body type are more susceptible to disordered eating. The table below gives some examples of these types of sports:
| Type of Sport | Specific Examples |
|---|---|
| 1. Subjective scored performance | -dance
-figure skating -gymnastics |
| 2. Endurance sports | -distance running
-cycling -cross country skiing |
| 3. Tight fitting clothing is worn in competition | -volleyball
-swimming -running |
| 4. Participation in weight categories | -horse racing
-martial arts -rowing |
| 5. Body type yields success | -figure skating
-gymnastics |
Table 1: Sports most at risk for developing the Triad [1].
Disordered eating impairs athletic performance, which can increase injury. A decrease in energy intake results in a decreased endurance, strength, reaction time, speed, and concentration [1]. In addition, with a low energy intake, there is little remaining energy after exercise. This can compromise physiological mechanisms such as cellular maintenance, thermoregulation, growth, and reproduction [2].
[edit] Amenorrhea
Long-term food restriction results in bodyweight loss, which can lead to menstrual dysfunction and ultimately amenorrhea (the complete absence of menstrual bleeding). There are two types of amenorrhea. Primary amenorrhea is classified as a woman who has not had menses at age 16 or is not sexually developed by the age of 14. There is a higher incidence of amenorrhea in women who began training before menarche. The second type is called secondary amenorrhea and is the absence of menstrual bleeding for 6 months or longer. Amenorrhea is relatively common and has been reported to affect 66% of the female athlete population, in comparison to only 2 to 5% of the general population. Amenorrhea can be reversed with periods of rest, but it is not correlated with weight gain. Amenorrhea suppresses estrogen levels and has a profound effect on bone [1].
[edit] Osteoporosis
Low levels of estrogen (due to irregular menstrual cycles) have been linked to a reduction in bone mass. Amenorrhea is linked with bone degeneration because intestinal and renal calcium homeostasis is less efficient. Bone deterioration can affect a female’s peak bone mass that is reached between the ages of 18 and 25 years. During this period, there is rapid bone growth and adequate energy intake is necessary to support it [1]. With the increase in bone mineral density (BMD) loss, there is a heightened risk for stress fractures. Active women with menstrual irregularities have a 2 to 4 times greater risk of stress fractures [2]. It is suspected that osteoporosis in women with amenorrhea is partially irreversible throughout a woman’s lifetime [1]. Disordered eating can cause the suppression of caloric intake, which correlates with a decreased rate of bone formation. Low energy availability also suppresses metabolic hormones that promote bone formation [3].
[edit] Prevalence
The prevalence of disordered eating, menstrual disorders, and low bone mineral densities will vary widely. The occurrence of disordered eating, which can develop into eating disorders, in elite female athletes differs based on the sport. A study conducted by the Diagnostic and Statistical Manual of Mental Disorders found that 62% of gymnasts had disordered eating behaviors, which included binge eating and strict dieting. In sports which stressed a thin body type, 31% had a diagnosed eating disorder, compared to 5.5% of the general population. In endurance sports, 25% of female athletes also had an eating disorder [2].
The incidence of secondary amenorrhea has been reported as high as 69% in dancers. In long-distance runners, the prevalence is 65% and is more apparent as running miles increase. A decrease in BMD is seen in about 22 to 50% of female athletes, while the prevalence of osteoporosis is seen in up to 13% of cases [2].
[edit] Diagnosis
Awareness and early detection is critical. Screening can be challenging and requires knowledge about the relationship between the three components. It is recommended that examinations occur at a sports pre-participation exam or at annual health screenings [2]. Physicians should look for signs of disordered eating by conducting nutrition screenings and by inquiring if the female is engaged in binging and purging, seen in bulimia nervosa. In addition, looking at body weight and weight satisfaction is also important. Obtaining a menstrual history and stress fracture history is also necessary to formulate a diagnosis.
Laboratory analysis should also be conducted. An initial test should evaluate electrolytes, a chemistry profile, blood count, erythrocyte sedimentation rate, and urinalysis. Hypothyroidism is a cause of amenorrhea and should be screened by looking at thyroid-stimulation hormone (TSH) levels. Testing prolactin and follicle-stimulating hormone (FSH) levels can also indicate amenorrhea. Bone density screenings are used when puberty and menarche are delayed. BMD should be assessed after a stress or low-impact fracture. It should also be evaluated after 6 months of amenorrhea or disordered eating [2]. This is accomplished by a dual energy radiograph absorptiometry (DEXA) scan [1].
Physically, an athlete with the female athlete triad is abnormally thin, has bradycardia, hypotension, and a history of fainting [1]. Cold and discolored hands and feet and parotid gland enlargement have also been seen. If an athlete is suspected of disordered eating, they should be referred to a mental health practitioner for further evaluation, diagnosis, and treatment recommendations [2].
[edit] Treatment
The aim is to reduce energy expenditure while increasing energy availability [2]. It is recommended that exercise intensity is decreased or to gain 2 to 3% more body weight. A daily calcium intake of 1200 to 1500 mg/day is also recommended to reduce future incidence of osteoporosis. Dietary restrictions should also be lifted. Including resistance training in the exercise regime can strengthen the skeletal muscles and protect against soft tissue injury. Estrogen replacement therapy (ERT) is prescribed for women who do not want to changes their dietary and aerobic lifestyle; effective results vary. ERT is not advised for young girls. Follow-up lab work and scans can determine success of the treatment [1]. BMD may never be fully restored. The oral contraceptive pill is prescribed for women over the age of 16 with hypothalamic amenorrhea and with decreasing BMD. The effectiveness of the oral contraceptive pill increasing BMD is still in debate.
Multidisciplinary treatment is vital. This should include a group of heath care providers such as a physician to treat amenorrhea and BMD, a registered dietitian to help with disordered eating, and a mental health practitioner to treat women with eating disorders. All these people should have knowledge on the demands of the specific sport and work alongside athletic trainers, coaches, parents, and other family members [2].
[edit] Prevention
Prevention is the best treatment for the female athlete triad. The long-term effects amenorrhea has on the body are still unknown. In adolescents, the American Academy of Pediatrics recommends that women with amenorrhea within the first three years of menarche should decrease their exercise and improve their nutrition [1].
Education is important to prevent the Triad [2]. Athletes, coaches, parents, and athletic trainers should be counseled on the signs and symptoms of the female athlete triad and its consequences. A healthy attitude toward body type and weight should be developed while training occurs in moderation. Establishing nutritious dietary intake is especially important to prevent amenorrhea, osteoporosis, and disordered eating [1].
[edit] References
[1] West RV. The Female Athlete. The Triad of Disordered Eating, Amenorrhea, and Osteoporosis. Sports Med. 1998 Aug;26(2):63-71.
[2] Nattiv A, Loucks AB, Manore MM, Sanborn CF, Sundgot-Borgen J, and Warren MP. American College of Sports Medicine Position Stand. The Female Athlete Triad. Med. Sci Sports Exerc. 2007 Oct;39(10):1867-1882.
[3] The Triad. Female Athlete Triad Coalition. 2002. Indianapolis IN. 17 Mar. 2008 <http://www.femaleathletetriad.org/faq.html>
