A Risk for Young Athletes: The Female Athlete Triad
The female athlete triad (“the triad”) is a serious and often missed condition that can affect women and girls who exercise and participate in sports. It involves three interconnected components: low energy availability, abnormal menstruation, and poor bone health. Together, these three issues can wreak havoc on a female athlete’s health and well-being. Let’s dive into these three components, how they affect the body, and what can be done to care for these athletes. Learn a risk for young Athletes: The Female Athlete Triad.
Breaking Down the Triad
Low Energy Availability
Of the three components of the triad, low energy availability is considered the foundational factor. Low energy availability simply means that the body is not getting enough food (energy) to keep up with daily activities.
Athletes can have low energy availability unknowingly or intentionally.
- Unknowingly, athletes often do not realize they are not eating enough food (or the best types of food) to support the demands of their sports. This can be from a lack of education or from following incorrect or misleading nutritional advice.
- Intentionally: There can be several reasons why an athlete may deliberately restrict their food intake. They may be trying to fit a certain look, be aiming to please someone else, or think that lower weight means better athletic performance. This falls into the spectrum of disordered eating. The severe side of this is eating disorders, such as bulimia nervosa and anorexia nervosa. There are specific diagnostic criteria for eating disorders, including mental health concerns such as an intense fear of gaining weight or an obsession with body image. Often, someone may try to hide this disorder and struggle with it in secret. The origin of low energy availability is more complicated and delicate to address and improve.
Low energy availability affects all components of bodily function, including menstruation and bone health, the other two components of the triad.
Abnormal Menstruation
On average, menstruation (monthly periods) starts at age 12, then occurs every 28 days for two to seven days. When the body is not getting enough energy or is stressed in another way, hormones can’t work properly. This can then cause abnormal menstruation: missed or irregular periods, or no period at all in someone who should be having normal periods. It is a myth that it is normal for female athletes to lose their periods when training; it is a sign that the body is not in a healthy state.
Poor Bone Health
Both low energy availability and abnormal menstruation cause poor bone health, specifically low bone mineral density. When the body is low on energy, it can’t keep bones as strong as they should be. Additionally, menstrual hormones are an essential factor in bone health, so abnormal periods can cause fragile bones. Interestingly, athletes should have higher bone mineral density than the average person because exercise helps bones grow strong and healthy. Without this added bone strength, athletes are at a higher risk of injury.
What Are the Consequences of the Triad?
In isolation, each of these components can cause major health issues. When these three components are combined, the effects on the body are more significant. Even someone displaying only one or two of the components can still develop health issues and be at risk of developing the third component of the triad.
Consequences of the triad include, but are not limited to, the following:
- Mental health disease
- Muscle injuries
- Longer healing times
- Osteoporosis
- Stunted growth
- Bone fractures (stress and sudden)
- Infertility
- Poor heart health
- Lifelong eating disorders or disordered eating
- Fatigue
- Poor concentration
- Chronic pain
- Decreased strength, endurance, and power
- Poor sport performance
- Inability to continue playing sports.
Who Is at Risk?
The triad can develop in female athletes of any sport. It is most common in sports that emphasize leanness, endurance, and subjective judging. This includes:
- Dance (especially ballet)
- Running
- Gymnastics
- Cheerleading
- Diving
- Figure skating
This condition can also occur with female athletes at any age, but the effects are more substantial with younger athletes. As mentioned above, osteoporosis can be a long-term consequence of the triad. Almost half of our bone mass is developed in adolescence, and bone mass development peaks between the ages of 20 and 25. Any loss of bone mass in our youth is very difficult to gain back, so young athletes with the triad can have bone health issues for the rest of their lives. Additionally, many eating disorders often begin in someone’s teenage years, which also puts younger athletes at risk.
Athletes who are highly competitive, perfectionists, and overly self-critical and who have low self-esteem, critical parents or coaches, and high pressure to perform well are also at a higher risk for developing the triad.
Care: A Team Approach Is Essential
The triad is complex, so care for this condition can also be complex. A team approach at all stages of care is the best way to support these athletes.
Prevention
Because the triad can have lifelong consequences for an athlete’s physical and mental health, prevention is essential whenever possible!
The best way to prevent the triad is through education, which should include the following topics.
- Nutrition: As low energy availability is the foundational factor in the triad, high-quality nutrition education is non-negotiable. Many athletes don’t actually know the nutritional demands the body needs to safely participate in sports. Those with disordered eating, including eating disorders, also often have low levels of nutrition knowledge, so everyone must receive high-quality nutrition education from qualified specialists.
- Healthy attitudes, behaviors, and beliefs: Having a healthy mindset toward exercise, body image, food, and self-image is essential. It is important for female athletes to have good role models who show them how to thrive in sports and other areas of life in healthy, sustainable ways.
- Proper rest breaks: Competitiveness, dedication to improve, and passion in a sport can be positive qualities in athletes. However, when taken to the extreme, they can become a problem, especially when an athlete does not take proper rest away from training. Athletes need to understand the benefits of rest for recovery and reenergizing the body.
- Cross-training: Cross-training is an excellent way to build dynamic strength. It also decreases an athlete’s risk for injury. It’s important to avoid doing the same activities over and over again without variety or breaks. This includes specializing in a single sport early on. The body grows best when it is exposed to a variety of activities, challenges, and opportunities to learn different skills.
It is crucial for athletes, parents, coaches, and all other athletic staff to be educated on these topics.
Screening
Unfortunately, the triad can often go unnoticed until it worsens enough to affect the athlete’s performance. Even subtle signs and symptoms of any of the three components (even if it is just one) need to be addressed as early as possible. Some warning signs include the following:
- Excessive exercise routine outside of usual practice
- Unusual agitation over time away from exercising (such as an injury or a rest day)
- Fixation on weight
- A new, specific diet without a medical prescription.
Routine screening of female athletes is an excellent way to catch components of the triad in their early stages. Screening questionnaires can be added at the start of a sport’s season or during annual physicals. These triad questionnaires primarily ask about nutrition and menstrual health.
Diagnosis and Treatment
If an athlete is diagnosed with the triad, they should have multiple specialists involved in their care. This should include a physician and nutritionist, and can also include a physical therapist, behavioral therapist, and/or psychologist (especially if the athlete is also diagnosed with an eating disorder).
Athletes can struggle with the treatment needed for the triad. It is often difficult for these athletes, who have pushed themselves to extremes for their sport, to learn how to reduce their training, change their eating habits, and rewire their behaviors and attitudes toward their sport. These changes can cause high anxiety, fear, and frustration.
However, the treatment phase is an excellent time for education and strengthening exercises as prescribed. Once these athletes believe that proper care equals better athletic performance in the long run, they often become more motivated and less anxious to change their habits. To feel safe and confident to make these changes, it’s important that athletes have a stable support system from their loved ones, coaches, and healthcare providers.
Physical Therapy: A Key Component of Care
Physical therapists play an essential role in all phases of care of the triad, including spotting the signs, helping with treatment, and keeping athletes strong and safe.
Physical therapists see athletes for many types of injuries. They tend to spend more time with their patients than most healthcare providers, which helps physical therapists build strong connections with their patients over the years. This often puts physical therapists in a unique situation to notice patients’ behaviors and attitudes, including those of athletes who may be at risk for developing the triad or who are displaying signs of any of the three components.
As part of the care team, physical therapists are key providers of high-quality injury care, injury prevention strategies, and education on safe and healthy attitudes toward physical activity and body image. Physical therapists don’t just look at how to get an athlete back to play: They also care about protecting and encouraging long-term health.
Next Steps for The Triad
If you suspect a loved one may be struggling with one or multiple components of the female athlete triad, it is important to approach this matter in a nonjudgmental and open way and begin care as soon as possible. If you think you may be struggling with the triad yourself, know this: You are not alone, and there are excellent resources to help you. With proper care, athletes can excel in their sport and thrive in their health and well-being.
Resources
Chamberlain R. The Female Athlete Triad: Recommendations for Management. American Family Physician. 2018;97(8):499-502. https://www.aafp.org/pubs/afp/issues/2018/0415/p499.html
Papanek PE. The Female Athlete Triad: An Emerging Role for Physical Therapy. Journal of Orthopaedic & Sports Physical Therapy. 2003;33(10):594-614. doi:https://doi.org/10.2519/jospt.2003.33.10.594
Raj MA, Creech JA, Rogol AD. Female Athlete Triad. PubMed. Published 2020. https://www.ncbi.nlm.nih.gov/books/NBK430787/
Stickler L, Hoogenboom BJ, Smith L. THE FEMALE ATHLETE TRIAD‐WHAT EVERY PHYSICAL THERAPIST SHOULD KNOW. International Journal of Sports Physical Therapy. 2015;10(4):563. https://pmc.ncbi.nlm.nih.gov/articles/PMC4527203/