Expert Health Articles

Female Athlete Triad

Rachel Niermann, RDN, LD

Armes Family Cancer Care Center, Blanchard Valley Health System

For female athletes training at any level of play and age, one of the challenges they may face is how to properly fuel with food. Nutrition is a vital piece in performing and competing well. If done incorrectly, performance is not the only impacted factor. With time, a female may experience the “female athlete triad,” which is defined as a medical condition involving three interrelated components. These include long-term calorie or energy deficiency with or without disordered eating, menstrual dysfunction, and diminished bone mineral density.

Energy or calorie deficiency is the main cause of the female athlete triad. A deficiency occurs when the number of calories consumed is less than the number of calories exerted during physical activity. This may occur from the desire to achieve leanness, a conscious avoidance of food groups, and problems with body image. These types of thoughts and practices may lead to eating disorders. Among top athletes, studies show that 13.5 percent deal with an eating disorder, far higher than figures reported for the general population. Eating disorders bring athletes down the path of calorie deficits and mental health concerns. On the other hand, sometimes lacking knowledge around the importance of fueling properly when undergoing activity leads females to simply under-eat and inadequately sustain the demands of their training. Either way, when a deficit occurs over an extended period, normal bodily functions begin to be impacted.

When the body is not receiving enough calories, it will adjust by shutting down nonessential functions within the body including menstrual function, a part of reproductive health. Other psychological changes that may occur with time are changes in metabolic rate, bone health, immunity, protein synthesis, cardiovascular health and psychological health. Athletes will most likely notice their overall performance begin to change before they see clinical symptoms. Not eating enough can quickly lead to dehydration, electrolyte imbalances and feelings of fatigue, anxiety and irritation. They may find it hard to concentrate and less motivated to do the activities they enjoy.

The second component of the triad is menstrual dysfunction or amenorrhea (lack of menstrual cycle for three months or more). Women’s bodies require enough calories to sustain adequate estrogen production to induce normal menstruation. With extended calorie deficits, hormonal imbalances occur resulting in either irregular cycles or amenorrhea. There are numerous reasons why a female may experience irregular cycles or amenorrhea besides low energy intake. It is important to ask questions about dietary intakes and menstrual cycles to recognize the symptoms of the female athlete triad to get the individual the help they need. When a female is experiencing irregular cycles or amenorrhea, they may be prescribed hormonal contraceptives to prevent or slow bone loss. However, this does not solve the underlying problem. Due to inadequate energy or calorie intake being the main cause of the triad, it is important that athletes are still counseled on how and why they need to increase energy intakes.

The third component of the triad is bone loss or, in the severe form, osteoporosis. As hormonal changes occur due to a prolonged calorie deficit, less estrogen is produced. This is important in maintaining bone health. Calcium and vitamin D are two nutrients vital for bone health as well. Deficiency of calcium and vitamin D intake may occur due to poor dietary intakes. These risk factors put female athletes at increased risk for stress fractures. From puberty to early twenties, is a vital time for bone-building in females. It is important to recognize and treat symptoms of the female athlete triad to prevent bone loss during a vital period in female lives.

It is not common for a female to experience all three symptoms at the same time, and severities of the components may vary. The triad can be thought of as a spectrum of symptoms with the most severe cases including all three components. Studies have shown awareness and knowledge of the triad and its health implications among female high school athletes and coaches are limited.

Prevention begins with awareness of risks, signs and symptoms of the triad. Begin educating females about nutrition and the importance of practicing a healthy relationship with food at a young age. This can lead to discussion about the triad and why nutrition is vital for safe participation in physical activity.