The female triad

Osteoporosis is a prevalent AN complication. In fact, the duration of AN is a predictor of low bone mineral density because the longer the illness lasts, the greater bone mineral density is reduced (Mehler 2003). For example, more than 50 percent of female patients with AN develop osteoporosis (Treasure and Surpell 2001). Miller and Klibanski (1999) add that the lack of nutrition is so severe in anorexics that an increased osteoporosis risk may exist due to associated endocrine abnormalities, including estrogen deficiency.

Amenorrhea and Osteoporosis

Continuing the triad syndrome's assault oil the female athlete's wellness is the relationship between the absence of menses and bone deterioration. Some athletes see amenorrhea as a sign of appropriate training levels, while others regard it as a great solution to a monthly inconvenience (National Institutes of Health 2003). There is a prevailing myth in women's athletics that equates a disrupted menstrual cycle with the appropriate level of elite training (Papanek 2003). Mickelsfield, et al., (1995) state that amenorrheic/oligomenorrheic athletes on average have lower bone mineral density than eumenorrheic controls. Stein and Shane (2003) agree that low bone mineral density is a consequence of exercise-induced amenorrhea. Osteopenia or significantly reduced bone mass occurring with prolonged loss of menses has been associated with an increased risk of stress fractures (Mansfield and Emans 1993).

Summary

The female triad is a unique phenomenon that does not occur overnight but rather appears to gradually infiltrate female adolescents' lifestyle. Under intense pressure from parents, coaches teammates and often themselves, many young women begin to fall into patterns of disordered eating and/or overintense calorie expenditure without the support of adequate rest and nutrition. The triad is especially troubling due to the fact that, while each affliction can occur independently, they often are interrelated by a chain reaction. Amenorrhea/oligomenorrhea is likely to follow the caloric imbalance, which leads to osteopenia and ultimately osteoporosis. This downward spiral can result in termination of an athletic career as well as a chronically unhealthy adult life.

Identification of the triad can be difficult. When confronted by family, friends, coaches and physicians about their eating behavior, athletes can be anywhere from elusive in their explanation to perfectly convincing that nothing is wrong. Although it is more common to find this syndrome affecting athletic women, it is certainly not exclusive to this population. In general, women struggle with the perception of the "perfect body image" society has unfairly placed upon them. Regardless of the circumstances, we as health care providers, coaches and parents are ultimately responsible for protecting the wellness of the young women in our care. Therefore, we must provide a proper wellness environment by nurturing sound physical training and nutritional habits.