Female Athlete Triad
by Dr. Steph Corrado
The Female Athlete Triad has been recognized in recent years in young women athletes. The triad consists of:
1. Disordered Eating
2. Amenorrhea
3. Decreased Bone Mineral Density
Disordered eating is defined as insufficient caloric intake in relationship to energy expenditure. Restricting caloric intake, excessive exercise to burn calories and/or overt eating disorders such as anorexia nervosa or bulimia may all be part of the female athlete triad. When caloric intake is insufficient for energy needs, estrogen levels decrease and amenorrhea (or loss of menstrual periods) may occur. Decreased estrogen levels can lead to low bone mineral density and increased risk for fractures. Disordered eating must be reversed along with restoration of weight and body fat to resume adequate estrogen levels and normal menstrual function. Athletes particularly at risk include gymnasts, runners and dancers due to both the high level of energy expenditure and pressure to be of low body weight or certain body type.
Amenorrhea is the absence or cessation of menstruation. Amenorrhea can be primary: never having had a period or, secondary: interruption of the normal monthly periods. There are many causes of amenorrhea each of which should be excluded with the appropriate evaluation. In the Female Athlete triad, low levels of estrogen, disordered eating and/or hyper exercising cause amenorrhea. Low body weight, low body fat, intense exercise, insufficient calories, stress and genetic factors can all result in hypogonadotropic hypogonadism which causes primary or secondary amenorrhea. As estrogen is crucial in protection of bone health, amenorrhea is a sign that estrogen levels may be low and bone strength may be at risk.
Bone density is influenced by multiple factors and can be evaluated by DEXA or a bone density scans. Comparison to age matched controls provides a value of bone density. Osteoporosis is diagnosed if bone density is measured more than -2.5 deviations below the mean. Osteopenia is diagnosed if bone density is measured -1.5 to -2.5 standard deviations below the mean. The risk of fracture depends on both the bone density measured and a variety of other factors. In the female athlete triad, bone density decreases have been seen in young women who experience amenorrhea secondary to excessive participation in athletics and disordered eating. Low levels of estrogen can lead to low bone mineral density that may lead to osteopenia or osteoporosis and risk for fractures.
Diagnosis: Evaluation by a medical provider is important for the evaluation and diagnosis of the female athlete triad. A complete history, physical exam, gynecologic exam, laboratory evaluation, and bone density scan is necessary to establish the diagnosis.
Treatment:Treatment goals are aimed at resuming normal menstruation. Normal menstruation reflects adequate estrogen levels which is the best protection for bone density. Limitation of exercise, increasing caloric intake and correction of disordered eating all contribute to normal hypothalamic function and normal menses. Calcium and vitamin D intake should also be increased for optimal protection of bone health.