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Female Athlete’s Triad Sports and exercise are healthy activities for girls and women of all ages. However, a female athlete who focuses on being thin or lightweight may eat too little and/or exercise too much. Doing this can cause long-term damage to health, or even death. It can also hurt athletic performance and/or make it necessary to limit or stop exercise. Three interrelated illnesses may develop when a girl or young woman goes to extremes in dieting or exercise. Together, these conditions are known as the "female athletic triad." The three conditions are disordered eating, menstrual dysfunction, and ostoporosis. Disordered eating Abnormal eating habits (i.e., crash diets, binge eating) when combined with excessive exercise may keep the body from getting enough nutrition. Menstrual dysfunction Poor nutrition, low calorie intake, high-energy demands, physical and emotional stress, or low percentage of body fat can lead to hormonal changes that stop menstrual periods (amenorrhea). Osteoporosis The decreased levels of Estrogen associated with lack of periods disrupts the body's bone-building processes and weakens the skeleton, making bones more likely to break. Females in any sport can develop one or more parts of the triad. At greatest risk are those in sports that reward being thin for appearance (i.e., figure skating, gymnastics) or improved performance (i.e., distance running, rowing). Fashion trends and advertising often encourage women to try to reach unhealthy weight levels. Some female athletes suffer low self-esteem or depression, and may focus on weight loss because they think they are heavier than they actually are. Others feel pressure to lose weight from athletic coaches or parents. Female athletes should consider these questions: Are you dissatisfied with your body? Do you strive to be thin? Do you continuously focus on your weight? If the answers are yes, you may be at risk for developing abnormal patterns of eating food (disordered eating), which can lead to menstrual dysfunction and early osteoporosis. Disordered Eating Although they usually do not realize or admit that they are ill, people with disordered eating have serious and complex disturbances in eating behaviors. They are preoccupied with body shape and weight and have poor nutritional habits.Females are 10 times more likely to have disordered eating than males. The illness takes many forms. Some people starve themselves (anorexia nervosa) or engage in cycles of overeating and purging (bulimia). Others severely restrict the amount of food they eat, fast for prolonged periods of time, or misuse diet pills, diuretics, or laxatives. People with disordered eating may also exercise excessively to keep their weight down. An adequate diet must include not only the appropriate caloric intake but also at least 1,500 mg of calcium per day. Disordered eating can cause many problems, including dehydration, muscle fatigue, and weakness, an erratic heartbeat, kidney damage, and other serious conditions. Not taking in enough calcium can lead to inability to produce healthy bone during the most important years of bone building capacity – adolescence and young adulthood. Menstrual Dysfunction With normal menstruation, the body produces estrogen, a hormone that helps to keep bones strong. Without a menstrual cycle (amenorrhea), the level of estrogen may be lowered, causing a decrease in bone density and strength (premature osteoporosis). Young women who participate in high level training before puberty may experience delayed onset of beginning menstrual cycles ( delayed menarche). This is defined by not having periods by age 16 years. This is called primary amenorrhea. Missing 3 or more periods in a row in women who have already begun menstruating is called secondary amenorrhea. This is also a cause for concern. The etiology of these and lesser menstrual dysfunctions is not entirely understood but is believed to be multifactorial. Inadequate calories, poor nutrition, disordered eating patterns, emotional/ psychological stress, high intensity and frequency of exercise, and abrupt changes in body composition are believed to contribute. Normal homone regulation of Estrogen at the level of the brain is disrupted. Resumption of normal menstrual cycles may take months or years after the psychological or physical stress is relieved. Osteoporosis Osteoporosis is a condition where bone is not as strong as it should be. If bone strength does not develop appropriately during youth it may become a serious problem later in life. The natural process of bone mineral loss begins after age 25. This increases significantly after menopause in women and after age 70 in men. Adolescence and young adulthood represent the most rapid periods of skeletal growth and development with peak bone mass in young healthy women occurring somewhere in the late teens and twenties. One of the potentially serious and possibly irreversible consequences of disordered eating and/or menstrual dysfunction is not reaching normal peak bone density. This results in increased fracture risk at all ages but especially when the body begins its normal acceleration of bone breakdown after age 30. It is critical when evaluating the young female athlete with a stress fracture to consider the possibility of early osteoporosis elated to amenorrhea. This is particularly so when there is no history of overuse or when this is not the first stress fracture for the patient. Diagnosis Recognizing the female athletic triad is the first step toward treating it. See your doctor right away if you think you might have disordered eating, miss several menstrual periods or get a stress fracture in sports. In amenorrheic women it is important to rule out pregnancy and medical problems, such as thyroid or pituitary disorders, before ascribing amenorrhea solely to a woman’s exercise program. The doctor will need to ask you some detailed questions about your medical history, examine you, and may use laboratory tests to check for pregnancy, thyroid disease, and other medical conditions. In some cases they may recommend a bone density test. Treatment Treatment often requires help from a team of medical professionals including your doctor, a nutritionist, and a psychological counselor. In the case of a high school or intercollegiate athlete, one should also involve the athletic trainer, the coach, and the patient’s parents. Treatment of more seriously disordered eating may require contracts between the physician and the patient specifying that the level of sports participation is decreased or competition is prohibited until certain goals such as a specific weight gain are reached. Treatment with replacement hormones may be necessary to prevent further bone loss. There is not complete consensus on what age is safe and appropriate to begin use of hormone replacement therapy/ birth control pills for young women with menstrual dysfunction. Summary Normal athletic activity is healthy in many ways. Athletes generally develop higher bone mineral density than their nonathletic counterparts. It is only when the athlete develops lowered estrogen levels that bone health is negatively affected. The most effective type, frequency, intensity , and duration of exercise for optimizing bone mass has yet to be clearly defined. Additional educational materials about these problems can be obtained from the American College of Sports Medicine and the NCAA.