THE FEMALE ATHLETE TRIAD By: Jessica Daniels

Defining the Triad “The female athlete triad (Triad) refers to the interrelationships among energy availability, menstrual function, and bone mineral density, which may have clinical manifestations including eating disorders, functional hypothalamic amenorrhea, and osteoporosis.” 1

Who is at Risk? According to Dunford, any female can be at risk, but the most common athletes to experience low bone mineral density, menstrual dysfunction, and low energy availability are distance runners, ballet dancers, swimmers, and rowers. 2 Hobart and Smucker found that most athletes do not meet the criteria listed in the DSM-IV for anorexia nervosa and bulemia, but they will exhibit disordered eating patterns as part of the “triad syndrome”. 3

At First Glance…

Criteria for Eating Disorders Anorexia Nervosa Refusal to maintain body weight at or above normal weight Fear of gaining weight when underweight Denial of current weight or image, disturbance in the way body image or weight is portrayed Absensce of at least 3 menstrual cycles **Classified as either restrictive or binge/purge. Hobart and Smucker 3

Criteria for Eating Disorders Bulemia Recurrent episodes of binge eating. Recurrent inappropriate compensation to prevent weight gain. Binge eating and compensatory habits twice a week, lasting for at least 3 months. Does not occur exclusively with anorexia. Body weight and image influence self evaluation. **Classified as purging or non-purging Hobart and Smucker 3

Eating Disorder Instruments Further identification of eating disorders within individuals can occur with the usage of additional instruments. 7 o Eating disorder questionnaires o Eating disorder surveys o Eating disorder inventory (EDI) o Eating Attitudes Test (EAT) o Eating Disorder Examination (EDE)

Amenorrhea Amenorrhea occurring in the athletic population can result due to a change in the hypothalamus, causing levels of estrogen to decrease. There are two types—primary and secondary. A history of amenorrhea is one of the easiest ways to detect the female athlete triad. 3

Amenorrhea o Primary amenorrhea: Menses fails to occur by the age of 16 years; if menses have not occurred by a time period of 4.5 years after breast development 9 o Secondary amenorrhea: loss of 3 to 6 menstrual cycles consecutively for a female who has begun menses 9 o Menstrual dysfunction is more common in athletic females when compared to the general population. 9

Osteoporosis Defined as ‘‘a skeletal disorder characterized by compromised bone strength predisposing a person to an increased risk of fracture”. 1 BMD levels reflect energy availability, menstrual status, and factors related to nutrition, behavior, and environment. Low BMD pertains to a history of nutrition deficiencies, stress fractures, hypoestrogenism, and secondary fracture factors.

Osteoporosis Bone strength and fracture risk is dependent on the BMD level. Bone mineral density (BMD) is used as a means of screening and diagnosis for osteoporosis. o Dual energy x-ray absorptiometry (DXA) testing can be used to quantify density. 10 According to von Schulthess and Zollikofer (2009), “the Female Athlete Triad becomes a diagnostic consideration for a radiologist when stress fractures and serous atrophy of the bone marrow are identified on magnetic resonance imagine (MRI).” 10

Signs and Symptoms Depression Frequent vomiting Excessive exercise habits Use of diet pills Use of duretics Excessive dieting for weight loss Weight loss Fatigue Amenorrhea Stress fractures Disordered eating habits Frequent trips to the bathroom Use of laxatives Anemia

Treatment In most cases, treatment will involve multiple parties (physician, dietitian, athletic trainer, exercise physiologist, coach, parents, friends, athlete). Psychotherapy Counseling with Sports Dietitian Early intervention Hormone replacement therapy (debated) Alter participation by health level Nutrition journal and goals (ex: calcium intake of 1500 mg/day)

Who is Involved in Care? Physician Psychiatrist/Psychologist Dietician Certified Athletic Trainer Coach Family Friends Coaches, family members, and friends can be a great source of support!

Risk Factors and Prevention The following have been listed as risk factors: restricted energy intake, excessive exercise, disordered eating behaviors, frequent weigh-ins, punishment for weight gain, pressure to succeed/win, over-controlling coaches or parents, social isolation. 3 Prevention is seen as extremely important in this population, as long-term effects of the triad are detrimental to self-esteem, psychological state, and major body systems. Education is a key element in preventing the female athlete triad. This can include athletes, parents, and coaches.

The “Triad” Illustrated ACSM 1

Proposed Expansion of FAT Now includes cardiovascular effects and sequalae 11 Has incorporated the recreationally active female

Example: Case report: 16-year old female figure skater trains approximately 6 hours a week. She begins to experience chronic knee pain that fails to improve with rehab and treatment. When she is ordered to stop training she alters her diet out of fear of gaining weight. After modifying her diet to eliminate foods such as grains, salads, protein sources, and vegetables she loses weight over a period of 3 weeks. She then begins to miss menstrual cycles. At this point she has a much higher level of fatigue and chronic shin pain at night. 8 Key points: In further investigation it becomes apparent that this athlete may have stopped formal training, but she continued off-ice training in addition to rehab. In essence, she deprived her body of vital nutrients, increased overall training, and added stress to her body. 8

References 1. American College of Sports Medicine. (2007). The female athlete triad. Medicine & Science in Sports & Exercise, 39 (10), Dunford, M. (2010). Fundamentals of sport and exercise nutrition. Champaign, IL: Human Kinetics. 3. Hobart, J. A., Smucker, D. R. (2000). The female athlete triad. Retrieved from 4. Griffith, H. W., Moore, S., Yoder, K. (2006). Complete guide to symptoms, illness & surgery (5 th ed.). New York, NY: The Berkeley Publishing Group. 5. France, R. C. (2011). Introduction to sports medicine and athletic training (2 nd ed.). Clifton Park, NJ: Delmar. 6. Manore, M. M., Meyer, N. L., Thompson, J. (2009). Sport nutrition for health and performance. Champaign, IL: Human Kinetics.

References 7. Brunet, M. (2005). Female athlete triad. Clinical Sports Medicine, 24, Alleyne, J., CASM, C. (2004). Female athlete triad: The flip side of living. The Canadian Journal of Diagnosis, American Academy of Pediatrics. (2000). Medical concerns in the female athlete. Pediatrics, 106(3), von Schulthess, G.K., Zollikofer, C.L. (2009). Musculoskeletal diseases. Segrate, Italy: Springer. 11. De Souza, M.J., Williams, N.I. (2004). Physiological aspects and clinical sequelae of energy deficiency and hypoestrogenism in exercising women. Human Reproduction Update, 10(5),