Female Athlete Triad Syndrome

Relative energy deficiency in sport (RED-S) is a syndrome in which disordered eating (or low energy availability), amenorrhoea/oligomenorrhoea, and decreased bone mineral density (osteoporosis and osteopenia) are present. RED-S is the broader, more comprehensive name for what was formerly known as female athlete triad (or simply the triad), which was a condition seen in females participating in sports that emphasize leanness or low body weight. As it was also seen in males, the name was changed to the comprehensive term RED-S. The triad is a serious illness with lifelong health consequences and can potentially be fatal. Relative energy deficiency in sport (RED-S) is a syndrome in which disordered eating (or low energy availability), amenorrhoea/oligomenorrhoea, and decreased bone mineral density (osteoporosis and osteopenia) are present. RED-S is the broader, more comprehensive name for what was formerly known as female athlete triad (or simply the triad), which was a condition seen in females participating in sports that emphasize leanness or low body weight. As it was also seen in males, the name was changed to the comprehensive term RED-S. The triad is a serious illness with lifelong health consequences and can potentially be fatal. The female athlete triad is a syndrome of three interrelated conditions. Thus, if an athlete is suffering from one element of the triad, it is likely that she is suffering from the other two components of the triad as well. With the increase in female participation in sports, the incidence of a triad of disorders particular to women—the female athlete triad—has also increased. The female athlete triad and its relationship with athletics was identified in the 1980s as the prevalence increased during this period, and symptoms, risk factors, causes, and treatments were studied in depth and their relatedness evaluated. The condition is most common in cross country running, gymnastics, and figure skating. Many of those who suffer from the triad are involved in some sort of athletics, in order to promote weight loss and leanness. The competitive sports that promote this physical leanness may result in disordered eating and be responsible for the origin of the female athlete triad. For some women, the disorder can have major health consequences. In addition, for some competitive female athletes, problems such as low self-esteem, a tendency toward perfectionism, and family stress place them at risk for disordered eating. Clinical symptoms of the Triad may include disordered eating, fatigue, hair loss, cold hands and feet, dry skin, noticeable weight loss, increased healing time from injuries (e.g., lingering bruises), increased incidence of bone fracture and cessation of menses. Affected females may also struggle with low self-esteem and depression. Upon physical examination, a physician may also note the following symptoms: elevated carotene in the blood, anemia, orthostatic hypotension, electrolyte irregularities, hypoestrogenism, vaginal atrophy, and bradycardia. An athlete may show signs of restrictive eating, but not meet the clinical criteria for an eating disorder. She may also display subtle menstrual disturbances, such as a change in menstrual cycle length, anovulation, or luteal phase defects, but not yet have developed complete amenorrhea. Likewise, an athlete's bone density may decrease, but may not yet have dropped below her age-matched normal range. These signs can be considered 'occult,' as no one symptom may be severe enough to seek medical attention, leaving the Triad to go unnoticed or untreated. Energy availability is defined as energy intake minus energy expended. Energy is taken in through food consumption. Our bodies expend energy through normal functioning as well as through exercise. In the case of female athlete triad, low energy availability may be due to eating disorders, but not necessarily so. Athletes may experience low energy availability by exercising more without a concomitant change in eating habits, or they may increase their energy expenditure while also eating less. Disordered eating is defined among this situation due to the low caloric intake or low energy availability. While most athletes do not meet the clinical criteria to be diagnosed with an eating disorder such as anorexia nervosa or bulimia nervosa, many will exhibit disordered eating habits such as fasting, as well as avoiding certain types of food the athlete thinks are 'bad' (such as foods containing fat). More severe examples of disordered eating habits may include binge-eating; purging; and the use of diet-pills, laxatives, diuretics, and enemas. By restricting their diet, the athlete may worsen their problem of low energy availability. Having low dietary energy from excessive exercise and/or dietary restrictions leaves too little energy for the body to carry out normal functions such as maintaining a regular menstrual cycle or healthy bone density. Amenorrhea, defined as the cessation of a woman’s menstrual cycle for more than three months, is the second disorder in the Triad. Weight fluctuations from dietary restrictions and/or excessive exercise affect the hypothalamus’s output of gonadotropic hormones. Gonadotropic hormones “stimulate growth of the gonads and the secretion of sex hormones.” (e.g. gonadotropin-releasing hormone, lutenizing hormone and follicle stimulating hormone.) These gonadotropic hormones play a role in stimulating estrogen release from the ovaries. Without estrogen release, the menstrual cycle is disrupted. Exercising intensely and not eating enough calories can lead to decreases in estrogen, the hormone that helps to regulate the menstrual cycle. As a result, periods may become irregular or stop altogether.