Female Athlete Triad
By Nancy Brinch, MS, RD, LSW

Why Should I Care About This?

The Female Athlete Triad is a combination of 3 medical conditions:

1) Disordered eating
2) Lack of menstrual periods
3) Weakened bones

Who Is At Risk?

Every female athlete and many physically active women are at risk. Highly competitive, elite athletes are at the highest risk. Female athletes who participate in sports where physical appearance is emphasized (diving, gymnastics, figure skating) or endurance sports (long distance running, rowing) may be more likely to develop the triad.

Protecting yourself from the female athlete triad will:

1) Reduce your chance of having a stress fracture. A stress fracture will keep you out of your sport for 4-8 weeks.
2) Improve your ability to recover from injuries and to fight infections.
3) Extend your athletic career or your participation in sports.
4) Support hormonal health.

What Are the Risks of the Female Athlete Triad?

Disordered eating. Disordered eating may be a full-blown eating disorder such as anorexia, bulimia or binge eating disorder. Or it may be restrictive eating - not eating enough to maintain a healthy weight. The athlete may deliberately try to lose weight or body fat by limiting her caloric intake, avoiding specific foods, fasting, or eating only twice a day. This restricted eating has a negative effect on athletic performance over time.

Sometimes an athlete's low caloric intake is not intentional. She may think that limiting her caloric intake and increasing her exercise will improve her performance. She may be eating normally for a nonathlete and she may not be aware that she is not consuming enough calories to meet her energy needs as an athlete.

Weight loss in someone who is at a healthy weight may actually improve athletic performance at first. But as weight loss continues muscle tissue is lost as well as fat tissue and this weight loss impairs athletic performance. Fatigue, anemia, and imbalances of electrolytes such as potassium result in poor performance. Low blood glucose level resulting from insufficient caloric intake (especially inadequate carbohydrate intake) causes weakness, shakiness and even fainting.

An athlete who purges (self-induced vomiting, laxative abuse) to lose weight develops severe health problems such as dehydration and electrolyte imbalances. This causes dizziness, fainting, irregular heart beat and even heart failure. Dental erosion and enlarged salivary glands also occur.

Lack of Menstrual Period. When a female athlete consistently consumes too few calories in relation to the calories her body burns she develops amenorrhea - absence of menstrual periods. A normal menstrual cycle is 25-34 days. Amenorrhea is the loss of menstruation for 3 or more months. It is more common in female athletes than in nonathletes. Experts once thought that amenorrhea in athletes was caused by exercise stress. However research now shows that it is caused by consuming fewer calories than the body needs for its daily energy requirement plus exercise energy expenditure. This is not always intentional. An athlete who has not menstruated for more than 3 months should seek medical consultation to determine the cause of her amenorrhea.

Why does amenorrhea matter? It matters because it leads to weakened bones which fracture more easily.

Low Bone Density. This is usually found in post-menopausal women, but it is also seen in female athletes. Restricted caloric intake causes low production of estrogen which results in weakened bones. These weak bones fracture much more easily than healthy bones. Fractures can occur in the hip, spine, foot or other sites. Low bone density is diagnosed by a simple DXA scan. A female athlete should be screened by having a DXA scan if she has:

1) Experienced amenorrhea for 6 months
2) Had many episodes of long menstrual cycles (over 35 days between periods)
3) Had numerous stress fractures

The best treatment for low bone density in an athlete is 1) alter the training regimen and 2) improve nutritional intake by consuming adequate calories - from protein (which is necessary for the formation of the bone's foundation,) from carbohydrate and from fat (to improve estrogen production.) Calcium intake should total 1500 milligrams daily from food and from supplements and a vitamin D supplement should be taken.

Where To Get Help

If you think you may have the triad or if you are concerned that a teammate or a friend may have signs of the triad, help is available.

1) Discuss your concerns with one of the certified athletic trainers. They can guide you toward appropriate treatment.
2) Schedule an appointment with Stockton's nutritionist, Nancy Brinch. She can evaluate your symptoms and determine the appropriate course of treatment. Appointments with the nutritionist can be scheduled by calling the Wellness Center at Ext. 5740 from on campus or 652-4701 Option #2 from off campus. Sessions are free and confidential.
3) Schedule an appointment with one of the physicians in Stockton's Wellness Center or with your personal physician. The physician will assess your symptoms and recommend treatment if this is necessary.