The Female Athlete Triad Literature Review

Emily Wignall
Group Members: Emily Wignall & Andrea Baier
Lifespan & Community Nutrition
10/16/2015

Introduction
The recent trend of the past decades shows an increase in women who exercise and
who are involved in athletics (1). An increased amount of women involved in athletics means
that there is a greater population that is at risk for the negative health consequences of the
female athlete triad. Indicators of the triad are often overlooked and athletes return to
competition before they are healthy enough to properly train or compete. Promotion and
awareness alongside evaluation, management, and treatment are crucial steps in ensuring the
health and safety of the athletes (2). Health consequences, epidemiology, low energy
availability, menstrual dysfunction, low bone mineral density, screening and diagnosis, low
energy assessment, Nonpharmacological treatment, interventions, and recommendations will
be explored and reviewed based on the studies and research of the Female Athlete Triad
Coalition, Journal of Medicine & Science in Sports and Exercise, and the Rhode Island Medical
Journal.
Health Consequences
There are an extensive amount of negative health consequences associated with the
female athlete triad. Consequences can be physical and psychological. Medical complications
involve the cardiovascular, endocrine, reproductive, skeletal, gastrointestinal, renal, and central
nervous systems (2).
Epidemiology (Prevalence)
Studies comparing lean-sport athletes versus non lean sport athletes demonstrated a
prevalence of all three components of the female athlete triad in up to 6.7% of lean sport

athletes compared to 2.0% of non-lean sport athletes(1). One example of a lean sport athlete
would be a distance runner. Secondary amenorrhea varies depending of the sport, the age of
the individuals, the weight, of the individuals, as well as the intensity of their training. In studies
it has been seen to be as high as 69% in dancers and 65% in long distance runners. In the pool
of distance runners the prevalence of amenorrhea increased from 3% to 60% as training
mileage increases form less than 13 km/week to greater than 113 km/week(2). this was also
due to the increased weight loss and probable energy deficit with the increased mileage.
Female Athlete Triad Definition
The female athlete triad involves low energy availability, menstrual dysfunction, and low
bone mineral density (BMD). The American College of Sports Medicine first recognized the
female athlete triad in 1992 (1). Over time the definition has changed to apply to different
situations in which the symptoms may manifest themselves slightly differently beyond the
original classification which included only disordered eating, amenorrhea, and osteoporosis.
The disease is seen as a continuum that is based off of the levels and appearance of low energy
availability, menstrual dysfunction and BMD which can effect individuals to varying degrees.
Low energy availability
Low energy occurs when the body is not taking in, or does not have enough energy to
meet the metabolic demands that the body needs to properly function. Factors that contribute
to the availability of energy include: the amount of energy expended, baseline metabolic
function, and caloric intake (1). If there is a negative energy balance it can cause problems with

bone development, the maintenance of bones, and the proper development of bones. The low
energy availability influences the other two parts of the triad.
Even if female athletes are following a nutrition plan according to average
requirements, they may not be getting enough. The demands of training require a higher
amount of calories, if these are not met it can create a calorie deficit. Other factors or issues
can also contribute to this deficit of calories or availability of energy including: use of laxatives,
use of stimulants, and use of diuretics, purging, or putting extensive restrictions on dietary
intake. If the individual has a clinically defined eating disorder it is important to reach out for
more help and should not be attributed just to low energy levels because of working out.
Menstrual Dysfunction
There are different types of menstrual dysfunction that can occur including: primary
amenorrhea, secondary amenorrhea, or oligomenorrhea (1). Primary amenorrhea occurs when
there is a normal pattern of sexual development and growth at age 15 but the menses does not
occur. It can also be labeled as primary amenorrhea if the menses has not occurred within
three years after the development of the secondary sex characteristics (1). Secondary is the
absence for 3 cycles where as oligomenorrhea occurs when the cycles are more than 35 days
apart. If a female has a negative energy balance it can offset the balance of hypothalamic GnRH
causing disruptions or lack of menstrual cycles (2).
Low Bone Mineral Density (BMD)
Involvement in sports may actually alter the bone structure of female athletes.
Rigorous athletic activity alters the development and maintenance of bone health in

preferential anatomic locations (1). It is very important for female athletes to take steps to
maintain their bone health. If a female is healthy her supply of estrogen keeps the osteoclasts
from acting on the bones allowing them to continue developing normally and to maintain an
acceptable bone mineral density. BMD decreases as the number of missed menstrual cycles
increases, the loss of BMD may not be fully reversible (2). If women are not having regular
menstrual cycles, often due to a negative energy balance, it can affect their production of
estrogen which can result in negative effects to the body. Women with menstrual dysfunction
and low estrogen can lose up to 2% of bone mineral density annually (1). If an athlete has a
stress fracture it may be a sign that she may be experiencing low bone mineral density and can
be a prompt to check for the other signs of the female athlete triad. Stress fractures more
commonly occur in in women who are physically active that have a menstrual irregularity or a
low bone mineral density (2).
Screening and Diagnosis
Primary care often plays a crucial role in diagnosing the female athlete triad in
individuals. Most establishments require some type of physical or screening to be able to
participate in athletics. Examples of this can be found from the middle school to college level.
Individuals may view the problems caused by the female athlete triad as separate problems and
may not see the connections between the issues. It is important for parents, athletic trainers,
and physicians to be familiar with signs of the female athlete triad and the risk factors that may
cause it to occur.

Awareness should also be raised concerning the negative effects of the female athlete
triad. The lack of education may be harmful to female athlete performance and overall health.
To most accurately diagnose the conditions of the disorders associated with the female athlete
triad it is pertinent that a multidisciplinary health care team is implemented. Members of a
multidisciplinary team should include a physician, a sports dietitian, and possibly a mental
health professional (3). It may also be beneficial to have an exercise physiologist, a certified
athletic trainer, and medical consultants as part of the team.
The athlete also plays an important role in the screening, evaluation, and diagnosis. If
the athlete does not want to participate or if they do not honestly disclose information than it
will be more difficult for them to be properly assessed and diagnosed. As progress is made it
should be documented and disclosed with the athlete and their parents if the situation
requires. Coaches and administrators should also be involved so they can be an additional
resource and provide support to the athlete (3).
Low Energy Assessment
History is an important part of this assessment to determine if the individual has the
optimal amount of energy to be able to function properly. Signs of energy availability (EA)
include a BMI that is less than 17.5 or less than 85% of expected body weight in adolescents (3).
Low body weight is not the only indicator. An athlete could be of normal weight but still be
diagnosed with EA. More information would be required to make this diagnosis. This includes
taking note of their current and past dietary habits, and their highest and lowest weight. It also
includes discussing with the individual what they view as their ideal body weight. Individuals

may have a skewed perspective of what they think that their body should look like due to the
influence of the media and social factors. By addressing this issue it may help to be address
unhealthy choices that may be occurring. Individuals should be assessed for disordered eating
such as: restriction, purging, or the use of laxatives or stimulants (1). Education about the
negative effects to the body may help to prevent disordered eating in the future. The activity
level of individuals should also be evaluated. This includes the assessment of involvement in
athletics or exercise based on the intensity and length of time spent on the activity daily. To get
an accurate measure vital signs, weight, and BMI should also be recorded and assessed.
Laboratory evaluation can also reveal other problems through the assessment of
complete blood counts, a metabolic profile, thyroid function tests, and urinalysis(1). Not all
facilities are going to have access to the resources for all of these forms of extensive evaluation,
but it is important to be educated of the signs that are most common and easily identified so
the individual can be referred to a specialist if they begin to experience problems.
Nonpharmacological Treatment and Interventions/Recommendations
The main issue that must be addressed in treatment is the low energy availability
because it is part of the causation of the other two parts of the triad. To bring the energy status
back to a normal level changes should be made in diet and exercise. Bringing the body to, or
back to a healthy weight, is the most effective strategy for the return of menses and in turn
improved health of the bones (3). The amount of weight that should be gained for this to occur
differs depending on the individual. In past studies, a range of approximately 5% to 10% of total

body weight, equal to 1 to 4kg of weight has shown to be successful to help return a normal
menstrual cycle(3).
It is also important to create a personalized treatment plan. A treatment plan should
include the athletes; unique diet, training schedule for practices, with regards to what the
athlete wishes to accomplish as well as other conditions that may affect them. There should
also be a systematic approach for keeping track of progress and monitoring changes (3). A
systematic approach may involve contracts or putting goals in writing as well as frequent
scheduled meetings with the members of the treatment team (3). This approach would hold
the athlete accountable and have a provide a greater amount of resources and support through
the members of the team.
Depending on the severity, there are different treatment approaches that specifically
target the EA levels and bringing them back to a normal level (3). Nutritional education may be
an appropriate approach if the causation for the low EA is under eating or if there is weight loss
without the prevalence of disordered eating patterns. This nutritional education program could
be implemented by a dietitian, preferably a sports dietitian, or an exercise psychologist. If the
causation is disordered eating (DE) the individual should receive nutrition counseling preferably
with a sports dietitian and also meet with a physician. If the individual has been diagnosed with
a clinical eating disorder (ED) the treatment becomes more complex and should involve:
treatment, evaluation, and management. They should then work with a team including a
physician, a sports dietitian, and a mental health practioner(3). The role of the mental health
practioner is important in this type of situation because a nutrition education approach only
would not prove to be successful.

Conclusion
Overall it can be concluded with the combined information from the Female Athlete
Triad Coalition, Journal of Medicine & Science in Sports and Exercise, and the Rhode Island
Medical Journal that awareness and education are two of the keys to the decreasing the
occurrence of the female athlete triad. Even with the current efforts of education and
awareness there are still no set guidelines to determine when athletes experiencing symptoms
of the triad should be removed from training or cleared to go back to training (3). The triad
continues to be a significant health risk for female athletes. This problem can be addressed and
decreased through education programs to promote awareness, alongside the implementation
of multidisciplinary teams to assist individuals to optimize health and reduce risk for injury and
illness associated with the triad (3).

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