The majority of women in sport derive significant health and social benefits from a wide variety of intense exercises and being on a sports or athletic team. However, everyday thousands of women may be at risk of significant harm from their participation in sport. Girls and women who may consider themselves at peak health may, in fact, be in danger of severe injury, illness, and even death. The cause of this risk is the Female Athlete Triad.

First described in the early 1990’s, the female athlete triad refers to disordered eating, amenorrhea, and osteoporosis. No one currently knows how commonly the triad occurs, but there is concern that it may go largely unrecognized by female athletes, coaches, trainers, and health care professionals. The major concern is that in addition to affecting current performance, ones health could be severely affected in the long term.

The components of the Female Athlete Triad are:

1. Disordered eating – the precipitating event for the triad. Rather than restrict this description to a narrower focus of “eating disorders”, the term, “disordered eating” refers to a broader array of abnormal eating behavior. At the severe end of the spectrum are those athletes who fulfill the diagnostic criteria for anorexia nervosa or bulimia nervosa. At the other end are those who may inadvertently be taking in fewer calories than they need. They may appear to be eating a healthy diet, which may be adequate for a sedentary individual, but for a female athlete is calorie restrictive. Regardless of how disordered eating develops it is thought that the mismatch between food intake and energy expenditure creates an “energy drain” on the endocrine system, which in turn leads to the second and third parts of the triad.

2. Amenorrhea – cessation of menstruation (periods) for 3 or more consecutive cycles. It is the result of inadequate estrogen production by the ovaries. Although some athletes may not be bothered by the absence of periods, such is an easily recognizable warning sign that something is not right. There are many causes of amenorrhea, including pregnancy thus, an athlete should seek qualified medical care. Once amenorrhea develops the athlete should not ignore it or attempt to minimize its significance.

3. Osteoporosis, the final part of the triad, is a consequence of inadequate estrogen. It is well documented that inadequate estrogen is not good for bones. In one of the original descriptions of the triad osteoporosis was termed, “premature bone loss or inadequate bone formation”. Although this is different from the World Health Organization’s more strict definition of osteoporosis, failure to build bone at a normal rate or losing bone density at a young age is not healthy. This can lead to short and/or long-term problems. In the immediate time horizon, poor bone formation spells trouble for an athlete in the form of stress fractures. Also, during young adult years, a woman reaches maximum bone mineral density and after age 30 can expect to lose an average of 0.5% of bone density per year. This rate that accelerates to 2% after menopause. Consequently, it is vital to maximize bone density when younger. There is concern that the female athlete triad poses significant risk of osteoporosis later in life.

While any one component of the Triad is harmful by itself, together they can cause a decrease in performance, medical and psychological harm, mental duress, and in severe cases, death. As a female athlete, coach, trainer, parent, administrator, or team physician, it is your responsibility to know about the Triad, how to recognize it, its causes, how to prevent it from occurring, and what to do if it occurs.

Causes of the Female Athlete Triad:

The causes of disordered eating can be very complex. External and internal pressures to be thin, i.e., body image, may cause the Triad to develop in an athlete. Unwittingly, coaches, fellow athletes, trainers, and many others may encourage athletes to be thin because they believe this will enhance performance or appearance. Nothing could do greater harm to an athlete who is susceptible to disordered eating.

The many pressures to win, both internal and external, also may be a cause of the Triad. Undue pressure or control can cause athletes to feel they lack self control over their lives and sports. Thus, to gain perceived control over some aspect of their lives, athletes may turn to excessive exercise and controlling food intake, usually in the form of restricting it to lower than required amounts.

The primary cause of the amenorrhea component of the Triad is an energy imbalance brought on when athletes fail to eat enough to replenish the energy they expend in training. This energy imbalance, which is due to both under eating and intense workouts, negatively affects the body’s regulatory systems, which leads to both amenorrhea and osteoporosis. Examples include:

• Although any athlete may suffer from the Triad, those who participate in sports that place a premium on appearance or thinness are especially susceptible, including the following: Sports where athletes wear skimpy or revealing clothing (swimming, track & field, volleyball, diving, cross-country skiing, track and field, cheer leading).
• Sports where a pre-pubescent body is emphasized (diving, gymnastics, figure skating).
• Sports in which performance is subjectively judged (dance, diving, gymnastics, figure skating, Pro Fitness, aerobics).
• Sports with weight categories (judo, wrestling, weightlifting, rowing, martial arts).
• Endurance sports (cycling, cross-country skiing, marathons).

The main group at risk of suffering symptoms of the female athlete triad are young and older teen athletes in these sports learning to cope with peer pressure, biological changes, fame due to thinness, i.e., spectator glorification, and focus on body image that occur during puberty.