Female Athlete Triad

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In 1972, Title IX of the Education Amendment Act was passed, prohibiting sex discrimination in any higher education program or activity that received federal financial aid. Since then, female athletic participation in the U.S. increased by more than tenfold. What has also increased since then is awareness of the link between athletics, eating disorders (i.e. bulimia and anorexia), and amenorrhea (absence of menstruation, or periods).

In 1992, the American College of Sports Medicine coined the term “female athlete triad.” This term described the combination of disordered eating, amenorrhea, and osteoporosis (at that time all three factors needed to be present). In 2007, they broadened the definition so that the syndrome can be diagnosed if any of the following are present: low energy availability (with or without an eating disorder), menstrual dysfunction, or decreased bone mineral density. Recognizing that low energy availability can affect athletes of either sex and have consequences beyond the female reproductive system and skeleton, in 2014, the International Olympic Committee coined the term “relative energy deficiency in sport.” Like the female athlete triad, this condition occurs when energy (food) intake falls below energy output to the point that it negatively affects the athlete’s physical and mental health.

The female athlete triad can be seen in high school, college, and elite athletes, and is common in sports with subjective judging (gymnastics, figure skating) or sports that emphasize leanness (running). Studies have shown that the prevalence of just one of the three triad components occurs in up to 60 percent of exercising women, two of the components are found in up to 27 percent, and all three in up to 16 percent. Low energy availability can be intentional (due to eating disorders) or unintentional (due to activities). Prolonged low energy availability is associated with low self-esteem, depression, and anxiety. The presence of eating disorders in female athletes is common and is found in up to 30 percent of them as compared to nine percent of the general population. Studies have shown that disordered eating is found in about 46 percent of athletes in sports that emphasize leanness like gymnastics and track as opposed to 19 percent in sports that don’t, like basketball and soccer. Low calorie intake and high-energy output can affect female reproductive hormones, causing menstrual problems and can affect bone mineral density as well. Considering that bone mineral formation peaks by 18 years of age, losing bone mineral before that age can cause severe osteoporosis later in life.

Untreated female athlete triad can lead to fatigue, poor sports performance, and related conditions like osteoporosis and osteopenia, stress fractures, anemia, heart arrhythmias, and amenorrhea. Therefore screening for this syndrome is important. Screening can be done by health professionals and family members alike. Treatment is simple – eat more and exercise less until a healthy balance is restored. Daily caloric intake in athletes should be a minimum of 2000 calories. Some Olympic athletes may require as much as 12,000 calories a day to maintain weight and performance. Goals include a BMI of at least 18.5 in adults and a body weight of at least 90 percent of predicted in adults. Consultation with a dietician is often a good idea for athletes to ensure proper bone health and growth, and those with eating disorders should seek help from a mental health professional.

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