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The Female Athlete Triad

Learn about the triad eating disorder syndrome in female athletes: anorexia, amenorrhea, and osteoporosis.

The Female Athlete Triad

The female athlete triad describes a syndrome of eating disorder (anorexia), lack of a period (amenorrhea), and thinning bones (osteoporosis). The triad is common and becoming more and more recognized in girls and women who work out a lot and do not eat enough. Most frequently occurring in women with disordered eating and calorie restricted diets, it has also been noted in girls who do not eat enough protein or meat and also in girls who work out excessively without proper rest. One of the greatest risks to health is thin bones and stress fractures. The most reliable signs that an athlete has the female athlete triad include being extremely thin (body fat less than 18 percent) and a loss of regular menstrual period, particularly for longer than six months. Other signs include being obsessed with body weight, worsening performance, and constant fatigue. The female athlete triad must be addressed by a doctor as soon as possible to restore normal hormone balance, bone health, and healthy eating habits. It often is treated with a multidisciplinary team of nutritionists, psychologists, and doctors.

Body Signs of Anorexia Athletica and the Female Athlete Triad

  • Extreme thinness (body fat Loss of appetite
  • Loss of regular periods
  • Constant pain
  • Stress fractures
  • Repeated injuries
  • Chronic fatigue
  • Poor endurance
Eating Disorders
Some athletic girls and women have milder forms of these diseases and are able to preserve their performance, although they are at risk of developing more severe forms of eating disorders. Being able to recognize the signs of anorexia (severe calorie restriction and limitation) and bulemia (bingeing and purging) can prevent development into a life-threatening disease, as treatment is more effective early in the course of the disorders. Often, these problems begin in junior high or high school, although younger girls can also feel pressures to be extremely thin.

Amenorrhea is the medical term for not having a period for more than six months. Most girls should be having regular (monthly) periods by age 14 to 16. Not having a period is a sign that the body is not cycling estrogen as it should. The reasons for amenorrhea are not fully understood, but low body fat and low calorie intake stresses the reproductive hormones to restrict their normal signals. Estrogen is necessary, not only for reproductive health, but notably for bone strength—just six months of not having a period leads to permanent bone loss. Amenorrhea can also be due to illness, overtraining, physical stress, psychological stress, low-calorie diets, low-fat diets, and low-protein diets. There are also some medical conditions that can cause this loss of regular periods.

Causes of Amenorrhea (Loss of Monthly Period)

  • High exercise intensity
  • Low body fat
  • Recent weight change
  • Hormone imbalance
  • Dieting
  • Pregnancy
  • Stress
  • Illness
  • Poor nutrition
  • Low-calorie diet
Osteoporosis, the disease of thinning bones, is usually a disease of older women, but girls and women with the female athlete triad, overstressing the body by not eating enough or working out too much causes osteoporosis to occur more frequently and at an earlier age. Osteoporosis also leads to poor posture, loss of height, decreased breathing and lung capacity, and frequent stress fractures (see chapter 5, "Bone Health and Osteoporosis"). In younger women, it is linked to the loss of estrogen and can also be present secondary to consistently poor nutrition such as low-fat, high-protein, and low-calcium diets. Osteopenia, a medical term used to describe thinning bones that are more likely to develop osteoporosis, is also a sign of potential risk from the female athlete triad. Having Osteoporosis or Osteopenia at a young age is a risk factor for fractures throughout life, because bones are developing their greatest density between the ages of 12 and 30. If a female has an eating disorder during these ages and does not properly nourish her bones and body with enough calcium, calories, and fat, proper bone development and strength will not occur.

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