The female athletic triad is a collection of symptoms that includes inadequate energy intake (and may or may not include eating disorders), hormonal imbalance (dysfunctional menstruation) and poor bone health (osteopenia and osteoporosis). The triad most often occurs in female athletics competing in sports that emphasize leanness. It can have serious implications on long-term health, beyond the time period of athletic competition. It can also occur in non-athletic women as well, however this is more rare.

Causes

Each of the main symptoms of the triad share the same origins in less than adequate energy intake. Inadequate energy intake occurs when dietary energy intake is less that the energy expended during exercise. In other words, it is a long term situation where energy input is less than output, leading to weight loss and most notably loss of vital fat stores.

This ‘energy crisis’ can stem from several causes; however most often it results from conscious restriction of food intake. This is most often associated with disordered eating patterns such as anorexia and bulimia. (Eating disorders are not always a part of the triad). Other types of disordered eating include fasting, purging, binging, over use of diets, enemas and laxatives. Body image, and a desire to be thin (whether from image or sports performance) are the primary reasons for the onset of disordered eating patterns.

Regardless of the cause of inadequate energy intake, the body recognizes this as a reason to slow down certain functions. A ‘side effect’ of low energy intake is the resultant loss of body mass, notably fat stores. Once a woman’s fat tissue mass reaches a certain low point, this signals the brain to cease reproductive function. It does this because it interprets that a certain level of fat as a sign of health and the ability to safely carry a pregnancy.

With the brain not wanting the body to become pregnant, it takes over and slows the production of the hormones necessary for creating a menstrual cycle. Women with the triad may have completely lost their menstrual cycles, or it may be irregular.

Low hormone levels, notably estrogen, are vital for bone health. Inadequate amounts lead to bone loss quite rapidly. Low bone density accompanied by the high activity and mechanical stress of sports leads to a high risk of fracture in women with the triad.

Female bone mass is thought to peak in a woman’s early 20’s. Women who suffer from the triad during this time of life may suffer from weakened and thin bones the rest of their lives.

Diagnosis

There are many symptoms associated with the female athletic triad. The main ones include severe weight loss, sensation of coldness, fatigue, poor sleep, hair loss, nail splitting, dry skin, loss of menses and bone fractures.

Theses aren’t the only symptoms a woman may have with the triad. Low self esteem, depression and other mental-emotional symptoms are often observed.

Physical examination will reveal notable weight loss, anemia, low blood electrolytes, low blood vitamin and mineral stores, low hormone levels, irregular heart rate, vaginal atrophy, hot flashes, night sweats, and low blood pressure.

It is important to have a complete workup by a qualified physician to determine the causes of these symptoms, all of which can signify a serious condition(s).

Treatment

Treatment of the female athletic triad involves working with a clinician that is knowledgeable in diet and nutrition, a therapist focusing on the psychological aspects of the triad, and decreasing training time by 10-12% as well.

Monitoring nutrient intake, while focusing on healthy weight gain is paramount. In addition to a healthy, energy replete diet, focused supplementation is key in repairing and restoring physiologic function.

Nutritional agents include Vitamin D; this aids in calcium absorbtion (for the bones) and to assist normalized regulation of the sex hormones. Calcium and other bone supporting supplements should be taken to achieve a daily calcium level of 1000-12000 milligrams.

Bioidentical hormones may be used for a period of time to supplement normal menstrual function, and to increase circulating hormone levels to aid in bone health and recovery. They should only be used for a period of time until the woman is able to achieve a healthy weight that supports a regular menstrual cycle. Working closely with a physician who is knowledgeable about bioidentical hormones and female athletes is key.

We do not recommend birth control pills as a method of treatment for this condition for a variety of reasons. We also DO NOT recommend bisphosphonate drugs (those used to treat Osteoporotic women- Fosamax, Boniva, Actonel) either. Both of these drugs (birth control pills and bisphophonates) mask they symptoms in these young women.

Lastly, taking a close look at any mental-emotional factors involved in the triad (specifically the desire to be lean and thin) is perhaps one of the most important steps. Often this is where the condition originates, leading to altered eating patterns and the aforementioned energy deficit. Working with a trained professional in this area is vital to making a proper recovery.