By Dena McDowell, MS, RD

Since the passage of Title IX (a federal law stipulating that schools receiving federal funding must provide equal opportunities for men and women involved in sports) the number of female athletes participating at the high school, collegiate and elite levels has increased nearly tenfold. When then the bill was passed in 1972, there were 294,000 high school female athletes in the United States. In 1997, there were 2.6 million high school female athletes. This is an 800% increase in a 25 year period.

What is the female athlete triad?

As the number of women of all age levels who participate in sports grows, there is also an increasing prevalence of exercise-induced medical conditions that are specific to the female athlete. The three most common female athlete medical problems include menstrual irregularities, disordered patterns of eating and decreased bone mineral density (which may lead to stress fractures). These three problems are known as the “female athlete triad.” The female athlete triad was defined by the American College of Sports Medicine (ACSM) in 1992 due to the increasing awareness of these problems in the female athlete population.

• #1: Disordered eating patterns.  The first of these interrelated problems is disordered patterns of eating in an attempt to lose weight or achieve a lean appearance. Researchers have shown that athletes who participate in sports—such as dance, figure skating, gymnastics, distance running, cycling, cross country skiing, volleyball, swimming, and cheerleading—may be most at-risk due to the subjective scoring, emphasis on low body weight and activities that require tight fitting clothing. The spectrum of disordered eating behaviors range in severity from restricting food intake to binging and purging to anorexia nervosa and bulimia nervosa as defined by the Diagnostic and Statistical Manual of Mental Disorders, 4 th edition.

• #2: Lack of a menstrual period.  The second component of the female athlete triad is the lack of one’s menstrual period. Amenorrhea is classified as the loss of the menstrual period for more than six months and may be primary or secondary in presentation. Primary amenorrhea is the absence of the menstrual cycle by the time a female has reached 16 years of age. Secondary amenorrhea is the cessation of the menstrual cycle due to excessive exercise, inadequate calorie intake or hormonal imbalance. A female athlete can have either form of amenorrhea.

• #3: Osteoporosis.  The last part of the female athlete triad is osteoporosis, which is characterized by low bone mineral density leading to enhanced skeletal fragility and increased risk of fractures. Although the exact mechanism of how female hormones affect bone mineral density is not known, researchers speculate that low estrogen levels decrease sensitivity of bone to parathyroid hormone. Parathyroid hormone (a regulator of calcium and phosphorus metabolism) stimulates the bone reabsorption process. When estrogen is low or absent, the bone appears to become more sensitive to the parathyroid hormone, thus shifting the remodeling process toward reabsorption, which consequently causes weakening of the bones.

Developing any component of the female athlete triad can be devastating to an athlete’s career due to decreased training capacity because of the lack of energy reserves which may lead to overuse injuries. With increased participation of women in sports activities, there has been a correlated increase in sports injuries and overuse syndromes in women. According the researchers there are known anatomical and physiological considerations that may give female athletes several unique injury risks and conditions as compared to their male counterparts. Such risks include an increased risk of low bone mineral density and stress fractures. It is not known whether the loss in bone mineral density at a young age will lead to premature fracture, but the incidence of stress fractures in amenorrheic athletes is increasing.

Treatment is available for female athlete triad medical problems

Currently the female athlete triad is being extensively studied in girls from high school through elite athletes. It is recommended that coaches and parents be aware of these interrelated problems and help the athlete to seek medical advice to prevent long term consequences of the disorder. With the help of a multidisciplinary medical team this disorder can be reversed. This involves close follow-up to make sure that proper meal planning and calorie intake is achieved as well as laboratory analysis, and bone scans to check hormone levels and bone mineral density.

Exercise benefits outweigh the risks of female athlete triad

When it comes to exercising, keep in mind that research shows that for women the benefits of an active lifestyle may include any of the following: higher self esteem, a reduction in depression, and a better body image. It has been well documented that exercise in adults (both male and females) has many benefits, including a lower risk of heart disease, reduced fat stores and better total cholesterol levels, better physical endurance and cardiovascular fitness, greater muscle mass and strength, greater flexibility, improved coordination, better memory and better quality of sleep.