Female AthleteTriad

The  female  athlete  triad  (triad)  refers  to  the  co-occurrence  of  three  interrelated  conditions:  low energy  availability,  menstrual  dysfunction,  and low  bone-mineral  density Factors  within  sport and  exercise  environments  can  increase  the  risk of  developing  these  conditions.  Though  the  prevalence  of  the  full  triad  is  low,  many  girls  and women  will  experience  one  or  two  of  the  conditions, which can increase their risk of developing the triad. The triad represents a significant health concern, as it can lead to serious and long-lasting health consequences.


The prevalence of low energy availability has not been  well  documented.  However,  estimates  of clinical EDs, which may contribute to low energy age-group  matched  controls,  lower  than  normal levels  of  estrogen,  history  of  deficient  nutrition, and previous bone fractures. Low BMD can result from  insufficient  accumulation  of  bone  mineral during  childhood  and  adolescence  or  from  bone mineral loss during adulthood.

 Interrelated Conditions

Originally,  the  triad  included  disordered  eating, amenorrhea, and osteoporosis. However, in 2007, the  American  College  of  Sports  Medicine  revised their position and redefined the triad as low energy availability, menstrual dysfunction, and low bone mineral  density  (BMD).  Low  energy  availability refers  to  the  amount  of  energy  after  exercise  or training  that  is  available  for  physical  functioning and may result from excessive exercise, insufficient caloric intake, or other methods of purging, such as  laxatives  or  vomiting.  Eating  disorders  (EDs), including anorexia nervosa (AN), bulimia nervosa (BN), and eating disorders not otherwise specified (EDNOS)  may  be  present  and  contribute  to  low energy availability. However, low energy availability can be present without EDs.

Menstrual  dysfunction,  the  second  defining condition  of  the  triad,  includes  primary  amenorrhea  (delay  of  menarche),  secondary  amenorrhea (absence  of  menstrual  cycle,  after  menarche,  for more  than  three  consecutive  months)  and  oligomenorrhea (more than 35 days between menstrual cycles).  Abnormal  menstrual  functioning  often results from low energy availability and can contribute  to  low  BMD.  Low  BMD  is  defined  as  a BMD  of  at  least  one  standard  unit  lower  than availability, range between 0% and 13.4% among college  and  elite  athletes.  Prevalence  of  subclinical  levels  of  disordered  eating  is  much  higher, though rates of specific pathogenic weight-control behaviors  vary  widely.  For  example,  few  athletes report  using  laxatives  or  diuretics  or  engaging  in self-induced vomiting, but many diet and exercise excessively.  Menstrual  dysfunction,  a  product  of low  energy  availability,  ranges  between  16.6% and  54%  among  high  school  athletes  and  up  to 63.9%  among  college  athletes.  Low  BMD  has been found in up to 21.8% of high school athletes and 11% of elite athletes.

Prevalence estimates of the co-occurrence of all three conditions are lacking. Several studies using the original, more narrowly defined, criteria report rates  of  1.2%  (high  school),  2.7%  (college)  and 4.3%  (elite).  In  a  study  using  the  current  ACSM guidelines  (2007),  the  triad  was  found  among 15.9%  of  college  runners.  When  considering  the presence of two of the three conditions, prevalence rates can range up to 18% among high school athletes and 26.9% among elite athletes. The presence of any of these conditions may increase the risk of developing the full triad.

Risk Factors

Numerous factors can increase female athletes’ risk for developing triad conditions. Distorted attitudes toward  food,  eating,  and  body  weight  and  shape are  associated  with  unhealthy  eating  and  weight control behaviors that can create low energy availability. Athletes in sports that emphasize leanness, low body weight, or appearance, such as distance running, gymnastics, or dance, may be more likely to experience pressures from coaches, teammates, family,  and  other  sport  personnel  (e.g.,  judges) about  body  size  or  shape.  Such  stressors  may lead athletes to restrict caloric intake and exercise excessively.

Evidence  also  suggests  that  sport  participation at  an  elite  competitive  level  increases  risk  of  the triad.  Pressure  and  expectations  to  consistently perform and achieve at a high level often increase among  elite-level  athletes.  Moreover,  there  may be serious consequences for poor performance for elite  athletes.  For  example,  losing  a  spot  on  the national team or losing a sponsorship or endorsement  may  significantly  impact  an  athlete’s  livelihood.  Thus,  athletes  competing  at  elite  levels  are not  only  likely  to  engage  in  extensive  physical training  but  also  may  be  susceptible  to  disturbed body  image  and  weight-related  pressures,  placing them at increased risk for low energy availability.

Health Consequences

All  three  triad  conditions  put  female  athletes  at risk for a number of negative health consequences. Disordered  eating  behaviors,  which  can  contribute to low energy availability, are associated with low self-esteem, anxiety, depression, and a myriad of physical health problems, such as cardiovascular  problems,  constipation,  electrolyte  imbalance, muscle  cramps,  or  muscle  weakness).  Menstrual dysfunction  can  increase  the  risk  of  infertility and  result  in  muscular  problems  and  decreases in  BMD.  Menstrual  irregularities  and  low  BMD increases the risk of stress fractures.

Screening and Prevention

The American College of Sports Medicine recommends screening for the triad during preparticipation and  annual  health  screenings.  Additionally, female  athletes  who  present  with  one  triad  condition  should  be  screened  for  the  other  two.  The Female Athlete Triad Pre-Participation Evaluation (Triad  PPE),  available  from  the  Female  Athlete Triad Coalition, can be used to assess eating habits and attitudes, weight and menstrual histories, and history of stress fractures. Potential low BMD can be evaluated via dual-energy X-ray absorptiometry (DXA) when there is a history of low estrogen, disordered eating, or history of stress fractures.

To reduce the risk of the triad, coaches, administrators,  and  sports  medicine  professionals  can create  body-healthy  environments  by  avoiding weigh-ins, weight logs, and weight-related joking, as well as pressures to achieve an unrealistic body size  or  shape.  Moreover,  sport  governing  bodies can  promote  healthy  sport  environments  by  providing  triad  education  and  training  to  officials,  coaches,  and  athletes.  Prevention  is  important because  treatment  can  be  challenging;  for  example, treatment may not result in restoration of normal levels of BMD and ED recovery rates are low. Education,  increased  awareness,  and  early  interventions are important steps in triad prevention.

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