Over the last few decades, there has been arise in the number of girls and young women athletes. There has also been an increase inthe diversity of sports and the intensity with which girls are participating.

Girls have unique issues and problems that arise for sports participation. One of those is the female athlete triad.

What is it? The female athlete triad was first described in 1993 linking three seemingly related problems that were noticed in female athletes: amenorrhea (lack of menses), eating disorders and osteoporosis.

Since that time, more research has been done to further define the links among these distinct yet interrelated disorders. In an article published in the Clinics in Sports Medicine in January 2007, the triad is more broadly defined as a spectrum of each of the disorders. The new research links these problems with the common thread of an energy imbalance as the underlying problem leading to the issues of changes in menstrual function and decreases in bone density.

How common is the problem? Most of the studies to date have focused on elite and collegiate athletes. Estimates from a broad range of studies report rates from as low as 15 percent to as high as 62 percent! A study in 2006 of female high school athletes in California estimated approximately 6 percent to 20 percent met at least one of the three criteria.

Who is at risk? All female athletes, but especially those in sports where a certain body type is encouraged. Examples include figure skating, gymnastics, ballet and long distance running. Also, any athlete who is in a highly competitive environment from coaches and peers is at risk for developing the disorder.

Disordered Eating. Many girls try to lose weight in order to enhance their performance. Often athletes are trying to be “healthy” by avoiding certain “bad” or “fatty” foods. This restriction can be mild to severe and can eventually lead to an energy imbalance. Contrary to what many of these girls believe, they need to take in more, not fewer, calories to optimize their performance. Rarely, athletes can go on to develop more severe forms of disordered eating, including anorexia and bulimia.

Menstrual dysfunction (irregular or no periods): Contrary to the beliefs of some, it is not normal for a female athlete to stop getting a period; however, it is common, with estimates ranging from 3.4 to 66 percent. While the exact cause of the menstrual changes is not yet known, the evidence appears to show that it is an energy deficit, or insufficient intake of calories, that leads to a disruption of the normal hormone cycles in a girl’s body. This, in turn, leads to abnormal menstrual cycles.

Osteopenia (weakened bones) This is the most severe consequence of this energy imbalance in the female athlete. The most severe manifestation is osteoporosis. Because of the stress of the energy imbalance in the body, there are lower levels of estrogen. Estrogen is very important in building and maintaining bone mass in females and the most critical time for “laying down bone” is in the teen years to the early 20s. In fact, 98 percent of a girl’s lifetime bone mass is deposited by age 20.

Why is this important? Athletes who develop the female athlete triad are at higher risk for problems with infertility, decreased immune function, stress fractures, premature osteoporosis and possibly cardiovascular problems as they get older.

What can we do? As parents and coaches, be sure to emphasize overall health and nutrition:

• Do not become overly focused on weight or body image.
• Get regular sports participation physicals where your athlete can be screened for this condition.
• Have your teen keep track of her periods.
• Make sure that your athlete is eating a balanced and energy appropriate diet for her level of activity.

If you have questions or are concerned about your daughter, you can contact your primary provider for information and a possible evaluation. He or she may refer you to our dietician, Karen Moberg, our sports medicine specialist, Gary Nichols, or any number of our providers who focus on adolescent health.

—Megan Jennings, MD