Female Athletic Triad Syndrome in young athletes

Written by: Jennifer Manz, PT, DPT, Mercy Sports Medicine and Rehabilitation Center

Studies show adolescents who play sports are healthier, get better grades, are less likely to experience depression and use alcohol, cigarettes, and drugs less frequently than those who aren’t athletes. But for some girls, not balancing the needs of their bodies and their sports can have major consequences.

If you’re a coach involved in girls’ sports, it’s likely you’ve worked with an athlete at risk of a problem called female athlete triad syndrome. She is driven and often puts in high mileage in cross country or track, or works out many hours in other sports. She is lean and seems to be conscientious about her diet. The female athlete triad syndrome is one or a combination of the following three conditions: disordered eating, amenorrhea, and osteoporosis.

Disordered eating: Disordered eating is not a clinical eating disorder. Athletes may have an intense fear of gaining weight or may try to lose weight to specifically improve their athletic performance. They may be preoccupied with food, fixation about their weight and/or have a distorted body image. This can lead to serious eating disorders such as anorexia nervosa or bulimia nervosa.

Health consequences of disordered eating may include:

  • Extreme fatigue
  • Decreased performance
  • Decreased aerobic capacity
  • Susceptibility to infections
  • Slow recovery from injury
  • Electrolyte imbalances
  • Menstrual irregularities
  • Increased risk for bone loss
  • Depression

Signs and symptoms of disordered eating include:

  • Dieting in spite of weight loss
  • Preoccupation with food
  • Brittle hair/nails
  • Cold sensitivity
  • Laxative use
  • Frequent trips to the bathroom before/after meals

There are specific nutritional needs for an athlete, depending on activity levels such as high endurance training:

  • Any athlete who consumes less than 1,800 calories per day is unable to meet caloric and nutrient requirements.
  • Athletes participating in 10-20 hours of exercise per week require 2,200-2,500 calories a day to maintain weight.
  • Athletes participating in high endurance training may require more than 4,000 calories a day.

Amenorrhea: This is an abnormal absence of the menstrual cycle. Some researchers suggest at least 17 percent body fat is necessary for menstruation to be maintained. Athletes may have shorter menstrual cycles than normal, which is due to lower than normal levels of estrogen and progesterone. They may also have menstrual cycles that occur at irregular intervals (between 5-10 weeks apart), again due to low levels of hormones.

Amenorrhea is defined as three or fewer menstrual cycles in a year, or no menstrual cycle for 6 months. Menstrual disorders in athletes vary from 1 percent to more than 50 percent. It is more common in sports that benefit from low weight (distance runners, ice skaters, gymnasts, ballet: less than 25 percent of these athletes have menstrual irregularities).

  • Twenty-eight percent of athletes running less than 40 miles a week and 45 percent who run less than 80 miles per week have amenorrhea.
  • Athletes weighing less than 110 pounds are twice as likely to have amenorrhea.
  • Fifty percent of amenorrheic athletes have subclinical or clinical eating disorders.

Osteoporosis/Osteopenia: Osteoporosis is weakening of the bone due to a loss of bone density and/or improper bone formation. Osteopenia is reduced bone mass, but less severe than osteoporosis.

Estrogen and progesterone act directly on bone cells to maintain the bone-turnover cycle. When these hormone levels are low, old bone resorbs while new bone formation is reduced. There is an increased incidence of stress fractures in athletes with menstrual irregularities. Adequate estrogen levels are necessary for normal bone turnover. There is slow bone adaptation, increased risk of micro-fractures, and slower healing when estrogen levels are low.

How to help: It is very important to improve their overall health to increase muscle strength, decrease risk of fractures, improve physical performance, avoid long-term effects on the reproductive symptoms and avoid cardiovascular problems. Overall signs and symptoms of the female athlete triad:

  • Weight loss
  • Fatigue
  • Decreased concentration ability
  • Irregular or absent menstrual cycles
  • Stress fractures

Approaching someone suspected of an eating disorder: Some athletes are unaware they even have disordered eating. Educating on proper nutrition and its role in performance is sometimes all they need (especially as it relates to the number of calories needed and the need for calcium and Vitamin D).

For other girls, they are aware they are consuming inadequate calories. They are likely to deny they have a problem, feel embarrassed and self-esteem may be threatened.  They may fear that if they admit to a disorder, they will be forced to gain weight or be prevented in training or competing.

The best person to approach the suspected athlete with an eating disorder is someone who they know and trust. Ensure the athlete that you genuinely care, ask how they feel and encourage treatment. If they are unwilling to discuss their diet, it may be beneficial to discuss with the parent.

If the sufferer admits she has a problem: Suggest consultation with a specialist, a trained counselor or a dietician. The athlete needs to maintain a sense of belonging. Do not alienate her from practice, even though she may be injured and unable to compete.

Tips for female athletes:

  • Keep track of menstrual cycle length and frequency to help watch for amenorrhea.
  • Ensure good calcium intake: the teenage years are when females should build the highest levels of bone mass for optimal health in current and future years.
  • Avoid skipping meals: keep week-long food journals and ensure adequate nutritional intake.
  • Incremental weight lifting programs can increase bone strength without “bulking” or gaining weight.
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