The female triad

American Fitness, May-June, 2004 by Lola Ramos, Gregory L. Welch

In the past 30 years the opportunities for adolescent girls and young adult women to participate in all levels of sports competition have increased tremendously. This is certainly a positive direction for women because with increased physical activity comes associated wellness benefits. Chronic physiological adaptation to exercise training is well documented in regard to improved cardiovascular efficiency, muscular strength, self-esteem and overall body image (Wilmore and Costill 1999).

In addition to women who train at a competitive level, many non-competitive women exercise vigorously as well. It is not just that they train at high intensities but that their ambition to train surpasses that of individuals who are more moderate in their exercise programs. This mindset is such that training becomes a lifestyle philosophy as well as a passion. While this is generally an admirable trait, it is not without significant risk. For example, "over training" injuries in the form of muscular strain, tendonitis and stress fractures will likely occur to many individuals who overprioritize their workouts at the expense of sufficient recovery and nutrition. Specifically for young women, there is an even greater health concern that far outweighs typical "overuse syndrome"--the female triad. If not dealt with appropriately, the female triad can damage women's wellness throughout their lives.

Defining the Female Triad

The female triad is a combination of three coexistent conditions associated with exercise training: disordered eating, amenorrhea and osteoporosis (Hobart and Smucker 2000). Originally termed "female athlete triad," the name was derived at a meeting led by members of the American College of Sports Medicine in the early 1990s (Yeager et al. 1993). Papanek (2003) reports that the meeting was called in response to the alarming increase in stress fracture rates, documented decreases in bone mineral density and menstrual dysfunction in otherwise healthy female athletes. Furthermore, the depiction of the triad as a triangle was developed to demonstrate the interrelationship between the three disorders normally considered independent medical conditions.

Over the last decade, the triad's definition has evolved to be more precise about the involvement of related clinical conditions. Anorexia nervosa (AN) and bulimia nervosa (BN) are the most common clinical disorders. A third category for eating disorders not otherwise specified (EDNOS) was created in an effort to expand treatment access for patients at high risk for an eating disorder (Papanck 2003). In other words, an athlete who falls short in meeting the criteria for AN or BN could still be recognized as needing treatment by being placed in the EDNOS category. See Table 1.

However, not all restrictive eating behaviors necessarily reach the clinical level (Beals and Manore 2000). Even with the addition of the EDNOS category, female athletes with the triad display a wide range of food-related pathologies. Therefore, the term "eating disorder" was found to be too restrictive and replaced by "disordered eating" to include the various forms of aberrant eating behaviors that disrupt caloric balance (Papanek 2003). Common disordered eating patterns exhibited by female athletes include food restriction, prolonged fasting as well as abuse of diet pills, diuretics and laxatives (Donaldson 2003).

Eumenorrheic or regular menstrual cycles are defined as regular flow occurring every 21 to 45 days, with 10 to 13 cycles per year, and oligomenorrhea refers to three to six cycles occurring per year (Rome 2003). Marshal (1994) classifies amenorrhea as primary or secondary and defines them as follows: primary amenorrhea or delayed menarche is defined as not having experienced a single menstrual cycle by the age of 16 and secondary amenorrhea is the absence of menses for six months or a length of time equivalent to at least three of the woman's previous menstrual cycle lengths. The main difference is that in secondary amenorrhea, at least one menstrual period has occurred. Physiologically, this means all parts of the reproductive axis (i.e., hypothalamus, pituitary, ovaries and uterus) worked together once, but for some reason, this integrative function has changed (Papanek 20O3).

Osteoporosis is a systemic, skeletal disease characterized by low bone density and microarchitectural deterioration of bone tissue, with a consequent increase in bone fragility and fracture susceptibility (O'brien 2001). To clarify, the term osteoporosis, as referred to in this writing, is actually secondary osteoporosis because it is caused or exacerbated by other disorders (Stein and Shane 2003). Additionally, osteopenia, which is abnormally low bone density and believed to be an osteoporosis precursor (Nelson 2000), has also been included when identifying the female triad syndrome. Amenorrheic adolescent athletes do not acquire proper bone mass and, thus, will be osteopenic in their early adult years (Elford and Spence 2002).