The Female Athlete Triad is a common problem in female endurance athletes and refers to the harmful effects of low Energy Availability on the reproductive and skeletal health of physically active women.
The Triad is a syndrome of three interrelated conditions that exist on a continuum of severity:
- Low Energy Availability / Disordered
- Eating Menstrual Disturbances /Amenorrhoea
- Bone Loss / Osteoporosis
The Female Athlete Triad is not restricted to women with these conditions
Some athletes with the Triad do not practice disordered eating behaviours or restrict their diets and some amenorrhoeic athletes do not have the Triad. Equally athletes with apparently normal periods (eumenorrhoea) can suffer from hormone irregularities and be susceptible to the Triad. The Triad is not caused by low body fat or excessive exercise.
What causes the Female Athlete Triad?
The Female Athlete Triad is caused by low Energy Availability and has three spectrums – Energy Availability (the amount of dietary energy remaining after exercise for other functions of the body such as cellular maintenance and repair), Menstrual Function and Bone Mineral Density. Athletes travel along these spectrums depending on their diet and exercise habits. Energy Availability affects menstrual function and bone density and stress fractures occur more commonly in amenorrhoeic athletes.
Low Energy Availability / Disordered Eating
Low Energy Availability is the primary cause of the Female Athlete Triad and occurs when Energy consumed less Energy expended during exercise leaves a lower than normal level of Energy available. In athletics, this is most often seen in female athletes who do a high volume and intensity of training but do not match this with the necessary calorie intake. It can also involve a conscious restriction of food intake, problems with body image and a high drive for thinness. Sometimes, these conditions can lead to disordered eating, or more serious eating disorders, like anorexia or bulimia.
Menstrual Disturbances / Amenorrhoea
The most serious menstrual problem associated with the Triad is amenorrhoea. Primary amenorrhoea refers to girls who reach the age of 16 without having had a period and secondary amenorrhoea is the absence of three consecutive periods in a woman who has started menstruating. Athletes who have irregular or regular menstrual cycles can also be susceptible to the performance and health consequences of the Triad.
Bone Loss / Osteoporosis
Women with the Triad are at higher risk of low bone mass, leading to weakened bones, called osteoporosis in its severe form. This type of bone loss can cause an increased risk of fractures, including stress fractures. The teenage years are peak bone building years.
Possible Symptoms and Signs
Athletes may show one or more of the following:
- Irregular or absent menstrual cycles
- Always feeling tired and fatigued
- Problems sleeping
- Stress fractures and frequent or recurrent injuries
- Restriction of food intake
- Preoccupation with weight or body shape
- Noticeable weight loss
- Cold hands and feet
- Excessive exercise habits
- Diagnosis and Treatment
- A team approach between the athlete, coach, parents, doctor and nutritionist is the best way to tackle the Female Athlete Triad.
The primary aim of treatment for the Triad is to increase Energy Availability. Eating frequent snacks and ensuring there is adequate recovery time in the training schedule can help to do this. A dietician or sports nutritionist can give advice on increasing Energy Availability.
Athletes who suffer from irregular menstrual cycles, stress fractures and/or restrict their eating should seek medical advice from their GP or sports doctor.
Many GPs will not be familiar with the Female Athlete Triad and if this is the case you should seek specialist input from a sports doctor who can then liaise with the GP about management of the case.
Even moderate restriction of food intake (with or without weight loss) or subtle menstrual cycle changes can be early indicators of the Triad. If one aspect of the condition is exhibited the other two should be investigated.
To diagnose the Female Athlete Triad a calculation of the athlete’s Energy Availability needs to take place, which should ideally be carried out by a sports nutritionist.
Regular DEXA scans can help to monitor bone health. In athletes displaying one or more features of the Triad annual DEXA scans are recommended.
Athletes suffering from disordered eating may need to see a clinical psychologist. Information and advice can be obtained from the Eating Disorders Association: www.b-eat.co.uk
More information about the Female Athlete Triad, including a specific section for athletes and coaches can be found on the website www.femaleathletetriad.org
The National Centre for Eating Disorders in Sport at Loughborough University provides world class education, assessment and support for athletes and sports professionals. You can contact the centre on 01509 228775 or firstname.lastname@example.org.
4 Tips to help you avoid the Female Athlete Triad
- Eat according to your energy requirements for your level of activity, not by appetite, as a high carbohydrate diet or prolonged exercise reduces appetite
- Ensure a healthy diet with good calcium and vitamin D intake
- If suffering from recurrent illnesses or tiredness check for low energy input
- If your periods become irregular or stop or you suffer a stress fracture check for low energy input and seek medical advice