How the Female Athlete Triad Can Ruin Your Sports Performance

Understand the female athlete triad, and learn what to do if you exhibit any of its symptoms.

I really enjoy working with athletes, because they tend to be very motivated, high-energy people. Athletic types are generally goal-oriented and committed to accomplishing their goals. However, for a smaller group of female athletes, the need or desire to push themselves to achieve performance goals can lead to serious negative health outcomes and poor athletic performance.

A condition known as the female athlete triad is a spectrum of disease encompassing three disorders—energy deficiency, unspecified menstrual dysfunction and low bone mineral density (BMD). The condition tends to be more prevalent in athletes who participate in sports in which leaness or aesthetics has a large impact on performance—such as long distance running, cycling, gymnastics, figure skating, dance and aquatic sports.

The prevalence of the triad is difficult to assess. A review that looked at active young women between 17 and 25 years of age who exercised and exhibited all three disorders found that the triad was present in 0 to 15.9 percent of the subjects. The wide range is due to many diagnostic challenges, including the fact that women usually don't present for all three disorders, but rather seek to treat a symptom that affects their health or athletic performance—for example, an injury. Furthermore, the three disorders are interrelated, and they seem to impact each other negatively.

A recent study in the International Journal of Sports Nutrition and Exercise found that eating disorders among all athletes, including those in aquatic sports, range from 18 to 45 percent in female athletes. Again, it's difficult to assess the true estimate, but this range indicates the need for education on healthy eating behavior at all periods of development for female athletes.

What is certain is the fact that when the triad is present, performance is hindered. Let's look at a few of the ways the three components negatively affect performance.

1. Energy Deficiency 

Athletes require additional fuel to perform. Limiting food or beverages, or exercising excessively, deprives the body of the fuel it needs to perform. Muscles require adequate carbohydrates, protein and fat. If a caloric deficit grows, muscles get weaker and become smaller in size, and the body tries to use whatever fuel is available for basic bodily functions. Diminished energy stores also lead to poor cognition or brain function. When the body is deprived of nutrients, the ability to think clearly is lowered, and the ability to focus, concentrate and perform specific tasks is negatively impacted. A loss of strength and cognition leads to a higher prevalence of injuries. Low energy intake leads to poor or delayed healing as well.

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2. Menstrual Dysfunction

Some female athletes consider this desirable, and a regular part of training, but this is not the case. An absence of regular menses over time can have a negative impact on performance, including a change in hormone regulation, and, along with a calorie deficit, lower estrogen production. Lower estrogen production is associated with bone loss, and continued bone loss over time can lead to injuries such as stress fractures. A 2010 research study examined bone mineral density and other features among 44 elite endurance runners. Low bone mineral density was noted in 34.2 percent of the athletes at the lumbar spine, and 33 percent of the athletes exhibited osteoporosis at the radius (lower arm). Researchers also found a relationship between increased training volume, menstrual dysfunction and loss of bone mineral density leading to bone loss in athletes.

3. Low Bone Mineral Density

Participating in athletic events tends to increase bone mass and strength. Thus, loss of bone density among female athletes is especially  concerning. Bone loss tends to lead to injuries such as stress fractures. Fractures keep you out of your game or activity for extended periods of time, and poor nutritional intake can further impair healing.

In addition, poor or inadequate healing tends to lead to multiple fractures over time. A recent article in the American Journal of Sports Medicine assessed risk factors associated with bone stress injury in four cohorts of physically active girls and women. The study involved 259 females, approximately 18 years old. Results indicated that 28 participants (10.8%) incurred a bone stress injury, and that the risk of injury increased from 30 percent to 50 percent when all three triad disorders were present. This data suggests an increased risk for bone stress injury when the number of triad risk factors increases.

The female athlete triad is a true indicator that these three risk factors can only hurt your overall health and performance. If you or someone you know is struggling with any of these issues, please ask them to seek medical attention as soon as possible. Correcting these issues now can lead to a much healthier future.

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