1- The Female Athletic Triad is not rare. It is composed of disordered eating, amenorrhea (missed menstrual periods), and osteoporosis (loss of bone density). It is most often seen in achievement-focused athletes, participating in sports where weight and body image are traditionally tied to performance: running, dance, gymnastics, figure skating, diving, cheerleading, weight calss sports, etc.

2- Simply, the Triad is caused by inadequate caloric intake and/or caloric consumption for the needs of athletic activity, training and competition. This causes a shutdown of normal female endocrine function and reduced estrogen production, in part through the decline of body fat, and hence, a loss of ovulation and menstrual function. Loss of estrogen reduces bone mineralization.

3- The incidence of severe eating disorders (anorexia and bulemia) in the general female population in the U.S. is 3-5%, but much higher in athletic women (as high as 15 to 62%). Females make up 90% of those with eating disorders, which means that 10% are males (e.g.- wrestlers).

4- A definition of an eating disorder includes: caloric restriction or elimination +/- compulsive overeating behaviors (dieting, bingeing, purging, and exercising) stemming from an abnormal focus on performance, body image and body weight.

5- The implications of loss of menstrual function, even temporarily, before age 30 are very serious. The loss of estrogen causes a permanent and life-long loss of bone mineral which cannot be replaced. Remember, 60-70% of female skeletal calcium is stored before age 28. Athletic amenorrhea (loss of menses)= loss of estrogen= loss of bone. One cannot regain this lost bone, only reduce the rate of further loss! The bone that is not deposited before age 30 cannot be deposited later in a catch-up fashion! Athletic amenorrhea is essentially a pre-menopausal menopause!

6- The weakened skeleton is prone to fracture (especially stress fracture). This may be the first sign of the Female Athletic Triad. Stress fractures that occur without obvious training errors and/or mechanical problems signal the possibility of the Female Athletic Triad. The bone of those affected is 4.5x more likely to fracture than those without this condition.

7- Recurrent soft tissue and overuse injuries also may suggest eating disorders, as one can view excessive or compulsive exercise (to the extent of injury) as an extreme method of weight control.

8- Symptoms and signs of the Triad, apart from loss of menstrual function and orthopedic injury include: excessive focus on body weight/image/dieting despite thin/normal habitus, bingeing/purging,use of diuretics/laxatives, poor physical/mental and athletic performance, loss of attention/concentration, depression, fatique, cold intolerance, fainting/dizziness, brittle nails/hair, sore throat, bloodshot eyes, abdominal pain/constipation/bloating, swollen face or extremities, etc.

9- It is very doubtful the those affected with this condition will overcome the denial that often accompanies the Triad, and ask for help, especially if positively reinforced by athletic success. Suspicion and compassion on the part of family, friends, teammates, coaches, athletic trainers, teachers, and health care professionals is necessary, coupled with the willingness to assist in getting help for this individual. Rememeber, anorexia is fatal in 14%! Get help and enlist a team approach: ask your trainer, nurse, primary care provider, orthopedic surgeon, nutritionist, or gynecologist.

10- The most common cause of amenorrhea is pregnancy.

Dan Wnorowski, M.D.