Get Adobe Flash player
NEDA TOOLKIT for Coaches and Trainers The Female Athlete Triad By  Kathryn Ackerman, MD, MPH The Female Athlete Triad (the Triad), a term coined in 1993 by the American College of Sports Medicine, refers to a syndrome commonly seen in athletic women. It involves the interrelated symptoms of disordered eating, menstrual irregularity and low bone mass. Although the exact prevalence of the Triad is unknown, studies have found that nearly three- quarters of female athletes have at least one sign of the Triad, according to a 2009 study in the Clinical Journal of Sports Medicine. The idea of the Triad has evolved to include different stages of a continuum on which many of our athletes live. At one end of the spectrum are athletes with mildly disordered eating (e.g., missing certain nutrients, skimping on calories) who have irregular periods (oligomenorrhea) and/or possibly experienced a stress fracture. At the other end are women who have eating disorders such as anorexia or bulimia, have long- standing amenorrhea and have bone density in the osteoporosis range. Low bone mass results in bones that are easily fractured. For an athlete, apart from being painful, such injuries can impair or even put an end to a promising athletic future. The interrelationship between food intake, menstrual dysfunction and poor bone health is still being elucidated. In general, when an athlete eats too few calories, it causes brain hormone levels to change, disrupting signals to the ovaries to produce estrogen, which helps build and maintain bones. Studies in individuals with anorexia have shown that the restoration of normal menstrual periods via the normalization of food intake and reduction of exercise is the only effective way to begin improving bone density. This is particularly important in adolescent girls, as 90% of peak bone mass is attained by age 18, with only mild gains up to age 30. This means that disrupting the menstrual cycle during adolescence and early adulthood has a profound effect on bone health. If caught early, however, some of the deleterious effects of the Triad on bone health may be corrected. Through their 30s, women’s bone densities tend to plateau if diet and exercise are adequate. Bone density then declines abruptly around menopause and usually remains on a modest decline through the rest of the lifespan. If young female athletes begin good habits early, their peak bone mass is expected to be higher than that of their sedentary counterparts, thus greatly reducing the risk of osteoporosis later in life. Causes of the Triad Recent research has helped increase understanding of what causes the Triad. One factor is the maintenance of adequate body fat levels. Although some athletes mistakenly believe that leaner is always better, this isn’t the case. If an athlete tries to maintain a body fat percentage that is too low for her individual genetic makeup, it can result in hormonal abnormalities that lead to Triad symptoms. However, low body fat alone doesn’t cause the Triad — in fact, symptoms have been documented in females with adequate body fat. The triggering factor appears to be prolonged inadequate energy intake, even without any weight loss. The stress of strenuous physical activity without sufficient energy replacement can cause the body to shut off reproductive functions, as it doesn’t have the energy to maintain a pregnancy. Therefore, increasing nutritional intake and/or decreasing activity should be the first line treatment for athletes with Triad symptoms. How do you detect the Triad? The signs and symptoms of the Triad are very broad, and they involve all of its three components: eating and exercise habits, menstrual irregularity and poor bone health. • Low bone mass may manifest as stress fractures or full fractures (e.g., in a long bone such as the tibia or fibula or as a compression fracture in the spine). Some stress fractures are secondary to overuse and sports technique (such as an uneven running gait), while others, such as lumbar and femoral stress fractures, are highly correlated with disordered eating. Fractures are often early signs of low bone density. Other low bone mass risks include a history of malabsorption (e.g., Crohn’s disease, ulcerative colitis, celiac disease), low calcium and/or vitamin D intake, excessive alcohol consumption, steroid use, and those with either or both of the other two aspects of the Triad. Low bone density can be detected by a dual x-ray absorptiometry (DXA) scan. Page  | 20