What is Female Athlete Triad?
Often times, female athletes complain of low energy, which means they are taking in less energy from the foods they eat than the energy they spend while exercising. This can happen whether it is on purpose or not and could be the result of exercising too much, not eating enough, or a combination of both. Over time, this can lead to a continuous energy shortage, which can affect the body systems responsible for movement and reproduction in female athletes.
There’s a particular condition known as the ‘female athlete triad’, which involves low energy levels (even in the absence of an eating disorder), menstrual issues and changes in bone health. Spotting low energy levels in female athletes early and understanding this condition in detail are crucial in preventing any short or long-term impacts it may have.
What Causes Female Athlete Triad?
For high-intensity sports that last a long time, the main factor that determines performance is how much energy you have. Most of this energy comes from carbohydrates, while proteins and fats provide a smaller amount. Ideally, if you’re using more energy, you should be eating more to keep your energy levels up. However, this doesn’t always happen.
Many female athletes, whether on purpose or by mistake, don’t eat enough to maintain their energy levels. It’s important to understand that there’s a direct relationship between the amount of carbohydrates available in the body and the health of the reproductive and skeletal systems.
Risk Factors and Frequency for Female Athlete Triad
All female athletes, regardless of the sport they participate in or their level of competition, can potentially develop a condition known as “the triad.” However, those involved in endurance sports like track and field, swimming, and rowing or sports that require subjective judging such as gymnastics and figure skating are at the highest risk.
When female athletes intentionally create an energy deficit, it is often characterized as an eating disorder. These athletes are 5 to 10 times more likely to have an eating disorder compared to male athletes. Clinical eating disorders, like anorexia nervosa or bulimia nervosa, are found in 16% to 47% of top female athletes. In addition to eating disorders, a significant percentage also struggle with personality disorders, substance abuse, or obsessive-compulsive disorder, and tragically, these women are at a higher risk of suicide than their healthy peers of the same age.
- All female athletes can potentially develop the triad, regardless of the sport or competition level.
- The highest risk is among those involved in endurance sports or sports requiring subjective judging.
- Female athletes are 5 to 10 times more likely than males to have an eating disorder.
- Among top female athletes, 16% to 47% have been diagnosed with clinical eating disorders such as anorexia nervosa or bulimia nervosa.
- A noteworthy percentage of these women also have personality disorders, substance abuse problems, or obsessive-compulsive disorder.
- The suicide risk for females with these challenges is higher than for healthy women of the same age.
Signs and Symptoms of Female Athlete Triad
All female athletes should regularly check their health condition, focusing on various aspects including their diet, musculoskeletal system, menstrual cycle, metabolic status, mental condition, performance, and medications.
- Nutritional history – This includes food intake patterns and consumption levels of protein, carbs, vitamins, and minerals.
- Menstrual history – This covers details like the age they got their first period, average length of their period, average gap between cycles, menstrual changes due to intensified workouts, and the total number of menstrual cycles in a year. Also, rule out pregnancy in cases of missing periods.
- Endocrine/metabolic history – Look for personal and family history of thyroid, pituitary disorders, and diabetes. Also check for symptoms of polycystic ovarian syndrome.
- Psychosocial history – Take note of their eating patterns. The Eating Disorder Inventory (EDI) can be helpful. Record any alcohol, tobacco, or drug use. Additionally, look into social support, experience with depression, anxiety, incidents of physical, emotional, or sexual abuse.
- Performance history – Inquire about any changes in strength or performance.
- Medication history – This should include all medicine, dietary supplements, and herbal products they have taken. Details about oral contraceptives should be noted separately as people often forget to mention them. Inquire about use of anabolic steroids or other substances like emetics, diet pills, stool softeners, or laxatives.
Physical check-ups should assess for any abnormalities that might be disrupting hormonal or metabolic functions. The thyroid gland needs to be checked for enlargement or irregularity. A detailed dental exploration should be done, looking especially for tooth decay resulting from frequent vomiting and rough brushing, as well as swollen parotid glands, like those seen in bulimia. Visual field testing helps check for large pituitary tumors causing pressure on the optic nerve, leading to vision loss. A full skin check should also be carried out.
A pelvic examination should be registered in suitable conditions, especially in cases of delayed or irregular periods.
Testing for Female Athlete Triad
If you’re an athlete going through an increase in your training regime, a coach or team doctor might suggest you undertake a baseline test measuring levels of a substance called ‘urinary acetoacetate’. This test, ideally, should be performed monthly and the goal is to eliminate the presence of ‘urinary ketones’ before and after eating, as well as before and after training sessions.
If you’re an athlete who usually has regular menstrual cycles, but then stops getting your periods (a condition known as ‘amenorrhea’), a B-HCG test is needed to eliminate the possibility of pregnancy. Besides, other lab tests can be carried out for deeper analysis. A complete metabolic panel can check how levels of different chemicals in your body (electrolyte levels) are doing and can test the health of your kidneys and liver. Also, a blood test can determine if you may be anemic.
A thyroid panel can test if your thyroid gland is functioning well. Furthermore, additional tests can check the levels of specific hormones in your body, such as testosterone, luteinizing hormone, follicle-stimulating hormone, estradiol, and prolactin.
When it comes to medical imaging, a pelvic ultrasound can be used to establish why you might have stopped having periods (the cause of ‘primary amenorrhea’). It does so by checking for the presence of the ovaries and uterus. If there’s a suspicion of abnormal functioning of the pituitary gland (a small gland at the base of the brain that controls many other glands in the body), an MRI of the head can be undertaken. An electrocardiogram, a test that measures the electrical activity of your heartbeat, may reveal a resting heart rate of fewer than 50 beats per minute (a condition known as ‘bradycardia’), which is common in athletes.
If there’s any sign from your medical history or physical examination that you might have a stress fracture, the first test needed is a plain radiograph or X-ray. If this test doesn’t show the injury, then a 3-phase bone scan might be carried out. A dual-energy x-ray absorptiometry scan might be used if you’ve had several stress fractures, or to check for lower bone density conditions such as ‘osteopenia’ or ‘osteoporosis’.
Treatment Options for Female Athlete Triad
The initial step in treating this condition involves addressing the root cause. Usually, this is due to the body not getting enough energy; this could be because of not consuming enough calories, being too physically active, or both. It’s crucial to speak to a nutritionist or a sports dietitian for advice in these situations.
If a female athlete is experiencing problems with her menstrual cycle, she should see an OB/GYN doctor. OB/GYN doctors specialize in women’s health, particularly in relation to reproductive health, pregnancy, and childbirth. These doctors can evaluate the patient’s condition and provide suitable treatment. Hormone replacement therapy, which involves supplementing the body with estrogen and progesterone, is often the first treatment tried for menstrual problems.
Female athletes showing signs of weakened bones (osteopenia) or significantly reduced bone strength (osteoporosis) may need additional nutrients. This could come in the form of oral vitamin D and calcium or bisphosphonates medication, depending on the degree of bone density loss and the individual’s fracture risk.
Lastly, if a female athlete is diagnosed with a mental health issue such as depression, anxiety, or an eating disorder, it’s vital that she is referred to a mental health specialist. This could be a psychiatrist, who is a medical doctor that can diagnose and treat mental health conditions including prescribing medication, or a psychologist, who can offer therapy and strategies to manage anxiety, depression or further evaluate her eating habits.
What else can Female Athlete Triad be?
There are several health conditions that could cause various symptoms, including hormonal imbalances, mood disorders, and nutritional issues. Here are some of them:
- Androgen excess – too much male hormones
- Drug interactions – adverse effects from mixing medications
- Depression – a mental health disorder marked by persistent feelings of sadness
- Hypogonadotropic hypoestrogenism – a condition where the body doesn’t produce enough sex hormones
- Hypothalamic disorders – issues with the part of the brain that controls body temperature, hunger, and thirst
- Hyperthyroidism – overactive thyroid gland
- Hypothyroidism – underactive thyroid gland
- Luteal phase inadequacy – a fertility problem due to insufficient progesterone
- Nutritional deficiencies – not getting enough nutrients
- Ovarian defect – problems with the ovaries
- Ovarian insufficiency – when the ovaries don’t function properly
- Pituitary disorders – problems with the gland that regulates many body functions
