The Female Athlete Triad
Note: In the past 5 years the International Olympic Committee (IOC) published a consensus statement that introduced the term “Relative Energy Deficiency in Sport” (RED-S) to describe what is currently called the Female Athlete Triad. The IOC authors intended for RED-S to be a more comprehensive, broader definition, which includes the Female Athlete Triad. Since then, the two terms have come under scrutiny and reassessment (Hu&Matzkin, 2015).
For the purpose of this post, I will be referring to the phenomenon as the Female Athlete Triad.
The Female Athlete Triad is a very real occurrence for young girls and women who are engaged in high demand, competitive physical activity. The existence of the Female Athlete Triad is dangerous for the individual in both an immediate and long term sense. This blog post is meant to be informative, but is not meant to stand in the way of the care of a medical doctor, or other qualified professional. All information contained in this post has been cited for further exploration and follow up.
Professional runner- Tara Welling- whom this post was inspired by, has generously offered to answer any questions that anyone may have pertaining to her podcast episode and the information that she shared. Tara suffered from side effects of the Female Athlete Triad as a young athlete, and while she still grapples with bone health complications- is healthy and thriving as a professional runner today.
Tara contact: firstname.lastname@example.org
A bit of history: In 1992 the Task Force on Women’s Issues of the American College of Sports Medicine (ACSM) was assembled. The term Female Athlete Triad was created to describe the interrelated pathologies of disordered eating, amenorrhea, and musculoskeletal injuries among female athletes. All three components had to be present simultaneously for a diagnosis of Female Athlete Triad. As a result, many female athletes with only one or two of the triad’s components were being overlooked. In 2007, the ACSM updated the diagnostic guidelines, and the Female Athlete Triad was defined as a spectrum of abnormalities in energy availability (EA), menstrual function, and bone mineral density (BMD). Each of the three components are part of a spectrum ranging from normal to increasing degrees of pathology (De Souza et al., 2014).
-Only white, distance runners primarily suffer from the Female Athlete Triad.
- Men cannot suffer from a similar phenomenon- (although male identified men with male sex organs cannot have the female athlete triad, they can experience disordered eating and low energy/burn out that results in undesirable health consequences).
The female athlete triad is a "spectrum of interrelated pathophysiologic consequences of low energy availability, menstrual dysfunction, and low bone mineral density. Components of the triad are not only counterproductive to athletic performance goals, but can lead to serious long-term negative health outcomes" (Horn et al., 2014).
Broken down, the Female Athlete Triad can be viewed as the relationship between:
- Disordered Eating: Does not have to be a full blow eating disorder- is often simply a female not consuming enough calories to meet the demands of her physical exertion. Example: A common misunderstanding by female athletes is that they should be following the same caloric guidelines as the general population. To most, this means no more than 2,500 cal a day. The reality is that a female athlete may need to be consuming somewhere between 3,200 calories or more a day just to "break even" - depending on her training.
-Menstrual Disturbances: It has become common for female athletes (particularly distance/endurance athletes) to assume that the loss or the irregularity of their period is normal. Not having a period is never "ok".
It is important to break down the various forms of menstrual disturbances, as they are all red flags when present in any woman:
Menstrual dysfunction may present as primary amenorrhea, secondary amenorrhea, or oligomenorrhea. *Primary amenorrhea: the absence of menses at age 15 in the presence of normal growth and secondary sexual characteristics or the absence of menses three years after development of secondary sexual characteristics.
*Secondary amenorrhea: is the absence of menses for more than three cycles or six months in women who previously had regular menses, or the absence of menses for more than nine months in women who previously had irregular menses.
*Oligomenorrhea: defined as menstrual cycles >35 days apart. Because eumenorrhea may not be established until late in adolescence or early adulthood, menstrual dysfunction may be difficult to establish. When a female athlete develops negative energy balance and subsequent hypometabolic state, hypothalamic GnRH pulsatility is altered. Hypothalamic dysfunction leads to anovulation and subsequent menstrual disturbances (Warren&Perlroth, 2001).
-Osteoporosis /low bone density/ low bone mass : In an effort to not get too technical, healthy bone development occurs through a process of break down, and build back up (osteoblastic and osteoclastic activity). Females with a negative energy balance are breaking down bone due to being in a hypoestrogenic state. In healthy menstruating females, estrogen suppresses osteoclastic activity, promoting bone development and normal bone mass development. Thus, low BMD in women with the female athlete triad is secondary to the lack of adequate estrogen supply for optimal bone health. Women with menstrual dysfunction and low estrogen can lose up to 2% of BMD annually (Diemel & Dunlap, 2012).
The gyst: Not enough calories and nutrients= hormonal imbalance= cellular dysfunction= things starts to BREAK down.
The lesson or takeaway from this post, is that the human body is fragile, and while it can withstand a lot- it needs to be carefully maintained, fueled, and restored. Female athletes, particularly young female athletes, are partly so susceptible because they are still developing, and their psychological ability to cope with the pressures of their sport are not always very strong.
Young female athletes also do not have the maturity that is needed to understand why it is so important that their body's function as intended. They do not have the perspective or ability to fully grasp the extent of the damage they may be doing to themselves - damage that is often irreversible.
SO what now:
The Female Athlete Triad is becoming increasingly more understood, and while it is still not discussed or monitored on the level it should be, there are actions being taken to address it.
Coaches who are part of the NCAA have access to a manual for "Managing the Female Athlete Triad"- which can be downloaded here:
For anyone who is concerned that they, or someone they know may be dealing with symptoms of the Female Athlete Triad (remember it is a spectrum), the best place to start is by addressing it with them, and then directly with a qualified medical professional who can make the appropriate referrals from that point.
You may also contact myself - email@example.com
Or Tara - firstname.lastname@example.org with questions.
Deimel JF, Dunlap BJ. The female athlete triad. Clin Sports Med. 2012;31:247-254.
De Souza, M. J., Nattiv, A., Joy, E., Misra, M., Williams, N. I., Mallinson, R. J., & ... Matheson, G. (2014). 2014 Female Athlete Triad Coalition Consensus Statement on Treatment and Return to Play of the Female Athlete Triad: 1st International Conference Held in San Francisco, CA, May 2012, and 2nd International Conference Held in Indianapolis, IN, May 2013. Clinical Journal Of Sport Medicine, 24(2), 96-119.
HORN, E., GERGEN, N., & MCGARRY, K. A. (2014). The Female Athlete Triad. Rhode Island Medical Journal, 97(11), 18-21.
HU, C. H., & MATZKIN, E. G. (2015). A Bone of Contention: Female Athlete Triad vs. RED-S. AAOS Now, 9(12), 33-35.
Warren MP, Perlroth NE. The effects of intense exercise on the female reproductive system. Journal of Endocrinology. 2001;170:3-11.