Mend Physical Therapy Blog and Injury Information

What Is The Female Athlete Triad?

December 14, 2020


By Berrin Boyce

Overall, the benefits of exercise, including high-intensity exercise are well researched and widely known. However, risks of excessive exercise are important to be aware of as they can contribute to negative health consequences.  A condition known as the female athlete triad can occur when an imbalance in energy expenditure is present over time, leading to menstrual dysfunction, and osteoporosis in female athletes of reproductive age. Disordered eating, meaning irregular or insufficient eating (not just specific eating disorders) is the third component of the triad. It is important to understand the signs and symptoms of the triad to better identify it in oneself, family members, or friends as to avoid the negative short and long health implications.

The prevalence of the triad is unknown, but it is more common amongst athletes who participate in sports that place an emphasis on aesthetics, body shape, and subjective scoring such as gymnastics and diving. (Irion et al 2010). Taxing training schedules or increased training volumes can result in unintentional energy expenditure imbalances, leading to the triad. 

Menstrual dysfunction can occur along a spectrum with obvious amenorrhea (absence of a period) to less obvious luteal phase deficiency or estrogenic anovulation. Luteal phase deficiency can be present with shortened luteal phase (time between ovulation and menstruation) and appear fairly asymptomatic, whereas estrogenic anovulation results in the absence of ovulation, appearing as a very long or very short time between menstruation. Low energy availability (decreased caloric intake compared to energy expenditure) appears to contribute to the development of athletic amenorrhea (Williams et al. 2001). Menstrual health is a good overall health indicator, so if one’s period is irregular or absent it is recommended to tell your healthcare provider. 

Many studies have identified the link between menstrual dysfunction and decreased bone mineral density (Keen et al 1997). Bone loss in young athletes is especially concerning as peak bone mass should be acquired by around age 18 years old. Sufficient bone mass maintained prior to menopause helps prevent osteoporosis later in life. Decreased estrogen in women with athletic amenorrhea leads to more bone turnover and less bone mass, increasing risk of fracture and injuries. The presence of stress fractures can be an important indicator to screen for energy expenditure imbalance in female athletes. 

Treatment for the triad is best when approached from a multidisciplinary team involving a physician, dietitian, psychologist, coaches, and the athlete to identify an accurate diagnosis. It is important to remember that simply being an athlete does not mean any medical issues are due to the triad. Pelvic floor physical therapists should know how to screen for menstrual dysfunction, be aware of increased risk for injury/fracture, and know who to refer to. Estrogen deficiencies can also contribute to stress urinary incontinence or painful intercourse so subjectively screening for possible hormonal dysfunction can help with differential diagnosis.

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