Running head: THE FEMALE ATHLETE TRIAD SYNDROME

The Female Athlete Triad Syndrome

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THE FEMALE ATHLETE TRIAD SYNDROME

Abstract
As the female participation in athletics increase, positive effects associated with exercise
on health become evident. With this growth in sportsmanship, a set of problems that affect
female athletes become prominent. This female triad syndrome includes the eating disorder,
osteoporosis, and amenorrhea. Research into the syndrome often reveals the condition as one of
the most unwanted effects of increased athlete physical activities, mounting pressure with
consistent performance as well as the preference for a slim body. This paper seeks to find the
causative factors, effects and find the available treatment options available to the syndrome.

THE FEMALE ATHLETE TRIAD SYNDROME

The Female Athlete Triad Syndrome

The female athlete syndrome is a frequent condition affecting the female athletes and
comprises of 1) eating disorder, 2) Osteoporosis and amenorrhea. This condition normally occurs
during adolescence period of the female athletes which as a result of increased physical activity
and eating prevalent disorder among them. These situations eventually lead to dysregulation of
the hypothalamic-pituitary-ovarian axis (HPO).This dysregulation then causes hypothalamic
amenorrhea associated with increasing risk of osteoporosis as well as the pathological fracture.
The basis of this disorder treatment is to reduce the intense physical activity and overcome the
eating disorder to treat amenorrhea. Hormone replacement physiotherapy is the consideration to
overcome the loss of bone density. In the end, a comprehensive approach is sought in early
stages from coach, parent, physician and athlete to manage the triad condition
The first condition that is most detrimental of the triad is the eating disorder. These triad
conditions are linked to one and each of the other although the main factor behind all this
condition is the eating disorder. According to the 2011 article, up to a 62% of the athletes fight an
eating disorder condition (Hausenblas & Carron, 1999). The athletes who are mostly diagnosed
with the eating disorder are those with low reduced body-fat such as the long distance runners,
rowers, gymnasts, swimmers, and divers. In such sports where a thin appearance is valued,
athletes consume little amount of the calories as compared to what they are putting in the sports.
Most of the times athletes find it unavoidable to control their eating disorders because of low
self-esteem, stress, perfectionism and even the pressure from coaches, peers, self and parents.

THE FEMALE ATHLETE TRIAD SYNDROME

Some of the females athletes are so passionate about their sport in that they fight at all cost to
improve their performance. In the long run, this eating disorder causes a loss in weight, decrease
in the immune system, loss of muscles, increased emotional stress and decaying of one's body.
Once a lady does not consume a substantial amount of calories, it can cause the other two
conditions since they are co-related. There is the reduced availability of energy i.e. the amount of
the dietary energy source remaining for the involuntary and voluntary activities of the body after
exercising and training such as, locomotion, immunity, growth, cellular maintenance
reproduction, and thermogenesis (Blum, 1994). This association is disordered eating as a result
of exercise energy being spend more than what is provided by the food from dietary energy
input. This compensation reduce the amount of the energy available to enable body parts
function at optimum by the physiological mechanisms.This tends to restore the energy balance
one's body promoting survival yet consequently impairs healthy.

The second effect, Amenorrhea, is predominant in females who have had their intense
training since a tender age and had either began menstruating or stopped because of the training.
Most of these young females welcome the start of amenorrhea since "they do not want to have
menstrual periods, which they find inconvenient and uncomfortable" (Cogan, 1996).
Amenorrhea affects most females who indulge in excessively exercise yet they consume the
insufficient amount of the calories. This then decreases the amounts estrogen in one's body and
causes a female to continue skipping their cycles. A fluctuation from the dietary restrictions on
excessive exercise affects the release of gonadotropic hormones from the hypothalamus.
Gonadotrophic hormones tend to "stimulate a growth of the gonads and the secretion of sex

THE FEMALE ATHLETE TRIAD SYNDROME

hormones." The gonadotropic hormones stimulate estrogen release from ovaries. Without the
release of estrogen, the menstrual cycle becomes disrupted (McFadden, 1999).With these two
conditions, especially amenorrhea and disordered eating, causes the third condition of the triad.
Many people associate this third condition, Osteoporosis with old age. This is a disease that
affects the young. Bone tissues change well according to the mechanical stress applied, this in
turn exercise with nutrition is essential for attaining peak bone formation and mass at the tender
age. Women with less energy and reduced estrogen level, however, have a high risk of being
osteoporotic. Low estrogen concentrations, low intake of calories, with poor nutrition may cause
slow bone development and bone loss may occur. The most critical time to build the skeleton
becomes the early stages before and after the puberty stage. Estrogen deficiency causes the
osteoclasts to live longer hence able to resorb more of the bone. As bone reabsorption increases,
there is the increase in bone formation and development of high turnover state leads to bone loss
and trabecular plates' perforation. With the Low mineral density of the bones, it renders it more
brittle and susceptible to the fractures. When young girls give less concern and time to the
growth of their bones, stress fracture, and severe bone injuries can occur. With the recent study,
the bone density has been discovered anywhere in 11-22% of the female athletes (Allison &
Grace, 1991).This may cause future bone problems in female's life and thus making us consider
it as an old person's condition though it starts at an earlier age.
With a bone mass thought to reach its peak between 18-25, behaviors that develop to low
density of bone among the youth could lead to detrimental bone health of the athlete through his
lifetime (McFadden, 1999). Because female suffering with triad also restricts their diet, they may
also be limiting the consumption of minerals and vitamins which essentially contribute to

THE FEMALE ATHLETE TRIAD SYNDROME

improved bone density.Additionally, not having enough vitamin D or calcium contribute to weak
bones that are susceptible to fractures and stress.

The three components are quite dangerous and apparently, females are at risk and
vulnerable to the triad. Estrogens help the bone formation and protect it from the bone
resorption, although deficiencies mainly in vitamin D, calcium and the other bone substances
that are from inadequate intake of nutrients may also contribute to bone resorption. Future risk of
osteoporosis is managed at a tender by attaining a good bone formation and peak mineral density
with exposure to the estrogen. Thus, increased periods of amenorrhea may cause increase risk of
osteoporosis.
The main cause of Triad is often seen in aesthetic sports such as athletics versus ball
games. Female in such sports are at risk of developing the female athlete triad and more
susceptible to future problems. Athletes, who restrict dietary energy consumption, limit the kind
and type of food they take and those who exercise for a longer period are at the greatest risk.
Many of the factors contribute to eating behavioral disorder and clinical disorders. Dieting is an
entry point and with interest focused on the input of social and environmental factors, low-selfesteem, abuse, genetics, biological factors, family dysfunction and psychological predisposition.
Also, factors such as early training for specific sport, dietary, a sudden increase of the training
volume and injury also contribute to the cause of triad. Surveys have shown a negative eating
trend in attitude associated with athletics disciplines and this favor's leanness (Greenlee, 1997).
Athletes who have disordered eating patterns and behavior's pose risk factors for the eating
disorders. Menstrual disorders causes are multiple and are not quite understood. These menstrual

THE FEMALE ATHLETE TRIAD SYNDROME

hormones are related to the metabolism, thus to metabolic and nutritional status. When the
energy availability is quite low over a given period, as indicated by the menstrual hormones, the
cycle is 'switched off'' temporarily to conserve energy.
Some of the clinical symptoms affecting those with triad may include fatigue, cold hands,
hair loss, disordered eating, and dry feet and hands visible weight loss, increased time of healing
especially from injuries, cessation of the menses and increased incidences of the bone fracture.
The affected females may develop depression and low self-esteem. Upon examination, a
physician may recommend the following symptoms: anemia, vaginal trophy, hyperestrogenism,
bradycardia, electrolyte irregularities and carotene in the blood (Hausenblas & Carron, 1999)..
An athlete can also show signs where he develops resistance to eating although does not meet a
criterion for the eating disorder. Other may display menstrual disturbances signs such as the
menstrual cycle period, luteal phase defects, and anovulation but does not depict complete
amenorrhoea. Likewise, athletes bone mineral density may reduce but not below her agematched range.
Prevention in athletes becomes difficult due to the nature of their game. Athletes tend to
resist increased body weight, using contraceptive pills (due to worries about weight gain, mood
changes, and breast tenderness) and decrease in training loads (Cogan, 1996). . Athletes find it
difficult admitting to eating disorders and menstrual problems. These points need to be kept in
mind especially when consulting the other athletes. The first step should be the agencies and
individuals made aware of the pertinent issues, long-term risks, and potential causes of the
female triad. Awareness should be created on the triad and its effects targeting groups such as
women athletes, medical staff, and parents.

THE FEMALE ATHLETE TRIAD SYNDROME

Screening should be conducted on all the athletes to counter any developments of a triad
at an early stage. This may pose a challenge since it requires in-depth knowledge from coach and
cooperation from the athlete. These screening courses may include assessments of the
electrolytes, bone density, regular physical exams, and echocardiograms. The final step should be
a creating a support system to help athletes in need. The female should be provided with
necessary resources to counter the triad, and they should be assigned a nutritionist and
psychotherapist to look after their development.
Treatment of the eating disorders should be carried out by professionals who are qualified
on outpatient and inpatient. This treatment plan should vary from one individual to the other on
the environmental and psychological basis. The goal of treating eating disorder is to increase the
nutrients of the women. This therapy will reverse the symptoms such as constipation, fatigue, dry
skin, lunago; menstrual disorders and bloating reduce the risk of osteopenia that are associated
with eating disorders. Many of the changes ultimately lead to increased muscle strength, reduced
injury risk and improving on training and consistent sports performance.
Non-pathological disturbances should be medically assessed, treatment should be based
on nutritional intake and training load. Athletes should decrease their intensity and duration
associated with training by 10% enabling them to reap maximum benefits from bone and weight
developments (McFadden, 1999). They ought to increase the intake of calories to boost their
energy.
Treatment of bone mineral deficiency should include estrogen replacement that can be
sought from the contraceptive pill, although some pills such as minipill should be always
avoided at all cost. It is advisable to keep in mind that the pills do not solve the problem at hand.
Monophasic pills should be used if menses is experienced and when placebo week is at least

THE FEMALE ATHLETE TRIAD SYNDROME

missed, however, this should be a short term solution. Many postmenopausal women have
benefited from hormone replacement program (McFadden, 1999). Hormone replacement
physiotherapy which is opposed to estrogens should not be used for long and must be avoided at
all cost.
Recommended treatment for the bone loss includes estrogen receptor modulators,
bisphosphonates, and intranasal calcitonin. The products are extensively used in older women
.Calcium intake ought to be the increase from 1500-2000 mg a day and should be taken with
vitamin D (Allison & Grace, 1991). Although calcium does not improve, bone density is
prevents other diseases. Finally, with the prescription of a psychiatrist, the athlete can be given
anti-depressants and in other situations benzodiazepines to aid in alleviating the severe distress
during mealtimes.
In conclusion, years ago, few people were conversant with the female athlete triad and
most people who were affected kept quiet. With the awareness created, and the treatment put in
place, we can reduce the number of casualties and those lost to the triad. The triad is a serious
disorder, but with these three steps including support team, awareness, and screening test, we can
alleviate this problem. An athlete who is at the risk of experiencing one of the disorders ought to
seek urgent medical checkup and further evaluation of the other conditions related to the triad.
These conditions pose a serious threat to the vulnerable groups and recognition, prevention and
treatment ought to be sought to ensure maximum benefits are reaped by women affected by the
triad. Prevention or early diagnosis of the triad certainly is better even than the cure. Efforts
should be taken to inform athletes, coaches, parents and officials on various aspects of it. This is

THE FEMALE ATHLETE TRIAD SYNDROME

10

quite important in ensuring that the sports in females pose a minimum impact on athletes
physiological and psychological status.

References
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Blum, D.E (1994).College sports L-word: Lesbians label damage careers of female athletes.
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Cogan, D.K (1996).Consultation with college student-athletes. College Student Journal, 30,9-16.
McFadden.(Ed.).(1999).Transcultural counseling(2nd ed).Alexandria, VA: American Counseling
Association.
Allison, M.T& Grace, K.R (1991).Role conflict and the female athlete: Preoccupations with little
grounding. Journal of Applied Sports Psychology, 3, 49-60.
Greenlee, C.T(1997).women athletes personal responses to sexual harassment in sport. Journal
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