The Female Athlete Triad, Part 1

The female triad is one of the biggest medical concerns for all female athletes, no matter what their sport. Some of the consequences may not be completely reversible. As a result, early recognition, treatment and prevention are of paramount importance.

The “female athlete triad” is a common condition referring to menstrual dysfunction and eating disorders in female athletes, and their association with decreased bone mineral density and premature osteoporosis.

What Research Has Shown
The impact of the female athlete triad has not been recognized until recently. More research is needed for many unanswered questions.

In the early 1980s, research demonstrated that female runners with menstrual dysfunction had lower bone mineral density, or BMD, at the spine — levels consistent with osteopenia and osteoporosis. A linear relationship exists: athletes with complete loss of menses, or amenorrhea, have the lowest BMD; athletes with normal menstrual cycles (11 to 13 per year) have the highest BMD; athletes with irregular cycles (6 to 9 per year) have intermediate levels of BMD.
The incidence of menstrual dysfunction in athletic women is not uncommon. At the collegiate level in a competitive division 1 setting, 60 percent of female athletes reported irregular cycles; 30 percent reported that at some point they had stopped having their cycle altogether.
Diminished BMD in athletes with menstrual dysfunction has been confirmed in several studies. It is evident not only in the spine, but also in the weight-bearing bones — femoral neck, femoral mid shaft and tibia — of the lower extremities. Less-than-normal hormonal influences of estrogen and progesterone result in an inability to deposit calcium into bone, no matter how much calcium and vitamin D are taken in.
Diminished BMD as a risk factor for the development of stress fractures and premature osteoporosis has been well demonstrated in several studies. In studies of amenorrheic runners who spontaneously regained their menses, BMD increased significantly at first, then slowed, and four years later remained below the BMD of runners with normal cycles.
Menstrual Dysfunction
Is it “normal” or “OK” for an athlete to lose their menses? Athletes are not immune to medical problems. Hormonal signals from the hypothalamus and pituitary are often diminished in women who exercise, such that the ovaries do not receive the proper “message” to make estrogen and progesterone. Several other factors must be considered: underlying medical problems such as thyroid or adrenal gland dysfunction or other hormonal imbalances.

Early treatment of menstrual dysfunction is critical to maintain bone health. Treatment includes:

A thorough work-up for other medical problems — a physical exam including pelvic exam and blood tests.
A nutritional assessment.
An assessment of body composition changes.
An assessment of exercise practices.
Once other etiologies have been excluded, treatment often includes:

Hormonal replacement, and
If BMD is severely diminished, additional medications such as calcitonin. Biphosphonates can be considered.
Treatment for female athletes of childbearing age emphasizes:

Only estrogen and progesterone replacement, as well as calcitonin are viable options.

Decreasing exercise volume and/or intensity, and increasing body weight or body fat, may also be important. More research is needed to determine whether these therapeutic options are effective.

Eating Disorders
Eating disorders, also common in the athletic female, classically include anorexia nervosa and bulimia nervosa.