The NCAA News - News and Features

April 20, 1998

SPORTS SCIENCES NEWSLETTER

The female athlete triad

A review of disordered eating, amenorrhea and osteoporosis

Active women and girls driven to excel in sports may develop the female athlete triad, a recently recognized syndrome that consists of three distinct but interrelated conditions -- disordered eating, amenorrhea and osteoporosis.

Disordered eating encompasses a range of poor nutritional behaviors. Amenorrhea refers to irregular or absent menstrual periods. Osteoporosis refers to low bone mass and microarchitectural deterioration, which leads to bone fragility and risk of fracture.

Exercise promotes good health

Physical activity should be encouraged since it promotes health, cardiovascular fitness, bone strength and longevity. Exercise alone is not a risk factor for development of the triad; however, an energy deficit in which caloric intake does not match energy expenditure is a risk factor.

External and internal pressure may foster development of the triad

Most women face societal pressure to be thin. Well-meaning coaches, friends and parents may encourage weight loss by a female athlete because of a mistaken belief that excessive leanness enhances performance. A young woman or girl who is determined to achieve a lean appearance or athletics success may attempt to excel through dieting and excessive exercise. (Such females are typically goal-oriented, perfectionistic and compulsive.) This misguided approach may lead to disordered eating, menstrual dysfunction and lower-than- normal bone-mass formation.

Anyone may be affected, but women and girls participating in activities in which leanness is emphasized are at high risk. Gymnastics, ballet, diving, figure skating, aerobics and running are examples. Sports with weight classifications, such as wrestling, rowing and martial arts also may foster disordered eating in athletes, males included.

Disordered eating is a spectrum of abnormal behaviors

In response to pressure to lose weight, women and girls may practice unhealthy weight-control methods, including restricted food intake, self-induced vomiting, consumption of appetite suppressants and diet pills, use of laxatives and compounds to increase urination, anorexia nervosa and bulimia. Anorexia nervosa refers to weight 15 percent below normal, obsessive fear of fatness, abnormal body image (i.e., a thin person who thinks she is fat) and amenorrhea. Bulimia is defined as binge eating at least two times a week for at least three months, loss of control over eating and purging (i.e., self-induced vomiting or use of diet pills, laxatives, enemas or excessive exercise to lose weight).

Warning signs of eating disorders

Some warning signs of eating disorders include:

excessive leanness or rapid weight loss; preoccupation with weight, food, meal-time rituals and body image; wide fluctuations in weight; daily vigorous exercise in addition to regular training sessions; and stress fractures (i.e., microfractures of bones that may progress to complete bone breakage).

Also, yellowing of the skin and soft baby hair on the skin, plus the following signs of self-induced vomiting: frequent sore throat despite no other signs of respiratory illness; chipmunk-like cheeks from swollen parotid glands; many dental cavities; and foul breath.

Other signs of eating disorders are fatigue, light-headedness, dizziness, depression and low self-esteem.

Disordered eating is often hidden

Many girls and women hide or deny their eating disorders because of embarrassment, shame, fear of losing control of their dieting and their mistaken belief that excessive weight loss enhances performance.

Performance in sport, school and work may decline from disordered eating

Disordered eating may cause weakness, dehydration, anemia (i.e., low oxygen-carrying capacity of blood), lack of concentration, impaired coordination, frequent and delayed recovery from injuries, illness and depression.

Eating disorders may be fatal

Eating disorders are serious, chronic medical and psychological illnesses. Individuals with untreated chronic anorexia or bulimia may die prematurely from heart problems, blood electrolyte (salt) disorders, suicide or other health problems. Christy Heinrich, a member of the U.S. gymnastics team died in 1994 at age 21 from consequences of anorexia nervosa. If these disorders are recognized early, treatment may be effective.

Amenorrhea warrants evaluation

An unbalanced diet, inadequate caloric intake relative to exercise level and perhaps excessive training may predispose females to menstrual abnormalities. Al-though women and girls may be relieved to not have menstrual periods, their absence may be due to a medical disorder and can be associated with osteoporosis.

Any female who doesn't start menstruating by the age of 16, misses three consecutive menstrual periods or has periods that occur at intervals greater than every 35 days should be evaluated by a physician. Before attributing menstrual abnormalities to exercise, other conditions such as pregnancy, abnormalities of the reproductive organs or thyroid disease must be excluded. Any female without periods who is sexually active may get pregnant, so contraception should be used if pregnancy is not desired.

Osteoporosis may occur prematurely

Osteoporosis refers to low bone mass and fragility of the skeleton. Bone mass of women typically peaks in the mid 20s to 30s. A 20-year-old woman without menses during her critical teenage growth period may have bone mass typical of a 70-year-old woman, predisposing her to stress fractures and other fractures later in life.

Adequate nutrition, including a balanced diet, adequate calories, relative number of calories spent during exercise and proper calcium fosters good bone formation. The calcium requirement for teenage girls and young women with normal menses is 1,200 mg per day. This can be obtained by consuming three to four dairy products per day or by taking calcium supplement tablets. Females with irregular or absent menses require 1,500 mg of calcium and 400 mg of Vitamin D per day.

Low estrogen levels and other hormonal changes, which accompany irregular or absent menstrual periods, may predispose females to osteoporosis.

The female athlete triad may be prevented

Proper nutritional practices should be taught to women and girls. Athletes and non-athletes should strive for proper caloric intake while eating a well-balanced diet.

Emphasis or pressure to achieve unrealistically low body weight should be avoided by coaches, parents, athletics administrators and health professionals. Out-of-competition weigh-ins should be discouraged. Rules governing sports should be examined and eliminated or revised if they encourage excessive leanness. Individuals working with active women and girls should learn the seriousness of each of the disorders in the triad and recognize warning signs.

Early recognition and treatments hasten recovery

Although individuals with disordered eating or amenorrhea may deny nutritional or health problems and are reluctant to seek care, medical attention is mandatory. An individual may be more likely to seek medical help if the risks of poor nutrition and amenorrhea are explained in a nonjudgmental way. An athlete also should be reminded that medical care and proper nutrition may enhance performance.

If an eating disorder or amenorrhea is suspected, the involved individual should be strongly encouraged or required to seek medical attention. If the individual refuses, the concerned coach, friend or parent should consult with a physician directly.

Treatment of the triad often requires intervention via a team approach. A physician, nutritionist and psychologist may need to work with the woman or girl, coach, parents and close friends. Nutritional monitoring, hormone replacement and reduced training may be recommended. Early intervention hastens recovery.

For additional information on the female athlete triad, contact the American College of Sports Medicine, Department F, P.O. Box 1440, Indianapolis, Indiana 46206-1440. Phone: 314/637-9200; fax: 317/634-7817; e-mail: natcoal@indy.net.