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Female athlete triad

Exercise and sports have many beneficial effects on women as well as on men. However, some women suffer from a syndrome called the ‘female athlete triad’. This is syndrome comprises three interrelated disorders: eating disorder, amenorrhea, and osteoporosis. The female athlete is most at risk of developing this syndrome during adolescence. It may occur in many sports, but is especially common in endurance runners and ‘appearance’ sports such as gymnastics, diving, figure-skating, and ballet. It is associated with the age at onset of training, the sport concerned, diet, and stress.

Eating disorders

There is a tendency in the modern world to feel pressure to lose weight. Some women feel this pressure more than others. For athletic women, the pressure may come from coaches who aim to improve performance or appearance in sports such as figure-skating, gymnastics, swimming, and running. This pressure may force women into a wide spectrum of harmful eating practices, which may be called ‘disordered’ eating. These range from voluntary starvation, purging, use of diet pills and diuretics, to the full-blown eating disorders such as anorexia and bulimia. The syndrome is also seen in long-distance runners who fail to meet the high energy needs of their demanding activity.


Amenorrhea can be defined as the absence of three to six consecutive menstrual cycles. It may be caused by impaired nutrition, and can lead to an increased incidence of musculoskeletal problems. If the athlete has been amenorrheic for longer than 6 months and pregnancy has been excluded, hormonal studies should be carried out, as well as bone mineral density assessment .


Osteoporosis is defined as having a reduction in bone mineral density due to an imbalance between resorption and formation; the bone most frequently affected is the trabecular bone found in the distal end of the radius of the wrist, vertebral bodies of the spine, and the neck of the femur. The risk for primary osteoporosis may be genetic, hormonal, or associated with nutrition or lifestyle (such as exercise).Secondary osteoporosis may be caused by underlying disease or drugs. Athletic amenorrhea and a subsequent reduction of ovarian hormones can result in osteoporosis.

Bone loss in young women with amenorrhea may equal the 2–6% loss that occurs in postmenopausal osteoporosis and it can be irreversible. Women with amenorrhea need intake of 1500 mg of calcium to stay in calcium balance. Calcium intake alone will, however, not prevent bone loss. The goal is the resumption of spontaneous menstruation;otherwise replacement doses of ovarian hormones should be prescribed to prevent further bone loss in this group of amenorrheic athletes.

Increasing body weight by 2–3% is recommended. Extreme activities should be avoided, but moderate exercise is desirable.Amenorrhea is reported to occur in 40% of female athletes in the USA and eating disorders in up to 60% of collegiate gymnasts. Long-standing amenorrhea should require a consultation with a physician. The disorders of the triad are chronic conditions with high morbidity rates due to dehydration, electrolyte abnormalities, cardiac arrhythmias (irregular heart rhythm), depression, and increased risk of injury including stress fractures. As these disorders are often hidden or denied, they may not be easily recognized.Early recognition and referral for treatment can improve the prognosis.

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