Female Athlete Triad

What is it?

The female athlete triad is a syndrome characterized by 3 interrelated conditions:

  1. Poor energy availability
    1. Poor energy availability is the result of a mismatch between the energy that is absorbed into the body (from food) and the energy that is expended (through physical activity).
    2. Optimal energy availability means that enough energy (carbs, fats, & proteins) is consumed to meet the needs of the workout PLUS everyday body functions.
    3. When energy is low or unavailable, the body shifts resources to vital physiological processes, which can result in long-term dysfunctions.
  2. Compromised reproductive function
    1. Exercise-associated menstrual disturbances are present in just over half of exercising women, and may include oligomenorrhea, amennorrhea, or another disruption.
    2. With amenorrhea (absence of menstruation), secondary causes need to be considered, and include: pregnancy, polycystic ovarian syndrome, prolactinoma, thyroid disorders, and others.
  3. Impaired bone health
    1. Low energy availability and compromised reproductive function both contribute to altered bone metabolism leading to bone weakening.

Who is at risk?

Adolescent athletes are at a greater risk because of increased growth requirements. Low energy availability can be especially harmful to this age group. Athletes are at a higher risk for the triad if they participate in sports that:

  1. Require endurance
  2. Score based on appearance
  3. Emphasize and reward leanness.
  4. Have weight-classes

Specific sports where risk may be increased include: wrestling, lightweight rowing, gymnastics, dance, figure skating, cheerleading, long and middle distance running, and pole vaulting.

What are the consequences?

Each of the three aspects of the triad brings its own set of detrimental health effects. A few consequences are reduced physical performance, negative musculoskeletal and cardiovascular health, and bone stress injuries.

What about screening?

All athletes should be screened. Screening should be performed in both collegiate and high school athletes. Athletes who are still developing (ie. adolescent athletes) should be screened carefully, because energy imbalances can have a greater health impact. Here is a list of questions (that evaluate different parts of the triad) that may be asked during screening:

  1. Do you worry about your weight or body composition?
  2. Do you limit or carefully control the foods that you eat?
  3. Do you try to lose weight to meet weight or image/appearance requirements in your sport?
  4. Do you currently or have you ever suffered from an eating disorder?
  5. What age was your first menstrual period?
  6. Do you have monthly menstrual cycles?
  7. How many menstrual cycles have you had in the last year?
  8. Are you presently taking any female hormones (estrogen, progesterone, and/or birth control pills)?
  9. Have you every had a stress fracture?
  10. Have you been told you have low bone density (osteopenia or osteoporosis)?

How is the triad diagnosed?

Depending on an individual’s responses to the questions above, a more comprehensive history, physical exam, and laboratory exam may be indicated. The effectiveness of the questions above and in the health history depend on athlete honesty. Therefore, a therapeutic alliance between athlete and health practitioner is absolutely required. A complete history includes nutritional, menstrual, fracture, and exercise questions. Depending on responses in the history and findings in the physical exam, the following areas may be further assessed in each of the three domains of the triad:

For energy availability, the practitioner may assess:

  1. Body mass
  2. Dietary (energy) intake versus energy expenditure
    1. Here is a website resource to help you estimate energy availability.
  3. Metabolic rate
  4. Various hormones

For amenorrhea, health practitioners may recommend tests for:

  1. Pregnancy
  2. Systemic diseases
  3. Endocrinopathies

To assess bone health, a DXA scan is commonly used and may be indicated for those who have:

  1. Disordered eating or an eating disorder
  2. A low BMI (<18.5)
  3. Late menarche (>15 years old)
  4. A history of <8 menses over the past year
  5. A history of stress fractures

How is it managed?

This is a condition that is best managed by a multidisciplinary team, including physicians, dieticians, athletic trainers, behavioural health clinicians, and exercise physiologists. The management plan needs to consider the goals of the athlete, and their unique diet, training practices, and level of competition.

Decisions may be modified based on the season, pressure from the athlete, coaches, family, friends, or administration, or other conflicts of interest such as a scholarship.

The primary goal is to improve energy availability. This may require decreased energy expenditure through exercise or increased intake through food… most likely both. The goal is a 20-30% increase in caloric intake, resulting in a gain of 0.5 kg every week. A 5-10% gain in body weight is usually, but NOT always associated with a resumption in menses. The goal is to add 45 kcal/kg of fat-free mass per day (45 is entered in the last box of the second table in the website resource)! Fat-free mass can be measured multiple ways. Generally, this includes an increase of 200-600 kcal/day, and consumption of at least 2000 kcal per day. Resumption of menses may take up to 1 year. During the management process, contraceptive use may be discouraged as its use can mask poor energy availability.

For bone health, calcium (1300mg) with vitamin D (600IU) are often recommended. Other bone vitamins may also help, and include vitamin K, B vitamins, and iron. Keep in mind that supplements are meant to “supplement” a well-balanced diet, which should be the primary focus.

To summarize, if you are concerned about components of the female athlete triad as an athlete, chat with a healthcare practitioner you trust. Also, engage in multidisciplinary discussion to expand your options. As a healthcare practitioner, it is important to include a team of practitioners in the management of the triad for the best success.

References

Committee on Adolescent Health Care. (2017). Committee opinion no. 702: female athlete triad. Obset Gynecol., 129(6), e160-e167

Petkus, D., Murray-Kolb, L., & De Souza, M. (2017). The unexplored crossroads of the female athlete triad and iron deficiency: a narrative review. Sports Med., [Epub ahead of print]

Weiss Kelly, A. & Hecht, S. (2016). The female athlete triad. Pediatrics., 138(2), e20160922