by Mimi Winsberg, M.D.

Since October is body composition month, I thought I would take the opportunity to discuss an important triad of disorders particular to female athletes. This triad is most often seen in sports that emphasize leanness, or where low body fat offers an advantage. Having just returned from Hawaii where the typical athlete looked to be about 5% body fat, I can safely say that triathlon falls in this camp.

Women have proven their proficiency in endurance sports for some time. Chrissie Wellington recently said, “It is not impossible that a woman could one day finish first at an Ironman event.” To be strong competitors, women can feel pressure to have the “right” body type for their sport. This can come with some risks.

The “Female Athlete Triad” was first described by the American College of Sports Medicine (ACSM) in 1993. This syndrome has presented in my psychiatry practice, and is commonly encountered in sports medicine. Difficult to recognize, and even more difficult to treat, it has wide ranging and life-long implications for women athletes, including, but not limited to the risk of bone loss and stress fractures.

Components of the Female Athlete Triad
The three components of the female triad are: disordered eating, amenorrhea and osteoporosis. While all three components of the triad can be present, female athletes can also suffer from only one or two components, and still be at risk for long-term health problems.

Many doctors suggest that “amenorrhea” (complete loss of menstrual cycle) be replaced with “exercise related menstrual alterations” in determining guidelines for the triad.

In fact, the ACSM revised their guidelines in 2007 to view the disorder as a continuous spectrum (much the way we view disorders in psychiatry). Disordered eating is now seen on a spectrum from “optimal energy availability” to “low energy availability with or without an eating disorder.” Amenorrhea is viewed on a spectrum from “eumenorrhea” (regular cycles) to “functional hypothalamic amenorrhea” (changes in hormone production with or without total disruption in cycles), and osteoporosis now ranges from “optimal bone health” to “osteoporosis” with osteopenia and bone weakness lying in between.

Dr. Michael Fredericson, Professor of Sports Medicine at Stanford University, and Head Physician for the Stanford Cross Country and Track Teams says, “The biggest risk a female athlete takes by maintaining low energy balance and a low hormonal state is low bone density.”

“If your energy state is low, and your hormone levels are low,” he explains, “then you’re not absorbing calcium properly, and it really affects your bone development. So these athletes can develop premature osteoporosis.” Osteoporosis is normally considered a disease of the elderly, but a young athlete in her twenties can end up having the bone mass of an older woman. This can put her at serious risk for fractures.

Women athletes, who should have healthier bones than their non-athlete counterparts, need to be storing bone in the first three decades of life to protect against the loss that inevitably begins with menopause. If they have put themselves into a premature low hormonal state, that bone may never be regained. The long-term risks of amenorrhea on fertility are also not clear.

Component 1 - Disordered Eating and Low Energy Availability
While the full fledged eating disorders of anorexia or bulimia are seen in female athletes, we also see athletes who do not meet the full criteria for these psychiatric diagnoses. Sometimes athletes are simply not taking in enough food to offset the calories burned in their workouts on a chronic basis. They also may be preoccupied with food, and worry about weight gain. Food restrictions are common, along with much more worrisome signs such as use of laxatives or diet pills.

Studies have estimated the rate of disordered eating in the female athletic population to be as high as 62%, and assessing the rate of low energy availability among female athletes is tricky at best. Many athletes will try to hide the extent of their behaviors from friends, family, or coaches. We do know that having an additional diagnosis of depression, anxiety or obsessive-compulsive disorder makes an athlete more likely to suffer from low energy availability (with or without disordered eating).

Component 2 - Menstrual Dysfunction
Since the definition has been broadened to include the full spectrum of menstrual disorders, clinicians are now able to identify female athletes who have low estrogen states but still menstruate. This includes women who have luteal suppression, anovulation, oligomenorrhea, as well as primary and secondary amenorrhea.

To define these terms:

• Luteal supression: A shortened luteal phase associated with decreased estradiol levels. The athlete ovulates later in the cycle than normal, and usually has a normal period.
• Anovulation: Associated with low levels of estradiol and progesterone. There is no ovulation. These athletes may suffer from infertility issues. They will still often get their periods, although cycle length may be shorted or prolonged.
• Oligomenorrhea is defined as greater than 35 days between cycles.
• Primary amenorhea is the delayed onset of menarche (first period) in a teenage girl.
• Secondary amenorrhea is the loss of menstrual cycles for greater than three months in a woman who did have cycles previously.

The prevalence of menstrual dysfunction among female athletes is difficult to assess, but is not insignificant. Because some of the sub-clinical states mentioned above are not likely to come to the attention of the athlete’s physician until the athlete has suffered related health issues such as a stress fracture, it is important that female athletes self-monitor their cycles and flag any noticeable disruption. Amenorrheic athletes can lose over 2% of bone mass density per year, and are thus much more susceptible to stress fractures than menstruating athletes. Bone loss can also be experienced by athletes with low estrogen states.

Component 3 - Bone Strength
The final component of the female athlete triad addresses the continuum of bone health to osteoporosis. Bone is in a constant process of turnover. While bone is broken down and resorbed by osteoclasts, new bone is also being formed. Bone quality is determined by the bone turnover rates of resorbtion versus formation. Low estrogen states allow osteoclasts to live longer and resorb more bone. Estrogen is important to facilitate the uptake of calcium into bone. In addition, low energy states and vitamin and mineral deficiency delay the formation of new bone.

Women athletes with bone disease may not realize the full damage to their bodies until they hit menopause, at which time bone loss accelerates.

Summary and Treatment
The main problem behind the female athlete triad is energy drain. These women athletes are typically consciously or unconsciously maintaining a calorie deficit which then goes on to wreak havoc with their hormonal and bone health.

The dilemma that is faced by many women athletes, is that what is perceived to be a high performance body composition is in fact laden with health risks.

Studies have shown that 30kcal/kg of lean body mass is crucial for maintaining normal hormonal function. Athletes can feel huge pressure to attain unrealistic body composition goals, and ignore the basic needs of their bodies to function in a healthy manner. Emotional stress clearly plays a role in this cycle as well, and needs to be addressed by the athlete’s doctors and support system.

“The first step for treatment,” says Fredericson, “is to correct the energy balance, as that is the really at the heart of the issue.” Fredericson, a former collegiate distance runner himself, understands the importance of optimal body composition for athletes. “Without question,” he adds, “when the problem is complex, a multidisciplinary approach is the best approach, and sometimes the only approach that works.”

A multidisciplinary treatment approach uses sports medicine to address any stress fractures or functional anatomy problems, a nutritionist to address dietary changes and eating patterns, and a mental health professional to address issues of life stress, issues of control, self-image, and any co-existing depression or anxiety.

Warning Signs
Here is a brief list of warning signs that can all be signs of negative energy balance:

• Restricting food intake, calorie counting, eliminating food groups, skipping meals
• Preoccupation with weight or body image
• Low BMI
• Stress fracture(s)
• Chronic tiredness
• Loss of libido, or changes in libido
• Any of the above outlined changes in menstrual cycle
• Loss of concentration, memory, personality changes