Female Athlete Triad Syndrome

Female Athlete Triad is a syndrome in which eating disorders (or low energy availability), amenorrhoea/oligomenorrhoea and decreased bone mineral density (osteoporosis and osteopenia) are present. Also known simply as the Triad, this condition is seen in females participating in sports that emphasize leanness or low body weight. The Triad is a serious illness with lifelong health consequences and can potentially be fatal.

Background
The female athlete triad is a syndrome of three interrelated conditions that exist on a continuum of severity. Thus, if an athlete is suffering from one element of the Triad, it is likely that they are suffering from the other two components of the triad as well. With the increase in female participation in sports, much of it attributable to Title IX legislation in the United States, the incidence of a triad of disorders particular to women — the female athlete triad—has also increased. Due to this increasing prevalence, the female athlete triad and its relationship with athletics was identified in the 1980s as the symptoms, risk factors, causes and treatments were studied in depth and their relatedness evaluated. The condition is most common in cross country running, gymnastics, and figure skating. Many of those who suffer from the triad are involved in some sort of athletics, in order to promote weight loss and leanness. The competitive sports that promote this physical leanness may result in disordered eating, and be responsible for the origin of the Female Athlete Triad. For some women, not balancing the needs of their bodies and their sports can have major consequences. In addition, for some competitive female athletes, problems such as low self-esteem, a tendency toward perfectionism, and family stress place them at risk for disordered eating.

Low energy availability/disordered eating
Energy availability is defined as energy intake minus energy expended. Energy is taken in through food consumption. Our bodies expend energy through normal functioning as well as through exercise. In the case of female athlete triad, low energy availability may be due to eating disorders, but not necessarily so. Athletes may experience low energy availability by exercising more without a concomitant change in eating habits, or they may increase their energy expenditure while also eating less. Disordered eating is defined among this situation due to the low caloric intake or low energy availability. The disordered eating that accompanies female athlete triad can range from avoiding certain types of food the athlete thinks are "bad" (such as foods containing fat) to serious eating disorders like anorexia nervosa or bulimia nervosa.

While most athletes do not meet the criteria to be diagnosed with an eating disorder such as anorexia nervosa or bulimia nervosa, many will exhibit disordered eating habits. Some examples of disordered eating habits are fasting; binge-eating; purging; and the use of diet-pills, laxatives, diuretics, and enemas. By restricting their diets, athletes worsen the problem of low energy availability.

Having low dietary energy from excessive exercise and/or dietary restrictions leaves too little energy for the body to carry out normal functions such as maintaining a regular menstrual cycle or healthy bone density.

Amenorrhea
Amenorrhea, defined as the cessation of a woman’s menstrual cycle for more than three months, is the second disorder in the Triad. Weight fluctuations from dietary restrictions and/or excessive exercise affect the hypothalamus’s output of gonadotropic hormones. Gonadotropic hormones “stimulate growth of the gonads and the secretion of sex hormones.” (e.g. gonadotropin-releasing hormone, lutenizing hormone and follicle stimulating hormone.)  These gonadotropic hormones play a role in stimulating estrogen release from the ovaries. Without estrogen release, the menstrual cycle is disrupted. Exercising intensely and not eating enough calories can lead to decreases in estrogen, the hormone that helps to regulate the menstrual cycle. As a result, a female's periods may become irregular or stop altogether.

There are two types of amenorrhea. A woman who has been having her period and then stops menstruating for ninety days or more is said to have secondary amenorrhea. Primary amenorrhea is characterized by delayed menarche. Menarche is the onset of a girl’s first period. Delayed menarche may be associated with delay of the development of secondary sexual characteristics.

Osteoporosis
Osteoporosis is defined by the National Institutes of Health as ‘‘a skeletal disorder characterized by compromised bone strength predisposing a person to an increased risk of fracture.’’ Low estrogen levels and poor nutrition, especially low calcium intake, can lead to osteoporosis, the third aspect of the triad. This condition can ruin a female athlete's career because it may lead to stress fractures and other injuries.

Immediate Effects on Low Bone Density. Patients with female athlete triad get osteoporosis due to hypoestrogenmia, or low estrogen levels. With estrogen deficiency, the osteoclasts live longer and are therefore able to resorb more bone. In response to the increased bone resorption, there is increased bone formation and a high-turnover state develops which leads to bone loss and perforation of the trabecular plates. As osteoclasts break down bone, patients see a loss of bone mineral density. Low bone mineral density renders bones more brittle and hence susceptible to fracture. Because athletes are active and their bones must endure mechanical stress, the likelihood of experiencing bone fracture is particularly high.

Additionally, because those suffering with female athlete triad are also restricting their diet, they may also not be consuming sufficient amounts vitamins and minerals which contribute to bone density; not getting enough calcium or vitamin D further exacerbates the problem of weak bones.

Long Term Effects of Low Bone Density. Bone mass is now thought to peak between the ages of 18-25. Thus, behaviors which result in low bone density in youth could be detrimental to an athlete’s bone health throughout her lifetime.

Risk factors
Gymnastics, figure skating, ballet, diving, swimming, and long distance running are examples of sports which emphasize low body weight. The Triad is seen more often in aesthetic sports such as these versus ball game sports. Women taking part in these sports may be at an increased risk for developing female athlete triad.

Athletes at greatest risk for low energy availability are those who restrict dietary energy intake, who exercise for prolonged periods, who are vegetarian, and who limit the types of food they will eat. Many factors appear to contribute to disordered eating behaviors and clinical eating disorders. Dieting is a common entry point and interest has focused on the contribution of environmental and social factors, psychological predisposition, low self-esteem, family dysfunction, abuse, biological factors, and genetics. Additional factors for athletes include early start of sport-specific training and dieting, injury, and a sudden increase in training volume. Surveys show more negative eating attitude scores in athletic disciplines favoring leanness. Disordered eating behaviors are risk factors for eating disorders.

Health consequences
Sustained low energy availability, with or without disordered eating, can impair health. Psychological problems associated with eating disorders include low self-esteem, depression, and anxiety disorders. Medical complications involve the cardiovascular, endocrine, reproductive, skeletal, gastrointestinal, renal, and central nervous systems. The prognosis for anorexia nervosa is grave with a sixfold increase in standard mortality rates compared to the general population. In one study, 5.4% of athletes with eating disorders reported suicide attempts. Although 83% of anorexia nervosa patients partially recover, the rate of sustained recovery of weight, menstrual function and eating behavior is only 33%.

Amenorrheic women can be infertile, due to the absence of ovarian follicular development, ovulation, and luteal function. Consequences of hypoestrogenism seen in amenorrheic athletes include impaired endothelium-dependent arterial vasodilation, which reduces the perfusion of working muscle, impaired skeletal muscle oxidative metabolism, elevated low-density lipoprotein cholesterol levels, and vaginal dryness.

Due to low bone mineral density that declines as the number of missed menstrual cycles accumulates, and the loss of BMD may not be fully reversible. Stress fractures occur more commonly in physically active women with menstrual irregularities and/or low BMD with a relative risk for stress fracture two to four times greater in amenorrheic than eumenorrheic athletes. Fractures also occur in the setting of nutritional deficits and low BMD.

Symptoms of the Triad
Clinical symptoms of the Triad may include disordered eating, fatigue, hair loss, cold hands and feet, dry skin, noticeable weight loss, increased healing time from injuries, increased incidence of bone fracture and cessation of menses. Affected females may also struggle with low self-esteem and depression.

Upon physical examination, a physician may also note the following symptoms: elevated carotene in the blood, anemia, orthostatic hypotension, electrolyte irregularities, hypoestrogenism, vaginal atrophy, and bradycardia.

An athlete may show signs of restrictive eating, but not meet the clinical criteria for an eating disorder. She may also display subtle menstrual disturbances, such as a change in menstrual cycle length, anovulation, or luteal phase defects, but not yet have developed complete amenorrhea. Likewise, an athlete's bone density may decrease, but may not yet have dropped below her age-matched normal range.

Treatment
The American Academy of Pediatrics and the AAFP contend that exercise is important and should be promoted in girls for health and enjoyment, however pediatricians should be wary of health problems that may occur in female athlete. The health related issues concerning this topic are grave and can lead to numerous health issues as previously demonstrated. The treatment plan will depend on the severity of the disorder, however some form of treatment has been show as helpful to produce successful progress towards a better health condition. Clearly, many health problems arise due to disordered eating.

The treatment team should consist of a physician, nutritionist, and mental health provider. Additional team members may include an athletic trainer and strength and conditioning coach. Coaches are discouraged from active participation in the treatment of eating disorders. In addition to conflicts of interest, coaches may be perceived to pressure athletes and potentially perpetuate components of the Female Athlete Triad. For example, in maintaining a place on the team or continued scholarship support, a female athlete may feel compelled to overtrain or restrict eating. Continued participation in training and competition depends on the physical and mental health of the athlete. Athletes who weigh less than 80 percent of their ideal body weight may not be able to safely participate.

Low energy availability with or without eating disorders, functional hypothalamic amenorrhea, and osteoporosis, alone or in combination, pose significant health risks to physically active girls and women. Prevention, recognition, and treatment of these clinical conditions should be a priority of those who work with female athletes to ensure that they maximize the benefits of regular exercise.

Multidisciplinary Approach. Athletes diagnosed with female athlete triad should be treated using a multidisciplinary approach. Patients are recommended to work with a dietician who can monitor their nutritional status and help the patient work towards a healthy goal weight. Patients should also meet with a psychiatrist or psychologist to address the psychological aspects of the Triad. Finally, it is generally recommended that athletes reduce the amount of time they spend exercising by 10-12 percent. Therefore, it is important that trainers and coaches are made aware of the athlete’s condition and be part of her recovery.

Pharmacologic Treatment. Patients are also sometimes treated pharmacologically. To both induce menses and improve bone density, doctors may prescribe cyclic estrogen or progesterone as is used to treat post-menopausal women. Patients may also be put on oral contraceptives to stimulate regular periods. In addition to hormone therapy, nutrition supplements may be recommended. Doctors may prescribe calcium supplements. Vitamin D supplements may be also used because this vitamin aids in calcium absorption. Bisphosphonates and calcitonin, used to treat adults with osteoporosis, may be prescribed, although their effectiveness in adolescents has not yet been established. Finally, if indicated by a psychiatric examination, the affected athlete may be prescribed anti-depressants and in some cases benzodiazepines to help in alleviating severe distress at mealtimes.