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The ‘Female Athlete Triad’ and Its Health Consequences

The female athlete triad is a syndrome that combines the following three components: a) low energy availability (with or without an eating disorder), b) menstrual dysfunction, and c) low bone mass. Although it is not common for all three components to be present in a young female, evidence suggests that the presence of at least one of the triad components ranges from 16 to 60% (1). Whilst it is commonly seen in elite athletes such as cyclists, runners, gymnasts and dancers, it is also prevalent in females who exercise for leisure (2).


Low energy availability refers to not consuming enough food and over-exercising which results in an overall caloric deficit. Individuals with disordered eating may even severely restrict their food intake, purge or use diet pills and laxatives to lose or maintain their weight. Long-term low energy availability can result in weight loss and nutrient and mineral deficiencies such as of protein, iron,calcium, zinc, selenium and chromium. Dehydration and electrolyte loss may also occur which can lead to pain and weakness, as well as arrhythmia and other heart problems. Menstrual dysfunction and the complete loss of the female period, known as amenorrhea, can lead in decreased levels of the hormone production (FSH, LH, oestrogen, and progesterone), which are responsible for the regulation of the menstrual cycle. Ultimately, this may result to infertility. As a result of low hormone production and nutrient deficiencies, female athletes can experience osteoporosis, a condition where bones become weaker. This can increase the incidence of fractures and injuries.

Diagnosis (signs and risk factors)

Risk factors for developing the female athlete triad include being pressured to look a certain way, competing or participating in a sport that emphasises the importance of looking good and over-training, even when they are injured.

Some signs that suggests an individual suffers from the triad include: constant preoccupation with food or weight loss, loss of menses, refusing to eat food in front of other people, going to the bathroom frequently during meals and long-term dieting and food restriction. Some other signs may get frequent injuries or take longer to recover, reluctance to resting or excessively exercising (3).


Treatment

- Increase calories and all macronutrients (protein, carbohydrates and fats) to restore lost period and normal weight or add a daily nutritional supplement (4). Evidence suggests that 2200 to 2500 calories are appropriate for a female athlete who exercises up to 20 hours per week (3).

- Gradually decrease physical activity to a normal level and monitor weight.

- Ensure nutrient-rich diet is followed. Supplementation with calcium (1500 mg per day) and vitamin D (400 to 800 IU per day) to improve bone mineral density (5).

- In some extreme cases, hormone replacement (progesterone and oestrogen) might be needed to help restore lost period (5).

- Individuals with eating disorders or depression should be referred to psychological counselling.



It is also fundamental for the family and coaches to be aware and educated to ensure the individual is supported and encouraged. Educating young females who participate on the role of nutrition on performance and health is also crucial to prevent this condition.


Having the dedicated support of a qualified nutrition professional can help you cater your diet to suit your needs as an active individual. Contact aaplusnutrition@gmail.com for more information on how A+Nutrition can help you.

This blog post was written by Alexandra Papasavva, a Biomedical Sciences graduate (BSc) and a Human Nutrition postgraduate (MSc), with a specialisation in Obesity and Weight Management from the University of Glasgow. You can find her Instagram at @alexliftss_.

References:

1. De Souza, M., Koltun, K., Etter, C. and Southmayd, E., 2017. Current Status of the Female Athlete Triad: Update and Future Directions. Current Osteoporosis Reports, 15(6), pp.577-587.

2. Raymond-Barker, P., Petroczi, A. and Quested, E., 2007. Assessment of nutritional knowledge in female athletes susceptible to the Female Athlete Triad syndrome. Journal of Occupational Medicine and Toxicology, 2(1), p.10.

3. Papanek, P., 2003. The Female Athlete Triad: An Emerging Role for Physical Therapy. Journal of Orthopaedic & Sports Physical Therapy, 33(10), pp.594-614.

4. Stickler, L., Hoogenboom, B. and Brown, J., 2019. The Impact of Nutritional Intervention on Menstrual Dysfunction in Female Athletes: a Systematic Review. SN Comprehensive Clinical Medicine, 1(9), pp.669-676.

5. Waldrop, J., 2005. Early identification and interventions for female athlete triad. Journal of Pediatric Health Care, 19(4), pp.213-220.

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