The Female Athlete Triad

By Ernest Joseph – 2007

Recently, HBO’s Real Sports documentary series aired a segment on a silent epidemic called The Female Athlete Triad. As the name suggests, Triad Disorder is a result of sequence of 3 symptoms – a domino effect – leading to this Disorder. And contrary to the name, it can also affect male runners, although women are overwhelmingly at risk. Triad is defined as ” disordered eating” in combination with intense training leading to a menorrhea (absence of menstruation that is not caused by pregnancy or menopause) and eventually leading to osteoporosis (Loss of bone mineral density). In case of male athletes, hypogonadism (low male hormone levels) leads to Triad Disorder. In one study, the incidence of amenorrhea among women running more than 70 miles per week was 43 % (American Journal of Obstetrics and Gynecology 143 :8 59-861, 1982). Public awareness and education about Triad Disorder is limited to mostly University setting, thus thousands of runners are unaware of its symptoms and treatment.

Symptoms and Signs:

To simplify, this Disorder is a series of 3 happenings leading to Triad. [1] Combination of intense training and disordered eating which le ads to [2] either Primary a menorrhea (complete absence of menstruation by age 16 in a female) or exercise-a sociated Secondary amenorrhea (absence of 3 to 12 consecutive menstrual periods after menarche which leads to [3] Osteoporosis (Sports Medicine 78 :34 5-356, 1994).

It is important to distinguish between the terms “disordered eating” and “eating disorder.” An eating disorder is a psychiatric diagnosis such as anorexia or bulimia. In contrast, disordered eating involves sporadic eating, poor nutrition, unnecessary dieting, or occasional bingeing and purging. Ask yourself if you demonstrate any of the traits mentioned above, and be candid in your answers. One does not have to wait to develop stress fracture or repeated bone-related injuries or series of missed menstrual periods to find out about loss of bone density. By correcting eating habits, an irreversible process like Osteoporosis can be avoided and long and healthy running career can be enjoyed.

Diagnosis and Treatment:

Prompt diagnosis can lead to early treatment and a better prognosis. Prognosis is much promising for athletes under 25 years of age, because onset of Osteoporosis can be halted with reducing exercise stress, gaining weight, or Pharmacotherapy. The medical community generally agrees that bone loss is irreversible, so the concern is not only for athletes’ risk for fractures but for their lifelong skeletal structure. This means poor prognosis for women over 25 years of age. Because the Triad Disorder has been recognized only recently, it is unclear if osteoporosis induced by amenorrhea is completely reversible. Research has indicated that amenorrheic women treated with hormone replacement maintain bone mineral density but replacement does not occur (Journal of Pediatrics, 126:683-689, 1995). In theory, these women may always have a greater risk for developing hip or vertebral spine compression fractures. Also it is important to remember that exercise-associated Secondary amenorrhea is a diagnosis of exclusion; therefore other causes of a menorrhea, such as pregnancy, hypothyroidism, pituitary tumors, etc. must be ruled out before EM can be ruled in. The American Academy of Sports Medicine now recommends that aII athletes with secondary amenorrhea be screened for other components of the Triad — disordered eating and osteoporosis.

Contrary to our image of osteoporosis as a condition of the elderly, the loss of bone mass can occur by the early twenties. One cause is poor nutrition. But the amenorrheic athlete is even more susceptible. She produces very low levels of ovarian hormones, and that lack of estrogen reduces bone mass more quickly and more severely than the lack of calcium does. That is why estrogen is so widely used to combat osteoporosis in postmenopausal women.

Summary:

It is hard to define intense training in terms of miles per week. It may very from individual to individuaI. And for that reason, it is better to look out for symptoms (poor nutrition, absence of menstruation, multiple stress fractures) and act promptly. This is only an effort to make runners aware about this condition or Disorder called Triad, and by no means to discourage anyone from running. The more informed we are, the better prepared we are for prevention. And prevention is better than cure.