Female Athlete Triad

Female Athlete Triad

I always, always make sure I discuss this with my female athletes, and so Icon athletes should be no exception. I feel strongly that all women should know what is, and is not, healthy when it comes to the effects training has on their bodies. So, let’s have a conversation about the female athlete triad…

The Female Athlete Triad is a medical condition comprised of 3 components: low energy availability (with or without disordered eating), menstrual dysfunction, and low bone mineral density. When allowed to progress long enough without intervention, the Female Athlete Triad can result in damage to the musculoskeletal and cardiovascular systems, as well as endocrine, gastrointestinal, renal and neuropsychiatric complications. Essentially, every major system of the body can be affected.

So what’s happening in the Triad? Well, high quality research on the topic has shown us that the cornerstone of the Triad – or the cause of the Triad – is one of the three conditions: low energy availability with or without an eating disorder.  When energy availability is chronically low, menstrual dysfunction and decreased bone mineralization occur.

Energy availability is the amount of energy (aka calories) after accounting for the energy cost of exercise that is available to the body for all other physiologic functions (breathing, circulating blood, functions of the central nervous system, etc.). This also includes menstrual functioning and bone density because menstrual function and bone health are not immediately essential for life, yet they ‘cost’ (= require) a lot of energy (= calories). Bone is very dynamic and is always turning over – when there is adequate energy (and other nutrients) bone turnover is positive promoting dense bones. Similarly, menstrual function requires energy for the normal healthy cascade of hormones including the release of estrogen.

When energy availability is low (that is, there is not a lot of energy ‘left over’ after accounting for the energy used for physical activity), the body then has to prioritize to where it sends energy. Naturally the body will prioritize sending energy to the essential functions for daily life (respiration, circulation, thermoregulation, etc…) before considering depositing minerals into bone and sending energy to reproduce. In fact, in a state of low energy availability, evolutionarily it is advantageous for the body to shut off menstrual functioning because it is apparent to the body that it cannot healthfully support its own life, let alone support the life of a new human. Thus the body shuttles energy away from these systems. The body is very smart.

The unfortunate result of this is that bone turnover is negative and can eventually result in osteoporosis; menstrual function can be disturbed which can result in amenorrhea (lack of menses) and low estrogen levels. Low estrogen will further exacerbate lack of bone mineral deposition promoting greater bone turnover and lowered density.  So while the 16 year old athlete may tell me they don’t care about losing their period, and they just don’t have the foresight to consider what osteoporosis might mean for them when they are 60, it is important they realize the effects this may have on them now. The effects of low estrogen (from amenorrhea) and increased bone turnover mean they are also at increased risk for stress fractures. These injuries can take them out of play for quite some time.

It is important to remember that while we used to consider an eating disorder as one of the requisite components of the Triad, we now know athletes can have low energy availability with or without an eating disorder. That is, some athletes intentionally restrict their caloric intake and engage in disordered eating; there are also athletes that inadvertently under-consume calories. These are athletes that are simply unaware of how many calories their bodies need to sustain their levels of activity and all other physiologic functions. So it is not just athletes with eating disorders that can face the consequences of the Triad.

Another myth many female athletes have faced is that it is normal – even good – to lose their menstrual cycle. It used to be thought that this was an indicator of intense training. Fortunately we now know that athletes can be very lean and train quite hard and still experience healthy menstrual functioning. It is all about consuming adequate calories.

So what do we do about the Triad? First and foremost the sooner we identify symptoms and intervene typically the better the prognosis. The cornerstone of treatment is correcting energy availability. There is a complex equation I use as a sports dietitian to specifically determine an athlete’s energy availability, and we know from the research what is considered to be optimal energy availability (45 kcal/kg/fat-free mass (FFM)), and what is considered low energy availability (<30 kcal/kg/FFM). I compute an athlete’s energy availability and if it is low, we correct it through increasing energy intake. It really is that simple.  It is not quick – it can take months for menstrual functioning to resume, and we cannot always fully recover lost bone mineral density. But, we can mitigate further losses. Importantly to the athlete, we can support improved performance – research shows time and again the detrimental effect inadequate energy intake has on performance, and sometimes this is the most motivating factor for the athlete to comply with recommended changes.

I think all female athletes should have a basic understanding of the Triad, and all coaches and staff working with female athletes should also be aware of symptoms so as to guide their athletes to seek help if symptoms present. If you (or an athlete with whom you are working) is experiencing chronic stress fractures or lack of menses, they should seek out professional help immediately. This includes working with a sports medicine physician and a sports dietitian; it would include collaboration with a therapist as well if there is disordered eating that is fueling the low energy availability.

Below are some great resources for those who are interested in learning more or would like to know treatment resources. As always, never hesitate to reach out to me if you have any questions or concerns!



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