The female athlete triad is a condition characterized by low energy availability, disrupted menstrual function, and low bone density. Although it can affect anyone, it is most often found among women and girls who participate in sports that emphasize thinness, such as gymnastics, ballet, and distance running. The female athlete triad can cause fatigue, increased susceptibility to infection and illness, and poor sports performance, and have long-term effects such as fertility problems and an increased frequency of bone breaks and fractures. Fortunately, lifestyle and nutrition interventions can help.
Low energy availability
Low energy availability essentially means that an individual isn’t eating enough to meet her needs. She may intentionally restrict her calories (e.g. to meet a certain weight class for a sport) or engage in disordered eating behaviors. However, not all those who experience the female athlete triad have clinical eating disorders. Low energy availability may also be unintentional if the individual suffers from a physiological or psychological condition affecting appetite, such as irritable bowel syndrome or depression.
Disrupted menstrual function
When you don’t eat enough your body prioritizes essential functions and puts others on the backburner. One of these “others” is reproduction. Low energy availability disrupts eumenorrhea (normal menstrual periods) and may lead to oligomenorrhea (infrequent menstrual periods) or amenorrhea (loss of menstrual periods). Although a range of medical conditions can impact menstruation, low energy availability does so by interfering with normal hormonal release from the pituitary gland, which results in low circulating estrogen levels. This type of amenorrhea is known as functional hypothalamic amenorrhea (FHA). It is important to note that while long-term inadequate energy intake usually results in weight loss, a low body mass index (BMI) is not always seen with FHA. As little as five days of inadequate energy intake can cause disturbances in menstrual function, and FHA often persists after body weight has stabilized if energy balance is not restored.
Low bone density
Estrogen plays an important role in bone growth and maintenance, so low circulating estrogen levels can result in compromised bone integrity. Estrogen deficiency decreases the activity of osteoblasts (cells that build bone) and increases the activity of osteoclasts (cells that break down bone). Low overall energy intake may also limit nutrients that are vital for bone health such as vitamin D and calcium. If untreated, this can lead to osteopenia (moderately decreased bone density) and osteoporosis (severely decreased bone density), which increase risk for bone fractures and breaks. As adolescence is a critical time for building peak bone mass, it is particularly important that teenage girls seek treatment early.
Mehta, Jaya, Bithika Thompson, and Juliana M. Kling. “The female athlete triad: It takes a team.” Cleveland clinic journal of medicine 85.4 (2018): 313-320.
Screening and Treatment Recommendations
Treatment of the female athlete triad requires a multidisciplinary team. The initial focus should be on restoring energy balance; a registered dietitian nutritionist can help the patient figure out her unique energy needs and ensure that she consumes a varied diet with adequate intake of essential nutrients. A mental health professional is often an integral part of the treatment team, particularly if an eating disorder is present. As chronic stress also disrupts hormonal balance, a therapist can help the patient identify sources of stress and come up with management techniques. An athletic trainer or exercise physiologist may be helpful in determining appropriate exercise levels; although strength training and walking are important to build and maintain bone, the patient may need to reduce cardiovascular exercise until caloric intake increases. An obstetrician-gynecologist and endocrinologist can assess sex hormone and bone density levels and provide suggestions for pharmacological interventions if needed.
Although the female athlete triad focuses on women by definition, many of its signs and symptoms are not gender-specific. In 2014, recognizing that many of the problems associated with the triad affect males as well as females, the International Olympic Committee introduced the acronym RED-S (relative energy deficiency syndrome). Men with low energy availability are also likely to suffer weight loss and nutrient deficiencies, and may experience hormonal changes and compromised bone integrity. However, more research is needed.
Conclusions
The female athlete triad is a physiologically complex condition that can significantly impact both daily functioning and long-term health. However, holistic attention from a multidisciplinary team can make a big difference. Healthcare providers should be aware of the signs and symptoms in both male and female patients and screen early to have the best chance of slowing and reversing the damage.
References
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Fontana, Roberta, and Sara Della Torre. “The deep correlation between energy metabolism and reproduction: A view on the effects of nutrition for women fertility.” Nutrients 8.2 (2016): 87.
Gibson, Marie Eve Sophie, et al. “Where have the periods gone? The evaluation and management of functional hypothalamic amenorrhea.” Journal of clinical research in pediatric endocrinology 12.Suppl 1 (2020): 18.
Lokuta, Ann. “CPA monthly: the female athlete triad, relative energy deficiency in sport — learn the research and current understanding of these conditions and treatment recommendations.” Today’s dietitian 19.2 (2017): 46.
Mehta, Jaya, Bithika Thompson, and Juliana M. Kling. “The female athlete triad: It takes a team.” Cleveland clinic journal of medicine 85.4 (2018): 313-320.
“Osteoporosis: Peak Bone Mass in Women.” National Institutes of Health, U.S. Department of Health and Human Services, www.bones.nih.gov/health-info/bone/osteoporosis/bone-mass.
Shufelt, Chrisandra L., Tina Torbati, and Erika Dutra. “Hypothalamic amenorrhea and the long-term health consequences.” Seminars in reproductive medicine. 35.3 (2017).
Weiss Kelly, Amanda K., and Suzanne Hecht. “The female athlete triad.” Pediatrics 138.2 (2016).
Williams, Nancy I., Siobhan M. Statuta, and Ashley Austin. “Female athlete triad: future directions for energy availability and eating disorder research and practice.” Clinics in sports medicine 36.4 (2017): 671-686.