This blog considers the literature on the ‘Female Athlete Triad’, and describes how you would investigate, diagnose and manage this condition in an athlete.
The Female Athlete Triad
The female athlete triad (FAT) refers to a collective of 3 clinical entities: menstrual dysfunction, low energy availability (with or without an eating disorder), and decreased bone mineral density (Nazem & Ackerman, 2012). Female athletes often present with one or more of the three triad components (De Souza et al., 2014) and an early intervention is essential to prevent its progression to serious end-points that include clinical eating disorders (EDs), amenorrhoea and osteoporosis (Nattiv et al., 2007).
The prevalence of menstrual irregularities, disordered eating, and low bone mineral density (BMD) varies widely in both the general population and in the athletic community (Nazem & Ackerman, 2012). In women who participate in sports that emphasize aesthetics or leanness, such as ballet or running, the prevalence of secondary amenorrhea can be as high as 69%, compared with 2% to 5% in the general population (Pettersson, Fries, & Nillius, 1973; Singh, 1981).
As understanding of the triad had developed, the American College of Sports Medicine revised its position statement in 2007, showing the entities originally described in 1992 (disordered eating, amenorrehoea and osteoporosis) to be too narrow in scope, existing at only the end point of the disorders spectrum (Javed et al., 2013). The revised position statement modified the components into energy availability, menstrual function and bone mineral density. Figure 1 demonstrates the spectra of the female athlete triad, by which De Souza et al. (2014) highlight the inter-related nature of the triad. Energy deficiency associated with eating disorders have a causal role in the development of menstrual disturbances, and an energy deficiency and a hypoestrogenic environment associated with amenorrhoea play a causal role in low BMD.
(De Souza et al., 2014)
Each component consists of a continuum from optimal health to subclinical and through to pathological. An athlete’s condition can fall anywhere along the spectrum of optimal energy availability to an eating disorder; menstrual regularity to subclinical menstrual disorders, orthorexia, or athletic amenorrhea; and low bone mineral density (BMD) to frank osteoporosis (Javed et al., 2013).
The spectrum of energy expenditure (seen in Figure 1) can be defined as the energy used by the body during normal daily activities and exercise. Energy availability defines the amount of energy remaining for physiological processes after expended from physical activity (George et al., 2011). Javed et al., (2013) explains that energy availability is best conceptualized as energy remaining from the energy intake after exercise energy expenditure (EEE) has occurred. Therefore, energy availability should ideally match, if not slightly exceed, resting energy expenditure (REE) in order to allow physiologic processes of the body to continue. A decrease in calorific intake combined with an increase in exercise related energy expenditure will result in low energy levels for physiological functions such as cellular maintenance, thermoregulation, growth and repair.
Menstrual dysfunction in the female athlete includes a wide spectrum of disorders (summarized in table 1). The most commonly discussed menstrual abnormality is amenorrhea, which is generally defined as the absence of menses 3 months or more, but can be subcategorized into primary and secondary types (Nazem & Ackerman, 2012). From delaying the onset of menarche to causing subclinical menstrual disorders, oligomenorrhea (infrequent or light menses), and amenorrhea (absence of menses), exercise can impact menstrual function in several ways (Javed et al., 2013).
(Nazem & Ackerman, 2012)
In young female athletes with the triad, a compromise in bone strength, ranging from low BMD and stress fractures. Osteoporosis is defined as a bone mineral density more than
Athlete having bone scan 2.5 standard deviations below the average for young adults and is associated with a reduction in bone mass with no alteration in the mineralisation of bone tissue. Bone tissue responds well to mechanical stress, and thus exercise, alongside nutrition, is essential in the teenage years to attain peak bone mass. Women with low energy availability and low oestrogen concentrations, however, have increased risk of becoming osteoporotic.
Investigation and Diagnosis
Nazem & Ackerman (2012) claim the greatest challenge in treating young female athletes with the FAT may be making the initial diagnosis of the condition. The accurate diagnosis of any of the triad disorders is dependent on a thorough evaluation of the athlete by the doctor and other members of an experienced multidisciplinary healthcare team (De Souza et al., 2014). Table 2 indicates 11 key risk factors to be screened for to assist in the FAT diagnosis.
(Adapted from De Souza et al., 2014)
In athletes with low EA, disordered eating, or amenorrhoea of over 6 months, BMD should be measured by DXA (Mountjoy et al., 2014). Athletes in weight-bearing sports should have 5–15% higher BMD than non-athletes. The definition of low BMD and osteoporosis can be found in figure 2.
(De Souza et al., 2014)
It is a well-established concept that prevention is better than treatment in relation to injury and disease. Birch (2005) argues that prevention of the FAT in athletes is made difficult by the nature condition. Athletes will resist increasing body weight, decreasing training loads, and using the contraceptive pill (because of worries about weight gain, breast tenderness, and mood changes). Athletes will also find it difficult to admit to menstrual problems and disordered eating or eating disorders. These points should be considered in the athlete management of this condition.
There is still much debate on the best method of treatment for young female athletes with the triad, however it appears universally accepted (Birch, 2005; De Souza et al., 2014; George et al., 2011; Javed et al., 2013) that treatment should focus on the points included in Figure 3.
(De Souza et al., 2014, p.7)
The first step in attaining these goals is modification of the diet and exercise regimens to increase overall energy availability (ie, reduce energy expenditure and maximize energy intake) (Nazem & Ackerman, 2012). The increase in nutritional status of the athlete aims to reverse the symptoms associated with disordered eating (eg. bloating, constipation, fatigue, lanugo, and dry skin), reverse menstrual disorders, and help reduce the risk of osteoporosis. Athletes may need to increase energy availability to at least 30 kcal/ kg of lean body mass per day to resume menses (Nazem & Ackerman, 2012), however this may need to be increased to over 45 kcal/kg lean body mass per day to increase bone mineral density (George et al., 2011).
Once menstrual disturbances have been established as non-pathological, treatment is based on training load and nutritional intake. Birch (2005) recommends an initial decrease training load of 10%, with graduated increase in energy intake. These changes will ultimately increase muscle strength, decrease the risk of injury, and thus increase training and sports performance. Some athletes may additionally benefit from pharmacological therapy (George et al., 2011). Athletes with low EA secondary to eating disorders may benefit from antidepressants. Those with low BMD may benefit from drugs aimed at increasing bone density.
De Souza et al., (2014) explain the recovery rates of different components of the triad with the appropriate treatment. Recovery of energy status is typically observed after days or weeks of increased energy intake and/or decreased energy expenditure. Recovery of menstrual status is typically observed after months of increased energy intake and/or decreased energy expenditure, which improves energy status. Recovery of bone mineral density may not be observed until years after recovery of energy status and menstrual status has been achieved.
Essential to the process of screening, evaluation, diagnosis and treatment is the athlete’s honesty and willingness to actively participate in each of these steps (De Souza et al., 2014; George et al., 2011). Members of the multidisciplinary team must develop a combined therapeutic alliance with the athlete, encouraging engagement and active participation in treatment that is often ongoing, due to the challenging nature of the restoration of adequate EA.
Advancement of research and continues to improve our understanding of aetiology, prevalence, pathophysiology, early diagnosis and management the female athlete triad. However, the FAT remains a complex and multifactorial condition that provides challenges for the treating practitioner. This report describes the important factors for consideration for the management of the FAT with the aim of restoring optimal health and athletic performance.
Birch, K. (2005). Female athlete triad Why are the three corners of the. BMJ, 330(January), 244–246.
De Souza, M. J., Nattiv, A., Joy, E., Misra, M., Williams, N. I., Mallinson, R. J., … Matheson, G. (2014). 2014 Female Athlete Triad Coalition Consensus Statement on Treatment and Return to Play of the Female Athlete Triad: 1st International Conference held in San Francisco, California, May 2012 and 2nd International Conference held in Indianapolis, Indiana, M. British Journal of Sports Medicine, 48(4), 289. doi:10.1136/bjsports-2013-093218
George, C., Leonard, J., & Hutchinson, M. (2011). The female athlete triad: a current concepts review. South African Journal of Sports …, 23(2). Retrieved from http://www.ajol.info/index.php/sasma/article/view/70190
Javed, A., Tebben, P. J., Fischer, P. R., & Lteif, A. N. (2013). Female athlete triad and its components: toward improved screening and management. Mayo Clinic Proceedings, 88(9), 996–1009. doi:10.1016/j.mayocp.2013.07.001
Mountjoy, M., Sundgot-Borgen, J., Burke, L., Carter, S., Constantini, N., Lebrun, C., … Ljungqvist, A. (2014). The IOC consensus statement: beyond the Female Athlete Triad--Relative Energy Deficiency in Sport (RED-S). British Journal of Sports Medicine, 48(7), 491–7. doi:10.1136/bjsports-2014-093502
Nattiv, A., Loucks, A. B., Manore, M. M., Sanborn, C. F., Sundgot-Borgen, J., & Warren, M. P. (2007). American College of Sports Medicine position stand. The female athlete triad. Medicine and Science in Sports and Exercise, 39(10), 1867–82. doi:10.1249/mss.0b013e318149f111
Nazem, T. G., & Ackerman, K. E. (2012). The female athlete triad. Sports Health, 4(4), 302–11. doi:10.1177/1941738112439685
Pettersson, F., Fries, H., & Nillius, S. J. (1973). Epidemiology of secondary amenorrhea. I. Incidence and prevalence rates. American Journal of Obstetrics and Gynecology, 117(1), 80–6. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/4722382
Singh, K. B. (1981). Menstrual disorders in college students. American Journal of Obstetrics and Gynecology, 140(3), 299–302. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/7246632