The Female Athlete Triad

I recently presented a short piece on the female athlete triad at school. While it wasn't a particularly thrilling topic to me, I did come across some concerning information. The problem being that there is a lack of knowledge on the issue. From doctors and coaches to the affected women themselves, they need to be made aware of the symptoms and consequences of the triad.

What is the Female Athlete Triad? 
The triad refers to the interrelationships between energy availability, bone mineral density, and menstrual function (ACSM, 2007). Triad, referring to the three aforementioned components exists as a condition when energy availability is insufficient to supply adequate energy for normal physiological processes like menstruation and subsequently maintenance of bone mineral density (BMD).

The diagram below from the American College of Sports Medicine's position stance describes the relationship of the three components of the triad.

When energy availability is kept high, normal menstrual function and optimal bone health are maintained (ACSM, 2007).
Common Signs or Symptoms of the Triad
- Irregular or absent menstrual cycles
- Always feeling tired and fatigued
- Problems sleeping
- Stress fractures and frequent or recurrent injuries
- Often restricting food intake
- Constantly striving to be thin
- Eating less than needed in an effort to improve performance or physical appearance
- Cold hands and feet

So, what's the big deal?
Immediately, decreased bone mineral density leaves an athlete susceptible to stress fractures. But more importantly, for younger adults decreased BMD during young adulthood means they will be more likely to experience osteoporosis and fractures as they age. Further, the BMD that is lost will not be replaced by estrogen replacement therapy, weight gain, or the return of regular menstrual cycles  -- once you've lost it, it may not come back (Burke & Deakin, 2010). Therefore, prevention and early recognition of the triad are crucial to prevent future problems.

Perhaps the most alarming thing about the triad is that most people do not know what it is, the symptoms of it, or its long term consequences. A study from Troy et al. found that in the United States, 52% of physicians, 57% of physical therapists, 62% of athletic trainers and 92% of coaches could not identify all three components of the triad. Of the physicians surveyed, only 9% replied that they were comfortable treating individuals with the triad (2006).

Clearly, there is a lack of knowledge of the topic. So, today I want to try to educate others by providing some information about screening for and preventing the triad.

The triad essentially boils down to energy availability. The athlete must consume enough energy to maintain regular physiological processes. Energy availability (EA) refers to the amount of dietary energy remaining after physical exercise. Therefore EA can be calculated as energy consumed minus energy expended during exercise. It is not difficult for most active women to meet EA requirements, but it can be complicated by heavy training or eating disorders.

For maintenance of BMD and reproductive health, a number of sources recommend an EA of 30 kcal/kg fat free mass/day (ACSM, 2007Ihle & Loucks, 2004; Loucks & Thuma, 2003). Applying this rule, a 55kg athlete with 14% body fat -- having 47.3 kg fat free mass (55 - 55*0.14 = 47.3), would need to consume a minumum of 1419 kcal/day before exercising. With an additional hour of running at 8:00/mile (-690 kcals) the athlete is at a minimum of  2109 kcal/day.

The problem with using this equation is that we don't all have DEXA scans or BOD-PODS to know our body fat percentage. Sure, we can estimate. We can also estimate energy expenditure from exercise. The 690 kcals from above came from Vivian Heyward's Advanced Fitness and Exercise Prescription, and is at best another estimate. Why take the time to calculate out EA if two of the variables are just estimates? Then there's the problem of reporting calories consumed. It just isn't practical to measure and record everything we eat every day, and try to calculate caloric intake. Further, if you have an athlete that is at risk for the triad, it is possible she has an eating disorder and she may not report her intake honestly.

A number of studies have demonstrated that appetite is not a reliable indicator of energy availability (Blundell and King, 1998; King et al., 1997;Westerterp et al., 1992). Therefore, “Athletes must learn to eat by discipline to preserve their reproductive and skeletal health” (Burke and Deakin, 2010).

As an Athlete
Instead of focusing strictly on dietary intake, educate yourself and know the symptoms of the triad -- monitor your menstrual cycles, performance, and know that stress fractures may be an indicator of sub-optimal bone health. Seek help from coaches, physicians, nutritionists if you suspect your body weight is too low, you have disrupted menstrual cycles, or any of the symptoms listed above.

Do Not Diet! Without proper supervision of a dietitian or nutritionist. Know that food is fuel for performance and recovery.

The Role of Coaches
Perhaps the most promising form of prevention is educating the professionals working with athletes. It is our job as coaches to be educated, aware, and to monitor our athletes. With that said -- if you work with female athletes, educate yourself on the symptoms of the triad. I strongly recommend reading the ACSM position stand and the IOC's position stand.

 As a coach, if you suspect an athlete to be at risk for developing the triad, screen them for it. If you feel comfortable enough, you can screen them yourself. If not, refer them to a physician that can. The screenings can be verbal or written form and should include questions about the athletes performance, body image, diet, injury status, and menstrual cycles. Below is a list of questions from the IOC's position stand that should be included in a screening.
The Female Athlete Triad, 2006. International Olympic Committee.
If you believe an athlete exhibits symptoms of the triad, refer them to a physician or dietitian for treatment.

Another role of the coach is to encourage athletes to eat for optimal performance, not weight or body image. Of course, coaches should be there for their athletes to encourage them and provide them with positive feedback and support. And finally, coaches should enlist others in treating individuals. Athletic coaches are not generally qualified to treat conditions or prescribe dietary interventions. Therefore, he should have a network of professionals to refer athletes to when needed. Treatment will likely be a multidisciplinary approach enlisting physicians, therapists, nutritionists, etc.

Coaches should also make their athletes aware of consequences of the triad, being diminished reproductive and bone health that can have life-long implications.

The ACSM sums up prevention of the triad in one sentence, "Athletic administrators and the entire health-care team should aim to prevent the triad through education.” If you've read this post, you're off to a good start but this certainly is not a comprehensive guide to the female athlete triad.

Blundell, J. E., & King, N. A. (1998). Effects of exercise on appetite control: loose coupling between energy expenditure and energy intake. Int J Obes Relat Metab Disord, 22 Suppl 2, S22-29.

Burke, L., & Deakin, V. (2010). Clinical sports nutrition (4. ed.). New York: McGraw-Hill Medical.

Heyward, Vivian. 2010. Advanced Fitness Assessment and Exercise Prescription. Sixth Edition. 

The Female Athlete Triad. (2007). Medicine & Science in Sports & Exercise, 39(10), 1867-1882.

Ihle, R., & Loucks, A. B. (2004). Dose-response relationships between energy availability and bone turnover in young exercising women. J Bone Miner Res, 19(8), 1231-1240.

King, N. A., Lluch, A., Stubbs, R. J., & Blundell, J. E. (1997). High dose exercise does not increase hunger or energy intake in free living males. Eur J Clin Nutr, 51(7), 478-483.

Loucks, A. B., & Thuma, J. R. (2003). Luteinizing Hormone Pulsatility Is Disrupted at a Threshold of Energy Availability in Regularly Menstruating Women. Journal of Clinical Endocrinology & Metabolism, 88(1), 297-311.

The Female Athlete Triad (2006). International Olympic Committee.

Troy, K., Hoch, A. Z., & Stavrakos, J. E. (2006). Awareness and comfort in treating the Female Athlete Triad: are we failing our athletes? WMJ, 105(7), 21-24. 

Westerterp, K. R., Meijer, G. A., Janssen, E. M., Saris, W. H., & Ten Hoor, F. (1992). Long-term effect of physical activity on energy balance and body composition. Br J Nutr, 68(1), 21-30.


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