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Female Athlete Triad


With the increase in female participation in sports (much of it attributable to Title IX legislation in the United States),
the incidence of a triad of disorders particular, but not exclusive, to women—the so-called female athlete triad—has also increased.

The female athlete triad, though more common in the athletic population, can also occur in the nonathletic population. However, even though this triad was first described at the 1993 meeting of the American College of Sports Medicine (ACSM),
associations between bone mineral density (BMD), stress fractures, eating disorders, and female athletics had been observed for decades before the syndrome was formally named.

The components of the female athlete triad, as put forth by the 1997 ACSM positional stand, consisted of disordered eating, amenorrhea, and osteoporosis.
Not all patients have all 3 components of the triad, and newer data suggest that even having only 1 or 2 elements of the triad greatly increases these females’ long-term morbidity.

In addition, a study by Burrows et al has suggested that the current triad components do not identify all at-risk women; rather, the authors suggest that criteria such as exercise-related menstrual alterations, disordered eating, and osteopenia may be more appropriate.

Subsequent research on the female athlete triad culminated in an updated definition published by ACSM in 2007. The 2007 ACSM positional stand looks at each disorder as a point on a continuous spectrum rather than as a severe pathologic endpoint, as follows

“Disordered eating” has been replaced by a spectrum ranging from “optimal energy availability” to “low energy availability with or without an eating disorder”

“Amenorrhea” has been replaced by a spectrum ranging from “eumenorrhea” to “functional hypothalamic amenorrhea”

“Osteoporosis” has been replaced by a spectrum ranging from “optimal bone health” to “osteoporosis”

The 2007 ACSM positional stand also emphasizes that energy availability is the cornerstone on which the other 2 components of the triad rest.
Without correction of this key component, full recovery from the female athlete triad is not possible.

Often difficult to recognize, the female athlete triad can have a significant impact on morbidity and even mortality in a relatively young segment of the population. Indeed, the full impact of this syndrome may not be realized until these women reach menopause, when bone loss is accelerated.

Significant research of the triad has been ongoing. Recently, there have been a series of meetings that have resulted in consensus statements released in 2014 by the International Consensus Conference on the Female Athlete Triad, in 2014 by the International Olympic Committee (IOC) and in 2017 by a Committee Opinion from the American College of Obstetricians and Gynecologists (ACOG) on Adolescent Health Care. The Consensuses and ACOG Committee opinion reiterated the 2007 ACSM positional stand on the etiology and the need to view the components of the triad as a spectrum.
The main purpose of the consensus statements were to provide specific guidelines in treatment and return to play to providers of athletes at risk and/or diagnosed with the female athlete triad.
The main purpose of the ACOG Committee Opinion was to discuss the obstetricians and gynecologists role in participating in the healthcare team for athletes with the FAT.

Furthermore, the IOC has proposed changing the name of the female athlete triad to the “relative energy deficiency in sport” or “RED-S”.
They believe the name change would more accurately describe the myriad of health issues affected by decreased energy availability, including “metabolic rate, menstrual function, bone health, immunity, protein synthesis, cardiovascular and psychological health” and include men, who can also be affected negatively by an imbalance in energy availability.

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