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The Female Athlete Triad — Be on the Lookout

By Dev K. Mishra, M.D.

I was recently with a friend watching his daughter in a NorCal Premier State Cup soccer game on a beautiful spring afternoon. The girls were skilled players and the game was played at a high level. The players were fit and athletic, and yet I was reminded that female athletes in many sports have unique pressures that can predispose them to injuries only girls can get.

The female athlete triad is a combination of three conditions: eating disorder, irregular menstrual periods or no menstrual periods, and osteoporosis. A female athlete can have one, two, or all three parts of the triad. An emerging concept is that these conditions start off with low energy availability and from there a cascading series of changes take place that can end in serious problems.

“Body image” sports where a thin appearance is valued can also put a girl at risk for female athlete triad. Sports such as gymnastics, figure skating, distance running, diving, and dance are examples of sports that value a thin, lean body shape. Coaches or judges may even tell some athletes that losing weight would improve their scores.

Even in sports where body size and shape aren’t as important, such as team sports like soccer, girls may be pressured by teammates, parents, and coaches who mistakenly believe that weight loss will improve performance.

Let’s briefly look at the components of the female athlete triad.

Eating Disorder. Most girls with female athlete triad try to lose weight as a way to improve their athletic performance or due to body image pressures. The disordered eating that accompanies female athlete triad can range from not eating enough calories to keep up with energy demands to avoiding certain types of food the athlete thinks are “bad” (such as foods containing fat) to serious eating disorders like anorexia nervosa or bulimia nervosa.

Irregular Menstrual Periods. Exercising intensely and not eating enough calories can lead to decreases in the hormones that help regulate the menstrual cycle. As a result, a girl’s periods may become irregular or stop altogether.

Some girls who participate intensively in sports may never even get their first period because they’ve been training so hard. Others may have had periods, but once they increase their training and change their eating habits, their periods may stop.

Osteoporosis. Estrogen is lower in girls with female athlete triad. Low estrogen levels and poor nutrition, especially low calcium intake, can lead to osteoporosis, which means there is poor bone density. Poor bone density means the athlete is susceptible to stress fractures and other injuries.

I will start thinking about the female athlete triad if a girl sustains a stress fracture

As an orthopedic surgeon, I won’t be the one treating the different components of the female athlete triad but an orthopedic surgeon is often the doctor who treats the stress fracture. I make it a habit to ask some questions of the girl with a stress fracture to screen for possible problems with the female athlete triad. I’ll ask about their general diet and weight loss habits, energy level, and menstrual periods. If there’s even a hint that something may be amiss I’ll refer her to a primary care sports medicine specialist for proper evaluation and treatment.

This condition can be difficult to fully treat and often requires what we’d call a “multidisciplinary approach,” meaning that doctors, nutritionists, psychologists, physical therapist, and athletic trainers may all need to be involved. It’s important to acknowledge the problem and take the right steps to seek help and treatment.

Key Points: • The “female athlete triad” is a medical condition composed of eating disorder, irregular menstrual periods, and low bone density. • Girls in sports in which there is pressure to conform to a certain body image are particularly at risk, such as gymnastics, figure skating, dance, and distance running. • Treatment often involves many different types of healthcare providers. • I will look for the female athlete triad for any girl who comes to the office with a stress fracture.