AARR: The Female Athlete Triad – Epidemiology, Endocrinology, Assessment and Nutritional Intervention

Sérgio Fontinhas. The female athlete triad – Epidemiology, endocrinology, assessment and nutritional intervention. Main article, AARR, May 1st, 2016.


The term 'Female Athlete Triad' refers to a pattern of inter-related symptoms of disordered eating, amenorrhea and osteoporosis in a number of female athletes. When these three medical conditions are present the effects are synergetic and cause a greater negative impact on health than each one alone.

Menstrual disorders are associated not only with intensive exercise, but also with low body mass and low body fat. Prolonged menstrual disorders have a negative effect on the quality and quantity of plasma lipoproteins, which favors the formation of atherosclerotic lesions.

There is a critical energy availability threshold of 30 kcal/kg LBM, below which there are several and severe clinical complications.  All types of exercise-associated menstrual cycle disturbances (EAMD) can be observed below 30 kcal/kg/LBM.

­Since pulsatile secretion of LH depends on the energy availability, LH pulsatility is disrupted within 5 days when the EA is reduced by more than 33% from 45 to between 20-30 kcal/kg/LBM. Low EA instigate cortisol release and high cortisol levels are associated with reproductive disturbances and with a direct effect on bone mineral density.

There is a significant decreased bone density (BMD) in athletes suffering from amenorrhea and oligomenorrhea and even after menstrual cycles are restored bone density can remain significantly lower compared to the average value. BMD reflects the cumulative history of energy availability and menstrual status, genetic factors, and exposure to nutritional and behavioral factors associated with disordered eating.

Typically, most female athletes only exhibit disordered eating habits rather than an eating disorder such as anorexia nervosa our bulimia nervosa. Fasting, binge-eating, diet-pills, laxatives and diuretics are all signs of disordered eating. Such practices lower the energy availability.

Ultimately the underlying cause of the menstrual disorder in athletes is an energy imbalance less than 30 kcal/kg FFM/d. This is most seen in in sports that emphasize leanness or low body weight which may result in disordered eating, and can potentially be fatal.

Increases in EA can reverse menstrual disturbances when exercise training persists, but menses resumption in female athletes can take approximately 6 months or 9–12 weeks, however the mean time to menses recovery could be longer than 1 year.

Athletes of different sports disciplines have low level of knowledge regarding the potential health effects of untreated menstrual dysfunctions. Female athletes also do not have sufficient knowledge on sport nutrition and they use inadequate dietary practice leading to low energy availability and nutrient deficiencies which can inhibit the reproductive function. Female athlete diets are found to be deficient several micronutrients and fiber. It may take up to three months of dietary intervention to change dietary habits of the athlete.


1. Intro
1.1 Epidemiology of eating disorders
1.2 Epidemiology of amenorrhea

2. Endocrinology
2.1 Energy availability and the triad
2.1 Critical threshold of energy availability
2.2 LH pulsatility
2.3. Bone mineral density (BDM)

3. Assessing the triad
3.1 Assessing disordered eating
3.2 Assessment of menstrual status
3.3 Energy balance
3.4 Assessment of nutritional status
3.5 Assessment of total energy expenditure and energy availability

4. Nonpharmacological dietary intervention

 Main article, AARR, May 1st, 2016
3700+ words, 113 references
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