The female athlete triad is often experienced by highly active women. It is a medical term that is characterised by the presence of one or more of the following three conditions:
- Low energy availability – Regardless of the presence of an eating disorder or not
- Abnormal menstrual cycles
- Low bone mineral density
It is common for female athletes to present with at least one of the above symptoms [1]. It is important to recognise and treat the symptoms before they lead to more serious complications such as osteoporosis, amenorrhoea (discussed below) and eating disorders – each of which have additional adverse health effects.
How are the three conditions interrelated?
A deficiency in energy consumption can lead to irregular menstrual cycles [1]. These two things together (energy deficiency and a hypo-oestrogenic environment) play a causal role in low bone mineral density [1]. The diagram below presents the three conditions and their progression from the healthy end of the spectrum to the unhealthy end.
Image sourced from: 2014 Female Athlete Triad Coalition Consensus Statement on Treatment and Return to Play of the Female Athlete Triad [1]
Energy availability
Low energy availability is classified as the amount of energy remaining to fuel other bodily processes, after exercise. A healthy energy intake is one that meets energy expenditure as well as the energy needed to maintain good bone health and reproduction [1, 2]. When there is insufficient energy to fuel all processes of the body, the body will reduce physiological functions in order to decrease the energy used – hence the cessation of menstruation and decrease in bone mineral density [2].
Disordered menstruation
Eumenorrhoea: This is normal, regular menstruation.
Amenorrhoea: This is classified as the absence of menstrual cycles for at least three months (secondary amenorrhoea). Primary amenorrhoea is the late onset of menarche – a woman’s first period.
Cause: Amenorrhoea develops from an energy deficiency, not how strenuous the physical activity is. It can even occur in women who are not physically active but are restrictive with their dietary intake. However, physical activity can exacerbate energy deficiency by increasing the amount of energy expended.
Bone mineral density
How does adequate energy intake preserve bone mineral density?
Adequate energy intake has both a direct and indirect impact on bone health. Meeting energy requirements produces hormones that encourage the formation of bone [1]. It also prevents dysfunctional menstruation which in turn preserves oestrogen production and promotes healthy bones [1].
Health consequences of the triad
Reproductive suppression can negatively impact cardiovascular/ musculoskeletal health [1]. This can lead to an increased risk of bone stress injuries, including fractures. As the conditions progress, an individual can be at risk of further complications involving the gastrointestinal, renal, neurological and endocrine systems [1].
The diagram below outlines the approximate time each of the three conditions take to recover, with proper treatment [1]. Increased energy intake and/ or decreased energy expenditure is required for the recovery of all three elements. Recovery of menstrual status will as well aid in the recovery of bone mineral density.
Image sourced from: 2014 Female Athlete Triad Coalition Consensus Statement on Treatment and Return to Play of the Female Athlete Triad [1]
Summary
If you or someone you know displays any of the discussed symptoms/ conditions, it is strongly advised they seek medical and dietetic assistance. A psychologist may be required in some cases. If caught early enough, conditions of the female athlete triad can be well managed and any serious complications can be prevented.
References
- De Souza M, Nattiv A, Joy E, Misra M, Williams N, Mallinson R, Gibbs J, Olmsted M, Goolsby M, Matheson G. 2014 Female Athlete Triad Coalition Consensus Statement on Treatment and Return to Play of the Female Athlete Triad. J Sports Med. 2014;48:289
- Australian Institute of Sport Sports Nutrition. Female Athlete triad [internet]. 2010 [updated Dec 2010; cited 24 Sept 2014].
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This article was written by our dietitian Belinda Elwin who is a Dietitians Association of Australia member and Accredited Practising Dietitian and Nutritionist.If you have questions about diet and exercise, make an appointment. We‘ll provide you with a simple and effective routine targeted to your concerns.
