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The Female Athlete Triad

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Musculoskeletal Health in Women

Abstract

The female athlete triad describes a spectrum of eating behaviors that result in low energy availability, accompanied by a range of less than ideal menstrual function and bone mineral density. Though the true prevalence of the triad along its full spectrum of interrelated pathologies remains unclear, limited studies have reported prevalence in 0–40 % of athletes and 0–3 % of controls. Diagnosis of the female athlete triad relies on a high index of suspicion among primary care physicians and sports specialists alike. If there is concern for one component of the triad, workup for the other components should be performed. Prevention is critical in high-risk groups. The mainstay of treatment is to increase energy availability. A multidisciplinary approach to treatment is best, with involvement of physicians from primary care, psychiatry, and sports specialists as needed, in addition to a nutritionist, trainer, and family members. Future investigation should focus on better quantifying the problem and options for intervention.

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Abbreviations

AN:

Anorexia nervosa

BMD:

Bone mineral density

BN:

Bulimia nervosa

FAT:

Female athlete triad

GnRH:

Gonadotropin-releasing hormone

LH:

Luteinizing hormone

OCP:

Oral contraceptive pill

References

  1. Thein-Nissenbaum JM, Carr KE. Female athlete triad syndrome in the high school athlete. Phys Ther Sport. 2011;12(3):108–16.

    Article  PubMed  Google Scholar 

  2. Sundgot-Borgen J, Torstveit MK. Prevalence of eating disorders in elite athletes is higher than in the general population. Clin J Sport Med. 2004;14(1):25–32.

    Article  PubMed  Google Scholar 

  3. Hobart JA, Smucker DR. The female athlete triad. Am Fam Physician. 2000;61(11):3357–64, 67.

    CAS  PubMed  Google Scholar 

  4. Brunet 2nd M. Female athlete triad. Clin Sports Med. 2005;24(3):623–36, ix.

    Article  PubMed  Google Scholar 

  5. Yeager KK, Agostini R, Nattiv A, Drinkwater B. The female athlete triad: disordered eating, amenorrhea, osteoporosis. Med Sci Sports Exerc. 1993;25(7):775–7.

    Article  CAS  PubMed  Google Scholar 

  6. Otis CL, Drinkwater B, Johnson M, Loucks A, Wilmore J. American College of Sports Medicine position stand. The female athlete triad. Med Sci Sports Exerc. 1997;29(5):i–ix.

    Article  CAS  PubMed  Google Scholar 

  7. Nattiv A, Loucks AB, Manore MM, Sanborn CF, Sundgot-Borgen J, Warren MP. American College of Sports Medicine position stand. The female athlete triad. Med Sci Sports Exerc. 2007;39(10):1867–82.

    Article  PubMed  Google Scholar 

  8. Beals KA, Manore MM. Disorders of the female athlete triad among collegiate athletes. Int J Sport Nutr Exerc Metab. 2002;12(3):281–93.

    PubMed  Google Scholar 

  9. Coelho GM, Farias ML, Mendonca LM, Mello DB, Lanzillotti HS, Ribeiro BG, et al. The prevalence of disordered eating and possible health consequences in adolescent female tennis players from Rio de Janeiro, Brazil. Appetite. 2013;64C:39–47.

    Article  Google Scholar 

  10. Doyle-Lucas AF, Akers JD, Davy BM. Energetic efficiency, menstrual irregularity, and bone mineral density in elite professional female ballet dancers. J Dance Med Sci. 2010;14(4):146–54.

    PubMed  Google Scholar 

  11. Hoch AZ, Pajewski NM, Moraski L, Carrera GF, Wilson CR, Hoffmann RG, et al. Prevalence of the female athlete triad in high school athletes and sedentary students. Clin J Sport Med. 2009;19(5):421–8.

    Article  PubMed  Google Scholar 

  12. Hoch AZ, Stavrakos JE, Schimke JE. Prevalence of female athlete triad characteristics in a club triathlon team. Arch Phys Med Rehabil. 2007;88(5):681–2.

    Article  PubMed  Google Scholar 

  13. Nichols JF, Rauh MJ, Lawson MJ, Ji M, Barkai HS. Prevalence of the female athlete triad syndrome among high school athletes. Arch Pediatr Adolesc Med. 2006;160(2):137–42.

    Article  PubMed  Google Scholar 

  14. Pollock N, Grogan C, Perry M, Pedlar C, Cooke K, Morrissey D, et al. Bone-mineral density and other features of the female athlete triad in elite endurance runners: a longitudinal and cross-sectional observational study. Int J Sport Nutr Exerc Metab. 2010;20(5):418–26.

    PubMed  Google Scholar 

  15. Quah YV, Poh BK, Ng LO, Noor MI. The female athlete triad among elite Malaysian athletes: prevalence and associated factors. Asia Pac J Clin Nutr. 2009;18(2):200–8.

    PubMed  Google Scholar 

  16. Schtscherbyna A, Soares EA, de Oliveira FP, Ribeiro BG. Female athlete triad in elite swimmers of the city of Rio de Janeiro, Brazil. Nutrition. 2009;25(6):634–9.

    Article  PubMed  Google Scholar 

  17. Torstveit MK, Sundgot-Borgen J. The female athlete triad exists in both elite athletes and controls. Med Sci Sports Exerc. 2005;37(9):1449–59.

    Article  PubMed  Google Scholar 

  18. Vardar SA, Vardar E, Altun GD, Kurt C, Ozturk L. Prevalence of the female athlete triad in Edirne, Turkey. J Sports Sci Med [Internet]. 2005;4:550–5. Cited 4 Mar 2013. Available from: http://www.jssm.org/vol4/n4/21/v4n4-21text.php

  19. Wade GN, Schneider JE, Li HY. Control of fertility by metabolic cues. Am J Physiol. 1996;270(1 Pt 1):E1–19.

    CAS  PubMed  Google Scholar 

  20. Krentz EM, Warschburger P. A longitudinal investigation of sports-related risk factors for disordered eating in aesthetic sports. Scand J Med Sci Sports. 2013;23(3):303–10.

    Article  CAS  PubMed  Google Scholar 

  21. Coelho GM, Soares Ede A, Ribeiro BG. Are female athletes at increased risk for disordered eating and its complications? Appetite. 2010;55(3):379–87.

    Article  PubMed  Google Scholar 

  22. Frisch RE, McArthur JW. Menstrual cycles: fatness as a determinant of minimum weight for height necessary for their maintenance or onset. Science. 1974;185(4155):949–51.

    Article  CAS  PubMed  Google Scholar 

  23. Loucks AB, Horvath SM, Freedson PS. Menstrual status and validation of body fat prediction in athletes. Hum Biol. 1984;56(2):383–92.

    CAS  PubMed  Google Scholar 

  24. Loucks AB. Energy availability, not body fatness, regulates reproductive function in women. Exerc Sport Sci Rev. 2003;31(3):144–8.

    Article  PubMed  Google Scholar 

  25. Redman LM, Loucks AB. Menstrual disorders in athletes. Sports Med. 2005;35(9):747–55.

    Article  PubMed  Google Scholar 

  26. Loucks AB, Verdun M, Heath EM. Low energy availability, not stress of exercise, alters LH pulsatility in exercising women. J Appl Physiol. 1998;84(1):37–46.

    CAS  PubMed  Google Scholar 

  27. Warren MP, Perlroth NE. The effects of intense exercise on the female reproductive system. J Endocrinol. 2001;170(1):3–11.

    Article  CAS  PubMed  Google Scholar 

  28. Ackerman KE, Slusarz K, Guereca G, Pierce L, Slattery M, Mendes N, et al. Higher ghrelin and lower leptin secretion are associated with lower LH secretion in young amenorrheic athletes compared with eumenorrheic athletes and controls. Am J Physiol Endocrinol Metab. 2012;302(7):E800–6.

    Article  CAS  PubMed  Google Scholar 

  29. Laughlin GA, Yen SS. Hypoleptinemia in women athletes: absence of a diurnal rhythm with amenorrhea. J Clin Endocrinol Metab. 1997;82(1):318–21.

    Article  CAS  PubMed  Google Scholar 

  30. Rodriguez-Pacheco F, Martinez-Fuentes AJ, Tovar S, Pinilla L, Tena-Sempere M, Dieguez C, et al. Regulation of pituitary cell function by adiponectin. Endocrinology. 2007;148(1):401–10.

    Article  CAS  PubMed  Google Scholar 

  31. Bennell K, Matheson G, Meeuwisse W, Brukner P. Risk factors for stress fractures. Sports Med. 1999;28(2):91–122.

    Article  CAS  PubMed  Google Scholar 

  32. De Souza MJ, Miller BE, Loucks AB, Luciano AA, Pescatello LS, Campbell CG, et al. High frequency of luteal phase deficiency and anovulation in recreational women runners: blunted elevation in follicle-stimulating hormone observed during luteal-follicular transition. J Clin Endocrinol Metab. 1998;83(12):4220–32.

    Article  PubMed  Google Scholar 

  33. Torstveit MK, Sundgot-Borgen J. Participation in leanness sports but not training volume is associated with menstrual dysfunction: a national survey of 1276 elite athletes and controls. Br J Sports Med. 2005;39(3):141–7.

    Article  CAS  PubMed  Google Scholar 

  34. Lambrinoudaki I, Papadimitriou D. Pathophysiology of bone loss in the female athlete. Ann N Y Acad Sci. 2010;1205:45–50.

    Article  CAS  PubMed  Google Scholar 

  35. Fehling PC, Alekel L, Clasey J, Rector A, Stillman RJ. A comparison of bone mineral densities among female athletes in impact loading and active loading sports. Bone. 1995;17(3):205–10.

    Article  CAS  PubMed  Google Scholar 

  36. Close GL, Russell J, Cobley JN, Owens DJ, Wilson G, Gregson W, et al. Assessment of vitamin D concentration in non-supplemented professional athletes and healthy adults during the winter months in the UK: implications for skeletal muscle function. J Sports Sci. 2013;31(4):344–53.

    Article  CAS  PubMed  Google Scholar 

  37. Lovell G. Vitamin D, status of females in an elite gymnastics program. Clin J Sport Med. 2008;18(2):159–61.

    Article  PubMed  Google Scholar 

  38. Riggs BL, Khosla S, Melton 3rd LJ. Sex steroids and the construction and conservation of the adult skeleton. Endocr Rev. 2002;23(3):279–302.

    Article  CAS  PubMed  Google Scholar 

  39. Prior JC, Vigna YM, Schechter MT, Burgess AE. Spinal bone loss and ovulatory disturbances. N Engl J Med. 1990;323(18):1221–7.

    Article  CAS  PubMed  Google Scholar 

  40. Snead DB, Weltman A, Weltman JY, Evans WS, Veldhuis JD, Varma MM, et al. Reproductive hormones and bone mineral density in women runners. J Appl Physiol. 1992;72(6):2149–56.

    Article  CAS  PubMed  Google Scholar 

  41. Cobb KL, Bachrach LK, Greendale G, Marcus R, Neer RM, Nieves J, et al. Disordered eating, menstrual irregularity, and bone mineral density in female runners. Med Sci Sports Exerc. 2003;35(5):711–9.

    Article  PubMed  Google Scholar 

  42. Christo K, Prabhakaran R, Lamparello B, Cord J, Miller KK, Goldstein MA, et al. Bone metabolism in adolescent athletes with amenorrhea, athletes with eumenorrhea, and control subjects. Pediatrics. 2008;121(6):1127–36.

    Article  PubMed  Google Scholar 

  43. Lewiecki EM, Gordon CM, Baim S, Leonard MB, Bishop NJ, Bianchi ML, et al. International Society for Clinical Densitometry 2007 Adult and Pediatric Official Positions. Bone. 2008;43(6):1115–21.

    Article  PubMed  Google Scholar 

  44. Ducher G, Turner AI, Kukuljan S, Pantano KJ, Carlson JL, Williams NI, et al. Obstacles in the optimization of bone health outcomes in the female athlete triad. Sports Med. 2011;41(7):587–607.

    Article  PubMed  Google Scholar 

  45. Vescovi JD, Jamal SA, De Souza MJ. Strategies to reverse bone loss in women with functional hypothalamic amenorrhea: a systematic review of the literature. Osteoporos Int. 2008;19(4):465–78.

    Article  CAS  PubMed  Google Scholar 

  46. Cobb KL, Bachrach LK, Sowers M, Nieves J, Greendale GA, Kent KK, et al. The effect of oral contraceptives on bone mass and stress fractures in female runners. Med Sci Sports Exerc. 2007;39(9):1464–73.

    Article  CAS  PubMed  Google Scholar 

  47. Miller KK, Lawson EA, Mathur V, Wexler TL, Meenaghan E, Misra M, et al. Androgens in women with anorexia nervosa and normal-weight women with hypothalamic amenorrhea. J Clin Endocrinol Metab. 2007;92(4):1334–9.

    Article  CAS  PubMed  Google Scholar 

  48. Warren MP, Brooks-Gunn J, Fox RP, Holderness CC, Hyle EP, Hamilton WG, et al. Persistent osteopenia in ballet dancers with amenorrhea and delayed menarche despite hormone therapy: a longitudinal study. Fertil Steril. 2003;80(2):398–404.

    Article  PubMed  Google Scholar 

  49. Keen AD, Drinkwater BL. Irreversible bone loss in former amenorrheic athletes. Osteoporos Int. 1997;7(4):311–5.

    Article  CAS  PubMed  Google Scholar 

  50. Drinkwater BL, Bruemner B, Chesnut 3rd CH. Menstrual history as a determinant of current bone density in young athletes. JAMA. 1990;263(4):545–8.

    Article  CAS  PubMed  Google Scholar 

  51. Wiksten-Almstromer M, Hirschberg AL, Hagenfeldt K. Reduced bone mineral density in adult women diagnosed with menstrual disorders during adolescence. Acta Obstet Gynecol Scand. 2009;88(5):543–9.

    Article  PubMed  Google Scholar 

  52. Anderson TJ, Uehata A, Gerhard MD, Meredith IT, Knab S, Delagrange D, et al. Close relation of endothelial function in the human coronary and peripheral circulations. J Am Coll Cardiol. 1995;26(5):1235–41.

    Article  CAS  PubMed  Google Scholar 

  53. Neunteufl T, Katzenschlager R, Hassan A, Klaar U, Schwarzacher S, Glogar D, et al. Systemic endothelial dysfunction is related to the extent and severity of coronary artery disease. Atherosclerosis. 1997;129(1):111–8.

    Article  CAS  PubMed  Google Scholar 

  54. Zeni Hoch A, Dempsey RL, Carrera GF, Wilson CR, Chen EH, Barnabei VM, et al. Is there an association between athletic amenorrhea and endothelial cell dysfunction? Med Sci Sports Exerc. 2003;35(3):377–83.

    Article  PubMed  Google Scholar 

  55. Rickenlund A, Eriksson MJ, Schenck-Gustafsson K, Hirschberg AL. Amenorrhea in female athletes is associated with endothelial dysfunction and unfavorable lipid profile. J Clin Endocrinol Metab. 2005;90(3):1354–9.

    Article  CAS  PubMed  Google Scholar 

  56. Hoch AZ, Papanek P, Szabo A, Widlansky ME, Schimke JE, Gutterman DD. Association between the female athlete triad and endothelial dysfunction in dancers. Clin J Sport Med. 2011;21(2):119–25.

    Article  PubMed  Google Scholar 

  57. Halcox JP, Schenke WH, Zalos G, Mincemoyer R, Prasad A, Waclawiw MA, et al. Prognostic value of coronary vascular endothelial dysfunction. Circulation. 2002;106(6):653–8.

    Article  PubMed  Google Scholar 

  58. Targonski PV, Bonetti PO, Pumper GM, Higano ST, Holmes Jr DR, Lerman A. Coronary endothelial dysfunction is associated with an increased risk of cerebrovascular events. Circulation. 2003;107(22):2805–9.

    Article  PubMed  Google Scholar 

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Author information

Authors and Affiliations

  1. Department of Orthopaedic Surgery, Brigham and Women’s Hospital, 75 Francis Street, Boston, MA, 02115, USA

    Elizabeth Matzkin MS, MD

  2. Department of Orthopaedic Surgery, Center for Advanced Orthopaedic Studies, Harvard Medical School, 99 Brookline Ave, RN 115, Boston, MA, 02215, USA

    Gabrielle M. Paci BA

Authors
  1. Elizabeth Matzkin MS, MD
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  2. Gabrielle M. Paci BA
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Correspondence to Elizabeth Matzkin MS, MD .

Editor information

Editors and Affiliations

  1. Department of Rheumatology, Gretchen and Edward Fish Center for Women’s Health,, Brigham and Women’s Hospital, Chestnut Hill, Massachusetts, USA

    Elinor Mody

  2. Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, Massachusetts, USA

    Elizabeth Matzkin

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© 2014 Springer-Verlag London

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Matzkin, E., Paci, G.M. (2014). The Female Athlete Triad. In: Mody, E., Matzkin, E. (eds) Musculoskeletal Health in Women. Springer, London. https://doi.org/10.1007/978-1-4471-4712-1_1

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  • DOI: https://doi.org/10.1007/978-1-4471-4712-1_1

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