The female athlete triad is a syndrome involving 3 inter-related things:
1. Low energy availability with or without disordered eating;
2. Amenorrhea (few or no regular menstrual cycles);
3. Osteoporosis / osteopenia (low bone density).
Is it common? In young athletic women – YES!
Is it important? ABSOLUTELY!
WHY? Because low bone density causes a stack of injuries like stress fractures (see our posts HERE and HERE for more information), and low energy availability causes a cascade of other negative effects including poor sport performance – basically there isn’t enough fuel being consumed to power all of the different systems in the body properly. Let’s dive into some more details.
Around 25% of young women engaged in sports have one or more of the 3 components of the triad (Skorseth et al 2020). Adolescence is a key time for bone acquisition, where the body is building a lot of bone to see you through life. We reach peak bone mass in our 20’s, and thereafter bone density tends to decline (Lu et al 2016). Anything that impairs the formation of the skeleton in this age group is particularly problematic, as it can lead to reduced peak bone mass which is a predictor of osteoporosis and fracture risk.
So how do these 3 components relate? Essentially if you have too little energy intake (whether by accident or due to disordered eating) this causes a range of effects throughout the body, one of which is shutting down the reproductive system. It’s a bit like the body is saying “hey – you’re barely keeping me alive, no chance for 2 of us here” and the female reproductive system is shut down. The first sign of a problem might be an infrequent or absent menstrual period. This is associated with a drop in hormones like oestrogen and progesterone, which are essential for bone health in women. Over time this leads to lower bone density. Often the first time an athlete learns there is a bigger problem is when she presents with a bone stress injury like a stress fracture (see our post HERE for more information).
It was not until the 1990’s that this syndrome was recognised, and more recently the International Olympic Committee has updated and expanded the condition to encompass all of the effects of “Relative Energy Deficiency in Sport”, along the way creating yet another acronym for us: “RED-S” (Mountjoy et al 2018). A lack of nutrition and energy results in widespread effects, not just on bone density and hormone levels in women, but can also affect men where testosterone levels can fall. Other hormonal effects are akin to overtraining syndromes where growth hormone levels fall potentially affecting long term growth and development; metabolic changes like a lower metabolic rate (which causes lower energy levels and a tendency to gain weight) along with abnormalities in metabolic hormones; poor immune function (causing recurrent illnesses) and psychological problems (which may be the cause of poor eating or a consequence of all of the above symptoms).
Sports which emphasise leanness, demand high energy expenditure like endurance sports, or have an aesthetic component (gymnasts, figure skaters) appear to be the most prone to the syndrome. Ironically the lack of energy, which for some athletes represents a deliberate attempt to remain lean, causes a whole cascade of problems that impair sports performance rather than assist it, so it is important to establish if the lack of energy intake is:
Intentional weight loss without disordered eating
A clinical eating disorder
This may require a multi-disciplinary approach with a Sports Nutritionist and Sports Psychologist. A Physiotherapist is often the first professional to identify the underlying issue when the athlete presents with an injury in which the underlying cause involves lowered bone density. It is also widely recommended that athletes monitor themselves with respect to energy and fatigue levels, menstrual regularity and any impairment or stagnation in performance. If you are noticing things aren’t quite right, speaking to your coach and seeking professional help early are good starting points. Education about how crucial a proper fuel supply is for an athlete is always part of the treatment, and overcoming some misconceptions about what this looks like is often required.
I’ll leave you with one parting thought: the female athlete triad is a situation where early identification of a potential problem and rectifying it is far better and far faster than waiting to break down and try and effect a cure afterwards.
Lu J et al (2016): Peak bone mass and patterns of change in total bone mineral density and bone mineral contents from childhood into young adulthood. J Clin Densitom 19:180.
Mountjoy M et al (2018): IOC consensus statement on relative energy deficiency in sport (RED-S): 2018 update. Br J Sports Med 52:687.
Skorseth P et al (2020): Prevalence of Female Athlete Triad Risk Factors and Iron Supplementation Among High School Distance Runners. Am J Sports Med 8:1.