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Most commonly observed in young female athletes in sports emphasizing a lean physique such as gymnastics, long distance running, figure skating, swimming and diving - however, female athlete triad can be seen in all sports.  

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Since the late 1970’s, women and girl’s participation in sports has greatly expanded. The National High School Athletic Participation Survey states that in 2016, 3.4 million females participated in sports as compared to less than 300,000 in 1971. The initiation of Title IX in sporting activities has promoted the equalization of the number of female athletes in competitive sports, and has created a higher level of involvement of women at the high school and collegiate level.

Studies show, women who are active as girls often have greater self-confidence and self-esteem. The American College of Sports Medicine (ACSM) encourages all girls and women to participate in physical and sport activities. The benefits of physical activity in females include improved cardiovascular fitness, increased strength and power, decreased morbidity and mortality, decreased high-risk behavior, decreased risk of breast cancer, improved cognitive function, higher bone strength and healthy aging.

Although, the benefits of physical activity far outweigh the risks for women and girls, there has been an increased awareness of new conditions unique to this population. In 1992, physicians and researchers coined a new term “The Female Athlete Triad.”

One example is Meagan’s case. “Meagan” is 16 and a competitive long distance runner. She trains approximately six to eight hours per week. One day during training, she experiences knee pain that becomes persistent and interferes with her ability to continue running or participate in her high school P.E. class. Despite physical therapy and modification of her running routine, there is no significant improvement and she is advised to stop running for six weeks. Her physician recommends pool therapy and cycling as an alternative way to train. Meagan begins to change her diet as she feels her training has been reduced and she doesn’t want to gain weight or “lose her edge”. After three weeks, she eliminates most carbs and dairy products and mainly eating salads, veggies and protein shakes. She weighs herself and notices that she has lost 7 pounds. In addition, she has missed two menstrual cycles in three months and is now experiencing fatigue, decreased endurance and a new onset of shin pain that wakes her at night.

The female athlete triad was initially recognized as three separate but related conditions of disordered eating, menstrual dysfunction and decreased bone mineral density or osteoporosis in female athletes. These conditions may occur alone or in combination. It is most commonly observed in young female athletes in sports emphasizing a lean physique such as gymnastics, long distance running, figure skating, swimming and diving - but the female athlete triad can be seen in all sports. Recent studies (Nichols et al, Archives of Pediatric Adolesc Med. 2006) have found that even high school-aged female athletes are at risk for one or more of the components of the triad. The triad can begin with disordered eating patterns which can then progress to menstrual disorders, and finally to decreased bone density and osteoporosis.

The first factor of the triad is typically initiated when an athlete’s dietary intake is intentionally or inadvertently restricted or their energy expenditure is very high and the caloric intake does not match the energy expenditure. Some athletes desire to lose weight by dieting. To some extent, all athletes are concerned with diet and body image, but in susceptible individuals, this can be concerning. An athlete’s view of herself, combined with sport-specific stereotypes can often lead to a distorted body image. Disordered eating patterns cover a wide spectrum, from simple food limitations to eating disorders of anorexia and bulimia nervosa. Low energy availability may also be due to insufficient education regarding healthy eating requirements and physical activity. All can have significant implications for an athlete’s health.

Low energy availability and disordered eating may result in alterations in several hormones which lead to the second component of the triad - menstrual dysfunction. Menstrual irregularity occurs with the absence of menstrual cycles for greater than 90 days or in which cycles are greater than 36 days apart (less than eight cycles per year). Exercise in itself does not directly cause the absence of the menstrual cycle, but it may contribute with inadequate dietary and nutritional intake.

The third factor of the triad is low bone mineral density and possibly premature osteoporosis. Low bone density is related to the inadequate absorption of dietary calcium and menstrual irregularities. Bone mass declines as the number of missed menstrual cycles accumulate.

The triad can pose potential negative health risks including cardiovascular problems, increased risk of future osteoporosis and fractures, reproductive dysfunction, low self-esteem, disordered eating/eating disorders and nutritional deficiencies, depression, anxiety, GI disorders and an increased risk of heat-related injuries. Stress fractures occur more commonly in physically active women with menstrual irregularities. Athletes also note impaired performance including excessive fatigue, increased recovery time (slow to heal) and decreased training responses. Additionally, a study in the Journal of Orthopedic and Sports Physical Therapy (February 2011) has found high school female athletes with disordered eating were over two times more likely to sustain a sports-related injury during a sports season. Sports-related injuries included stress fractures, thoracic spine fractures, patellofemoral syndrome, and other ligamentous knee injuries.

Treatment of an athlete with any of the triad disorders should be multi-disciplinary and includes your physician, dietician, mental health professional, athletic trainer, physical therapist, coach and parents. Prevention is by far the best method of treatment. Screening and intervention programs designed to identify and decrease the prevalence of disordered eating should be implemented in high school females. This can be accomplished through education and annual pre-participation physicals offer an excellent opportunity to screen for the disorder. Athletes, coaches, and parents may all benefit from education in optimizing energy availability and the connections between energy balance and health.

This week’s community health column is brought to you by Marcus Daly Memorial Hospital. For questions and or comments, please contact Desiree Dutton, MS PT at the Marcus Daly Rehabilitation Department at 1200 Westwood Drive, Hamilton MT, 59840 or call 406-375-4570. Working together to build a healthier community!