Swimmers’ Health – Female Athlete Triad

NOTE: The information included in the following articles is intended to promote the health, safety, and knowledge of our swimmers, parents, coaches, and other participants. Prior to implementing any new routine into your athletic performance, consult a physician.  Sovereign Rehabilitation cannot be held responsible for any personal injury resulting from misuse of the information listed in the site.

swimmers2The number of females participating in sports has undoubtedly risen to all-time highs. The benefits of regular exercise for these girls and women are huge including increased strength, endurance, coordination, and mental well-being, all of which outweigh the risks of athletic injury. However, girls (especially adolescent girls) are at risk for a different kind of sports-related health concern of which every parent should be aware.

The “Female Athlete Triad,” or triad, is made of up eating disorders/disordered eating, amenorrhea/oligomenorrhea, and decreased bone mineral density (osteoporosis and osteopenia). The triad is a result of inadequate nutrition and a high caloric expenditure associated with exercise training. In swimming, a sport in which weight and body type are hard to disguise, pressure from parents, coaches, and peers can result in dieting at too early of an age, and thus medical complications such as the triad begin. Let’s review each part of the triad for a further understanding. As you read, it’s important to recognize that the female athlete triad is a syndrome that can be prevented, though it is a condition not to be treated lightly.

Eating Disorders/Disordered Eating:  Disordered eating occurs whether an athlete has a diagnosed eating disorder, is on a diet at too early of an age, or is simply not consuming enough nutrients to create a positive energy balance to counteract the energy costs of the athletic training she is participating in. Athletes with disordered eating may engage in a wide variety of harmful eating trends that can include food restriction, binging, & purging.

Amenorrhea/Oligomenorrhea: Amenorrhea is the absence of menstrual periods and can be subdivided into primary amenorrhea and secondary amenorrhea. Primary amenorrhea is the absence of menses by A) 16 years of age with normal pubertal development B) 2 years after completed sexual maturation or C) age 14 without the onset of secondary sexual characteristics (Normal pubescent development includes onset of breast and pubic hair between the ages of 8-13). Secondary amenorrhea is defined as the absence of menstrual bleeding for A) 6 months after establishing regular menses B) a length of time equivalent to at least 3 cycle lengths or C) by 18 months after menarche.  Oligomenorrhea refers to menstrual cycles that occur at 35 day or more intervals or 3-6 cycles per year. Studies show that amenorrhea occurs in 3.4 to 66% of female athletes compared with only 2-5% of women in the general population. Amenorrhea is not a normative part of athletic training.

Osteoporosis is a word not commonly associated with young females, though it is the third component of the triad and is a reality for many young girls. Osteoporosis is the loss of bone mineral density and inadequate formation of bone. This can lead to an increased risk of fractures including stress fractures. Because bone density is built up significantly before the age of 30, lost bone density in adolescent females may be irreplaceable and result in further problems with age.

Prompt diagnosis and treatment are essential to health of the athlete. Treatment of the triad requires a change in eating habits and modification of exercise training. A balance between the intake of calories and the output of energy must be reached with the ultimate goal of healthy eating and a normalized menstrual cycle. A comprehensive treatment team will incorporate the athlete, the family, the coaches, the nutritionist, and the psychologist. Consult your physician for more information.

Additional Resources:
1. Handout from the American Academy of Family Physicians: Risk Factors, Diagnosis, and Other FAQs
2. ACSM: Performance Issues for Parents: How to fuel active kids (see page 7)

References:
Papanek PE. The female athlete triad: an emerging role for physical therapy. Journal of Orthopaedic & Sports Physical Therapy. Oct 2003;33(10):594-614.
Hobart JA, Smucker DR. The female athlete triad. American Family Physician. June 2000;61(11):3357-64,3367.
Rome ES. Eating disorders. Obstetrics & Gynecology Clinics of North America. 2003 Jun;30(2):353-377.
Goodman LR, Warren MP. The female athlete and menstrual function. Current Opinion in obstetrics and Gynecology. Oct 2005;17(5):466-470.
Lo BP, Herbert C, McClean A. The female athlete triad: no pain, no gain? Clinical Pediatrics. Sep 2003;42(7):573-580.
Gittes EB. The female athlete triad. Journal of Pediatric & Adolescent Gynecology. Oct 2004;17(5):363-365.