Female athlete triad (syndrome)

Female athlete triad (syndrome) is a collection of three medical conditions primarily present in active teenage girls. These conditions include an energy imbalance with or without the presence of an eating disorder, menstrual irregularity, and decreased bone mineral density with or without the presence of osteoporosis. Female athlete triad is most often seen in females who participate in sports that demand lean muscle tone and low body weight. The triad can have long-term consequences for those affected and is sometimes fatal. Female athlete triad is also referred to as relative energy deficiency in sport (RED-S), and medical professionals have begun to prefer this designator as some of the symptoms have also been documented in male teen athletes.

Background

The increase in female participation in sports throughout the late twentieth century and the early twenty-first century has coincided with a rise in the incidence of specific medical disorders primarily seen among female athletes. Medical professionals identified a pattern of conditions they began referring to as the female athlete triad. Although it most often occurred among the female athletic population, the condition was also known to occur in the nonathletic population.

The triad was first outlined in 1993 at a meeting of the American College of Sports Medicine, where a group of sports-medicine professionals identified a link between bone mineral density, stress fractures, eating disorders, and female athletics. The group acknowledged these associations had been present among female athletes for decades and decided the group of syndromes needed a formal name. The identifying components were narrowed to disordered eating, amenorrhea (lack of menstruation), and osteoporosis. Although all three components did not need to be present for diagnosis of female athlete triad, the presence of just one condition greatly increased a person's chance of developing the other two conditions. Female athlete triad was also associated with long-term health problems.

The description of female athlete triad was updated in 2007 to reflect a greater understanding of the syndrome. Its three main components were given broader definitions to account for varying presentations among patients. For example, the disordered eating component was listed as "energy imbalance with or without an eating disorder." The female athlete triad as a whole was given a more spectrum-oriented arrangement to better accommodate patients. Continued research of the triad found that some of the conditions also affected men. This led medical professionals to suggest a name change from female athlete triad to relative energy deficiency in sport (RED-S), which experts believed more accurately described the numerous health problems seen in those affected.

Overview

The female athlete triad consists of three related areas that affect one another: eating habits, menstrual cycles, and bone density. Problems with just one of these habits can increase the chances of experiencing problems with any of the other habits and can increase the chance of developing female athlete triad. The three primary factors associated with female athlete triad are energy imbalance with or without an eating disorder, menstrual disturbances, and decreased bone mineral density with or without osteoporosis. Signs and symptoms of female athlete triad include low energy and fatigue; weight loss; decrease in bone mass; irregular or absent periods; stress fractures; eating disorders such as anorexia nervosa or bulimia nervosa; and extreme exercise.

The main cause of female athlete triad is energy imbalance usually resulting in an extreme lack of energy. This is usually a result of the athlete expending more energy than they are consuming. Female athletes who are very active usually have this problem. Energy imbalance is often diet-related, and if a person does not supplement the expended energy through food intake, an imbalance can occur. Improper diet may be accidental or the result of a serious eating disorder. Many girls with female athlete triad try to lose weight in an attempt to improve their athletic performance. Sometimes this leads to disordered eating that sees a female athlete not eating enough calories to balance her energy demands. Some girls simply avoid foods they think are bad for them, such as fats and carbs, which are major sources of energy in the diet. Others develop dangerous eating disorders such as anorexia nervosa or bulimia. In both cases, girls are not taking in enough calories to resupply their energy levels, leading to energy imbalance.

The energy imbalance that results from extreme exercise without enough calorie intake can lead to problems with a female's menstrual cycle. This imbalance can affect the hormones regulating the menstrual cycle, and a girl's period may become irregular or disappear altogether as a result. Girls who engage in intense sports training from a young age often do not get their periods until much later than less active girls. Girls who had their periods prior to intense training may see changes in their cycle once training begins.

Hormones that affect a female's bone mass are also affected in female athlete triad. The hormone estrogen is lower in girls with female athlete triad. Paired with poor nutrition, particularly low calcium intake, low estrogen levels can lead to reduced bone density and result in osteoporosis. This condition weakens the bones and can lead to improper bone formation. It also increases the chance of developing stress fractures and other bone injuries.

Treatment of female athlete triad involves re-establishing a healthy balance of diet and exercise. It is important for teen girls to get the proper amount of essential vitamins and minerals in their diets on a daily basis. This can be done through food or with supplements, although it is of primary importance that a person takes in a healthy amount of calories through food each day. Retaining a healthy amount of body fat helps protect and maintain strong bones, so athletes should refrain from avoiding healthy fats found in foods such as fish and nuts. Rebalancing the body's energy levels will help alleviate other symptoms associated with female athlete triad, such as bone-mass problems and menstrual irregularities.

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