The Female Athlete Triad: Disordered Eating, Amenorrhoea and Osteoporosis


The female athlete often feels pressure to fit a specific athletic image in order to reach her performance goals. She may control her weight and may develop a pattern of disordered eating. This disordered eating may lead to menstrual dysfunction and resultant amenorrhoea or oligomenorrhoea leading to premature bone mineral density loss; osteoporosis.

The incidence of anorexia nervosa in the general population is of the order of 0.5-1.0% and of bulimia nervosa to 2-4%. Various studies have shown elite and national standard female athletes have an incidence of disordered eating ranging as high as 62%. Amenorrhoea (absence of menstrual bleeding for six months or more) or oligomenorrhoea (cycles longer than 35 days ) has a population incidence of approximately 5% but as high as 40-50% in elite runners and professional ballet dancers. Mortality amongst treated anorexic women (non-athletic) is between 10 and 18% with additional lifelong morbidity of psychological and health related problems. The emphasis in treating this disorder must be on prevention and early recognition.

Certain sports have a higher incidence of the Female Athlete Triad (FAT); distance running, professional ballet, gymnastics, weight dependant sports (lightweight rowers), triathletes and the performing arts. Doctors and healthcare professionals dealing with these athletic groups must be sensitive to this disorder.

Disordered eating presents with behavioural problems, thought disorders and overt anorexia nervosa and bulimia nervosa. Routine questioning about the menstrual history needs to be done sensitively but accurately and provided other causes of secondary amenorrhoea are excluded, early referral for bone mineral density assessment must be considered. Unfortunately there is a poor correlation between the duration of amenorrhoea/eating disorder and bone mineral density.

There are predisposing factors which are both internal and external to the FAT. Internal factors include focus on fitness or an ideal body type and weight. There is a mismatch between calorific intake and expenditure and suppression of the hypothalamic pituitary ovarian access. Life stressors, abrupt changes in body composition, nuliparity and previous history of delayed menarche and/or menstrual irregularity and genetic factors predispose to the F.A.T. syndrome. External factors are a “win at all costs” mentality, strict weight standards, overtly controlling parent or coach, inappropriate comments, social isolation, family history and societal influences are all important.

Funding for Olympic athletes and increasing designation of team doctors with squads should encourage screening for the FAT. The athletes should be evaluated carefully and sensitively, many will have had poor experiences of medical care particularly for the psychological aspects of this condition. Screening should include a history, physical examination and appropriate blood tests. A multi-disciplinary team approach including a sports nutritionalist and psychologist is essential. Prevention relies upon widespread education both of athletes and of coaching staff and parents. We need to promote positive and realistic images for active athletic women.

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