The “female athlete triad” is a syndrome that has the potential to affect any sportswoman (although most commonly affects gymnasts, dancers and endurance athletes) and consists of 3 inter-related disorders:
- 1. Menstrual disorders
- 2. Disordered eating
- 3. Osteoporosis
These disorders, individually and in combination, can be detrimental to your long-term health as well as your sports performance. Certainly the increased risk of infertility, stress fractures, eating disorder, and osteoporosis in later life is a high price to pay for involvement in sport, which is supposed to be a healthy activity! Especially, as they are preventable.
Gymnasts and endurance althletes at risk!
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How are the 3 corners of the triad inter-related?
The 3 corners of the triad are inter-related through psychological and physiological mechanisms.
The psychological pressure to perform to an optimal standard, which is often accompanied by a perceived requirement to maintain a low body mass, results in a high volume of training. If the high volume of training is done with a low energy intake for a prolonged period of time it may lead to alteration of the menstrual cycle and ultimately a loss of periods. The consequence of a loss of periods is a decreased production of oestrogen. This hormone has an important role in maintaining adequate bone density, so a low-oestrogen state can lead to an increased risk of osteoporosis.
Periods
It was initially thought that a low body fat and high volume of endurance training caused menstrual disorders. However, it has recently been found that specific hormones related to metabolism (and thus to nutritional and metabolic status) are more important. In fact if energy availability is low over a significant duration of time, as indicated by these hormones, the menstrual cycle is temporarily "switched off" or suppressed to conserve energy.
Energy Intake
Habits of disordered eating are more common than eating disorders. As a result, the term “anorexia athletica” has been used to distinguish between the well-known eating disorder, anorexia nervosa, and eating disorders associated with training and sports performance.
If you have traits of perfectionism, compulsiveness, competitiveness, high self-motivation, along with menstrual disturbances, and at least one unhealthy method of weight control (fasting, vomiting, and use of diet pills, laxatives, or diuretics) then you are more likely to have disordered eating.
Sadly, it is estimated that 15-60% of female athletes have habitual disordered eating, with 50% of these women compulsively over-exercising.
It is really important to remember that “energy in = energy out”. And, when energy intake matches expenditure, body weight will not increase but maintenance of muscle mass will increase performance.
If you do want to lose weight, it must be done slowly and over a long period of time. Losing weight quickly means you are probably losing muscle mass as well as body fat.
Bones
The final part of the triad, osteoporosis, is associated with a reduction in bone mineral density and an increased risk of stress fractures.
The body is continually re-absorbing and re-building skeletal bone. When the amount of re-absorption is greater than the amount of re-building then the bone mineral density decreases. Oestrogen protects the skeleton from bone re-absorption; so maintaining regular periods are an important part of preventing osteoporosis.
Bone tissue responds well to mechanical stress, hence weight-bearing exercises can help improve bone mineral density. Adequate calcium intake is also important.
Pic athlete having bone scan
Management
As with most things, prevention is better than cure.
Prevention of the female athlete triad in sportswomen is made difficult by the nature of the game. Female athletes will resist increasing body weight and decreasing training loads for fear of impairing performance. In addition, athletes will find it difficult to admit to menstrual problems and disordered eating or eating disorders.
The first step to take, having identified a problem, is to decrease the intensity or duration of training by around 10% or increase energy intake, as high volume training accompanied by insufficient energy intake is the main instigator of the problem.
Occasionally, medication may be required although this does not correct the underlying problem. Oestrogen replacement through the combined oral contraceptive pill may be required alongside an increased calcium intake in sportswomen who are not having regular periods. These measures should be done under the supervision of a doctor (ideally one experienced in sports medicine).
Top Tips
- Prevention is better than cure
Be aware of the potential of the female athlete triad to affect any sportswoman and act early if you notice any tell tale signs.
Always try to maintain an adequate energy intake for the amount of training you are doing. If you find it difficult to gauge how much extra you need per day (in addition to your daily metabolic requirement of approx 2,000 calories per day) you may find it helpful to use a heart rate monitor during your training sessions (many give you “calories burned”).
Keep a healthy balanced diet with a good intake of calcium. If you are not having regular periods consider adding calcium (plus vitamin D) supplements.
Reduce the amount of training you are doing by 10% or increase food intake until your body's status quo is regained. It will also help your performance.
- Know when to see a doctor
If you are concerned about your periods or any disordered eating habits, especially if it has been more than just a short-term thing, then you should see a doctor. Your GP will be able to help initially and will be able to suggest other specialist avenues if required.
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DISCLAIMER: Advice and information is provided via SheCycles.com Clinic on a free of charge basis as a supportive service to women in sport. It should not replace the use of your General Practitioner for medical problems.
Copyright 2006 - Dr K Hurst
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