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The female athlete triad

The female athlete triad is a condition that occurs in females who participate in sports, particularly cheerleading, gymnastics, figure skating, dancing and distance running. The female athlete triad is defined as amenorrhea (absence of menstrual period), disordered eating, and osteoporosis (decreased bone density). Pressure to succeed, which can be exacerbated by coaches and pushy parents, can increase the risk of developing the female athlete triad. This risk is most prominent in sports where there is a subjective aesthetic judgement, where a thin physique is deemed desirable and may be emphasised by revealing outfits.

Disordered eating ranges from poor dietary habits to anorexia nervosa and bulimia. Whereas eating disorders affect 3% of the general population, there have been reports of up to 60% of competitive athletes affected by disordered eating. Women are ten times more likely than men to suffer from eating disorders. Anorexia and bulimia are serious conditions in their own right and poor dietary habits can contribute to hormonal and skeletal problems that manifest themselves as sports injuries.

Anorexia is a mental disorder where there is a disordered body image and an intense fear of weight gain which produces a bodyweight which is less than 85% of the height related norm. Anorexia causes amenorrhea, weight (fat and muscle) loss, lightheadedness, an inability to concentrate and a slow heart rate. Bulimia involves overeating and binging followed by purging by vomiting or using laxatives. Symptoms may include abdominal pain, sore throat, yellowing teeth and bloodshot eyes, as well as weight loss and menstrual dysfunction. These dietary deficiencies lead to hormonal changes that reduce the level of estrogen (the female sex hormone), which cause calcium resorption from bones and Amenorrhea (absence of a menstrual period).

Amenorrhea is defined as three months without a menstrual period in a female of menstruating age. Amenorrhea in athletic individuals can cause decreased bone mineral density which may lead to stress fractures and an early onset of osteoporosis. It can also lead to an increased risk of cardiovascular disease, infertility and ovarian cancer. Osteoporosis is a reduction in overall bone mineral density which leads to adverse changes in the architecture of bones. It is four times more likely to occur in females than males and means that the risk of fracture is higher. The bones of the lower back (vertebrae), pelvis and lower limbs are most likely to be affected.

All symptoms of the female athlete triad require assessment by a sports doctor and it should be stressed that not every person will have all three aspects, therefore any of these symptoms will require treatment with a doctor. The prognosis is better if the diagnosis of female athlete triad is established early. Treatment will depend upon the exact circumstances of each individual, but typically involves reduction the intensity of exercise (especially weight bearing / impact exercise) and correcting nutritional problems. An assessment by a dietician will evaluate the optimal dietary requirements for the desired level of physical activity. The aim of treatment is to ensure that adequate energy is derived from a healthy balanced diet. Because of the complex nature of the female athlete triad a team approach to treatment is often required. A clinical psychologist and gynaecologist can often be required to provide complete care.

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