The Female Triad

The Female Athlete Triad
Ann M. Heaslett, M.D.
Psychiatrist, Madison, WI USA
Member USA 100K Team 2002-5
The Female Athlete Triad?
What is the Female Athlete triad?
Disordered Eating
The Female Athlete Triad
Originally described in 1992
First recognized as three separate but
unrelated entities
Now recognized by the American College
of Sports Medicine (ACSM) as a spectrum
of symptoms and conditions between
health and disease
The Female Athlete Triad
The three spectrums include:
Energy availability (which may occur with
or without disordered eating)
Menstrual function
Bone Mineral Density
The Female Athlete Triad
Dysfunction in any of any of the components
can lead to dysfunction of the other
While energy availability may change daily,
the effects on menstrual cycle may not
occur for months, and an effect on bone
mineral density may not occur for years.
Energy Balance & Body Wt.
When an athlete eats enough calories to
meet basic and athletic needs, wt should
be stable. However, it isn’t that simple.
When there is a caloric deficit, the brain &
body try to help reestablish energy
balance by decreasing resting metabolic
rate. The body begins to conserve
calories, and this starts a cascade of
events we’ll call low energy availability.
Low Energy Availability
Can occur with or without a formal eating
May be due to abnormal eating behaviors
such as dietary restraint, binge eating, etc.
OR failure increase dietary intake to match
training needs.
Low energy availability leads to
Disruption of the GnRH pulse generator in
the hypothalamus, possibly because of
changes in:
- leptin
- insulin, IGF-1,glucose, f.a.’s.,ketones
- growth hormone
- T3, etc.
Changes in factors previously
described have an inhibitory effect
on the hypothalamus
Decreased stimulation of the pituitary with
GnRH pulses
Decreased LH and FSH pulses, resulting in
less stimulation of the ovaries to produce
progesterone and estrogen
Abnormal Menses
So why are abnormal menses
-Because Bone Mineral Density decreases
with the number of missed menstrual
cycles accumulated over the months and
years. This leads to increased incidence
of stress fractures in active women with
menstrual irregularities.
Bone Mineral Density
60-80% Genetically Determined, peak
BMD achieved between ages 11-15
While weight-bearing exercise should
increase BMD, decreased estrogen
decreases BMD, as do:
-smoking, alcohol, malnutrition
Women with normal menses who are
active have 5-15% higher BMD than
sedentary controls.
May result from failure to achieve peak
BMD during adolescence or from
accelerated bone loss
Prevalence of the Triad
Unsure… Why?
inadvertant low energy availability-prevalence is
disordered eating without a formal eating d.o dx
– 28-62% prevalence in thin-build athletes
formal eating disorder – 25-31% prevalence in
thin-build athletes compared with 5-9% general
Prevalence of Menstrual Disorders
Amenorrhea is present in 65-69% of
endurance runners compared to 2-5% in
the general population
Prevalence of Low BMD
T-score between -1 and -2.5:
22-50% prevalence among female
T-score less than -2.5:
0-13% prevalence among female athletes
These are higher than the 12% and
2.3%prevalence estimates, respectively, in
a normal population distribution.
Key Concepts
It is not necessary to have all three
components of the Triad simultaneously to
have negative effects on bone health
The triad can be seen in all sports, not just
those traditionally seen as low body wt
sports such as long distance running
Additional Consequences of the
cardiovascular risk
-Increased risk for
-Excessive fatigue
-Increased recovery
-Decreased response to
-Impaired Performance
If one component of the Triad is present,
screen for the other two, as there is
significant likelihood they are present.
1. Low Energy Availability: look for high
dietary restraint, high drive for thinness,
excessive or compulsive exercise,
restriction of specific food groups,
repeated dieting, eating disorder.
Screening, Continued
2. Menstrual dysfunction: how many
periods has the athlete had within the
past 12 months? Has she missed >3
periods in a row?
3. BMD: consider performing DXA scan of
the spine and hip if hx of stress fx and/or
h/o > 6 months of amenorrhea,
oligomenorrhea, disordered eating or
eating disorder.
Education of the athlete as to how much
energy is required to do the kind of
training/performance she is asking of her
body. Increasing nutritional intake or
decreasing training volume may be
needed to restore/maintain energy
Provision of adequate Calcium 12001500mg/day and Vit. D 400-800IU/day.
Prevention and Treatment,
Adding hormones in the way of OCP’s will
not restore BMD unless adequate nutrition
is present
Biophosphonates should not be used in
young athletes with amennorhea or low
Changing the mindset is important, and
successful female ultrarunners seem to
understand that food is not “the enemy” but
rather what fuels activity and performance and
promotes development of training effect and
allows for healing and growth.
The Female Athlete Triad is NOT an inevitable
consequence of training and being an athlete.

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