For most girls and young women, participation in sports can be a healthy and enjoyable experience. However, there are rare cases in which sports participation plays a role in disordered eating, amenorrhea (loss of menses), and osteoporosis (loss of bone mass). There are steps to take, though, to help prevent these unfortunate outcomes from becoming more frequent.

Those three interrelated problems compose what has been termed the "Female Athlete Triad." The Triad can affect female athletes in all sports and at all levels
of competition. It often begins with "disordered eating," which ranges from simple unhealthy dieting to full-blown eating disorders. For a variety of reasons, the athlete may either willfully (that is, dieting to lose weight or body fat) or inadvertently not be ingesting enough calories to adequately fuel her physical activity and normal bodily processes.

If this "energy drain" is severe and persistent, the reproductive system shuts down. Without adequate levels of estrogen, menstrual dysfunction occurs. Bone growth and health depend on estrogen. Without it, the athlete can lose bone mineral density, which can lead to osteopenia or even osteoporosis. At a time when she should be adding bone mass, she is losing it. Disordered eating can in turn further worsen bone health.

Due to the prevalence of eating disorders among young women, the prevalence of amenorrhea or menstrual dysfunction among athletes -- and the pressures some athletes feel to be lean or thin to perform better or meet an appearance standard for their sport -- the prevalence of the Triad is higher than it should be. A recent Norwegian study found that the Triad affects a significant proportion of elite women athletes, but also a significant proportion of physically active nonathletes.

Although the risks of the Triad have been known for about 20 years, a large section of the public is unaware of it. Even more alarming is the fact that the Triad is not well-known in the athletics community, either, including sports medicine professionals and other healthcare workers.

The American College of Sports Medicine (ACSM) has taken the lead regarding education and prevention of the Triad and in 1997 published the first position statement on identifying, treating and preventing it. Other efforts have been offered by the International Olympic Committee Medical Commission, the Athlete Special Interest Group of the Academy for Eating Disorders (AED), the Female Athlete Triad Coalition and the NCAA.

In October, the AED sponsored a conference on the Triad in Indianapolis and drew about 100 attendees from the sports and healthcare fields. Also in October, the Female Athlete Triad Coalition, a group of concerned professionals from the sport, sport medicine, and healthcare fields, including researchers investigating the Triad, met at the NCAA national office to raise awareness and advocate for solutions.

Also, the NCAA in 2003 surveyed coaches about how they identify and manage disordered eating and other signs of the Triad. Preliminary results of that study, which will be published later this year, indicate that Triad symptoms occur in all sports. The study also suggests that while coaches understand the seriousness of disordered eating for both the athlete's health and performance, they need more information about identifying and managing disordered eating and amenorrhea.

As a result, the NCAA, in conjunction with experts in the field, developed a coach's handbook for managing the Triad that will be provided to coaches of targeted women sports. The book also is available online at www.ncaa.org/health-safety.

Experts in the field agree that recent efforts have been productive. Nonetheless, much remains to be done to ensure that female athletes are not unduly exposed to unnecessary risks regarding the Triad. Additionally, more needs to be done to expedite the identification and treatment of those affected to minimize the physical and psychological consequences.

The possibility of developing symptoms of the Triad should not be misconstrued to mean that sport participation is unhealthy. On the contrary, we want to encourage sport participation by girls and young women. But we also want to encourage everyone in the athletics community to become better educated about identifying, managing, treating and, ultimately, preventing the Triad.

Ron Thompson, co-author of the NCAA Coaches Handbook, is a psychologist who specializes in the treatment of eating disorders. He has been a consulting psychologist to the athletics department at Indiana University, Bloomington, for 18 years.