Female athlete triad

The female athlete triad is a medical condition seen in female athletes characterized by the interplay between three different disorders: low energy availability (with or without eating disorders), amenorrhea, and osteoporosis.Nattiv et al. 2007. ‘Female Athlete Triad: Position Statement.’ Office Journal of the American College of Sports Medicine. < http://71.18.91.123/downloads/FAT2007.pdf> Retrieved on 2007-10-11.] Also know simply as the Triad, this condition is seen in females participating in sports that emphasize leanness or low body weight. [Torstveit et al. 2005. ‘The Female Athlete Triad: Are Elite Athletes at Increased Risk?’ Medicine and Science in Sports and Exercise. vol. 37, no. 2. p. 184-93.] The Triad is a serious illness with lifelong health consequences and can potentially be fatal.Hobart, Julie A. and Douglas R. Smucker. 2000. ‘The Female Athlete Triad.’ The American Academy of Family Physicians. < http://www.aafp.org/afp/20000601/3357.html> Retrieved on 2007-10-11.]

Triad Components

Low Energy Availability

Energy availability is defined as energy intake minus energy expended. Energy is taken in through food consumption. Our bodies expend energy through normal functioning as well as through exercise. In the case of female athlete triad, low energy availability may be coupled with eating disorders, but not necessarily so. Athletes may experience low energy availability by exercising more without a concomitant change in eating habits, or they may increase their energy expenditure while also eating less.

While most athletes do not meet the criteria to be diagnosed with an eating disorder such as anorexia nervosa or bulimia nervosa, many will exhibit disordered eating habits. Some examples of disordered eating habits are fasting; binge-eating; purging; and the use of diet-pills, laxatives, diuretics, and enemas. By restricting their diets, athletes worsen the problem of low energy availability.

Having low dietary energy from excessive exercise and/or dietary restrictions leaves too little energy for the body to carry out normal functions such as proceeding through a regular menstrual cycle or conducting bone maintenance.

Amenorrhea

Amenorrhea, defined as the cessation of a woman’s menstrual cycle for more than three months, is the second disorder in the Triad. Weight fluctuations from dietary restrictions and/or excessive exercise affect the hypothalamus’s output of gonadotropic hormones. Gonadotropic hormones “stimulate growth of the gonads and the secretion of sex hormones.” [Online Medical Dictionary. 1997. Center for Cancer Education. Retrieved on 2007-10-24.] (e.g. gonadotropin-releasing hormone, lutenizing hormone and follicle stimulating hormone.) These gonadotropic hormones play a role in stimulating estrogen release from the ovaries. Without estrogen release, the menstrual cycle is disrupted. [Menstruation and the Menstrual Cycle. The National Women’s Health Information Center. 2007. < http://www.4women.gov/FAQ/menstru.htm> Retrieved on 2007-10-19.]

There are two types of amenorrhea. A woman who has been having her period and then stops menstruating for ninety days or more is said to have secondary amenorrhea. Primary amenorrhea is characterized by delayed menarche. Menarche is the onset of a girl’s first period. Delayed menarche may be associated with delay of the development of secondary sexual characteristics.

Osteoporosis

Osteoporosis is defined by the National Institutes of Health as ‘‘a skeletal disorder characterized by compromised bone strength predisposing a person to an increased risk of fracture.’’ [Osteoporosis. 2006. National Institutes of Health. Retrieved on 2007-10-24.]

Immediate Effects of Low Bone Density. Patients with female athlete triad get osteoporosis due to hypoestrogenmia, or low estrogen levels which is part of amenorrhea. Estrogen slows bone resorption by impeding the action of osteoclasts, bone cells which break down bone. [Ott, Susan. 2007. Estrogen: Mechanism of Bone Action. Department of Medicine University of Washington. < http://courses.washington.edu/bonephys/esteffects.html> Retrieved on 2007-10-24.] As osteoclasts break down bone, patients see a loss of bone mineral density. Low bone mineral density renders bones more brittle and hence susceptible to fracture. Because athletes are active and their bones must endure mechanical stress, the likelihood of experiencing bone fracture is particularly high.

Additionally, because those suffering with female athlete triad are also restricting their diet, they may also not be consuming sufficient amounts vitamins and minerals which contribute to bone density; not getting enough calcium or vitamin D further exacerbates the problem of weak bones.

Long Term Effects of Low Bone Density. Bone mass is now thought to peak between the ages of 18-25. Thus, behaviors which result in low bone density in youth could be detrimental to an athlete’s bone health throughout her life time.

At Risk Populations

Gymnastics, figure skating, ballet, diving, swimming, and long distance running are examples of sports which emphasize low body weight. The Triad is seen more often in aesthetic sports such as these versus ball game sports. Women taking part in these sports may be at an increased risk for developing female athlete triad.

Identification and Treatment

ymptoms of the Triad

Clinical symptoms of the Triad may include disordered eating, fatigue, hair loss, cold hands and feet, dry skin, noticeable weight loss, increased healing time from injuries, increased incidence of bone fracture and cessation of menses. Affected female may also struggle with low-self esteem and depression. [The Triad. Female Athlete Triad Coalition. < http://femaleathletetriad.org/index.html> Retrieved on 2007-10-10.]

Upon physical examination, a physician may also note the following symptoms: elevated carotene in the blood, anemia, orthostatic hypotension, electrolyte irregularities, hypoestrogenism, vaginal atrophy, and bradycardia.

Treatment

Multidisciplinary Approach. Athletes diagnosed with female athlete triad should be treated using a multidisciplinary approach. Patients are recommended to work with a dietician who can monitor their nutritional status and help the patient work towards a healthy goal weight. Patients should also meet with a psychiatrist or psychologist to address the psychological aspects of the Triad. Finally, it is generally recommended that athletes reduce the amount of time they spend exercising by 10-12 percent. Therefore, it is important that trainers and coaches are made aware of the athlete’s condition and be part of her recovery.

Pharmacologic Treatment. Patients are also sometimes treated pharmacologically. To both induce menses and improve bone density, doctors may prescribe cyclic estrogen or progesterone as is used to treat post-menopausal women. Patients may also be put on oral contraceptives to stimulate regular periods. In addition to hormone therapy, nutrition supplements may be recommended. Doctors may prescribe calcium supplements. Vitamin D supplements may be also used because this vitamin aids in calcium absorption. Biphosphates and calcitonin, used to treat adults with osteoporosis, may be prescribed, although their effectiveness in adolescents has not yet been established. Finally, if indicated by a psychiatric examination, the affected athlete may be prescribed anti-depressants and in some cases benzodiazepines to help in alleviating severe distress at mealtimes.

ee also

*Eating disorder
*Anorexia
*Bulimia
*Body dysmorphic disorder
*Gonadotropin

Notes

* Kamida et al. 1997. ‘Estrogen Inhibits Bone Resorption by Directly Inducing Apoptosis of the Bone-resorbing Osteoclasts.’ The Journal of Experimental Medicine. vol. 186, no. 4. Retrieved on 2007-10-19.
* Edwards, David M. and Mary Allen. 2006. ‘Little Girls in Pretty Boxes.’ Quest Publishing Company, Inc. Retrieved on 2007-10-19.
* Task Force on USA Gymnastics Response to Female Athlete Triad. 2005. USA Gymnastics Online. Retrieved on 2007-10-19.