THE FEMALE ATHLETE TRIAD

The American College of Sports Medicine recognised the interrelationship of three health problems effecting female athletes, and labelled this phenomenon the FEMALE ATHLETE TRIAD. The triad is an combination of osteoporosis, disordered eating and amennorhoea.

Research on female athletes has focused on reduced bone mineral density associated with menstrual cycle irregularities and in some cases, menstrual cessation in athletic pre-menopausal women. Such occurrences minimize the benefits of exercise on bone mass, increasing the risk of osteoporosis and fracture later in life, even if normal menstrual function does eventually resume.

Females who train intensely often fall into severe negative energy balance or engage in disordered eating to facilitate weight loss. Disordered eating is one component of the triad. Disordered eating can be as severe as anorexia nervosa or bulimia nervosa or simply an obsession with counting kilojoule intake or constantly weighing oneself. A reduction in body mass and body fat leads to menstrual dysfunction. Oligomenorrhoea is defined when there is 35-90days between periods and secondary amenorrhoea is the cessation of menstrual cycles for at least three consecutive months after regular cycles have begun. Amennorhoea is considered the “red flag” or most recognizable sign of the triad’s presence in the female athlete. Premature cessation of menstruation has detrimental effects on the hormonal status of bone health. Oestrogen plays a pivotal role in bone protection by increasing calcium absorption in the intestine, reducing urine calcium losses and decreasing bone turnover. When menstruation is ceased, the young woman becomes significantly more prone to calcium loss and therefore bone degradation. Osteoporosis is the third feature of the triad.

Certain sports and events focus more on body image. Sports such as gymnastics, figure-skating, dancing, weight class events (light-weight rowing) and distance running require the individual to be diligent in maintaining a certain image or build for optimal presentation or performance. Coaches of these athletes must be aware of the internal and external pressures facing young women concerning body image and body weight, compounded by the pressures of their own sport.

Once it is recognized that an athlete has amenorrhoea, the treatment should begin as soon as possible through behaviour change. Gradual increases in energy intake must be supported by the coach, family and peers of the athlete and usually facilitated by a dietitian. Also, calcium intake must be monitored and increased to above the normal recommendation of 1300mg/day. Training dose should be reduced by 10-20% until normal menstruation returns. By increasing total energy intake and slightly reducing training load, there will be a beneficial increase in body weight. Once the triad has been treated, further monitoring of the athlete must be done by the coach, family and a professional such as psychologist, physician and/or dietitian to ensure relapse is prevented.