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Woman Athletes Face New Health Challenges
by Sara J. Lee, M.D., Division of Physical Medicine and Rehabilitation
As women increase their participation in organized athletic programs, they are at risk of developing serious health problems. One of these is the Female Athlete Triad or "TFAT", consisting of disordered eating, amenorrhea, and osteoporosis. The Female Athlete Triad (TFAT) is a syndrome affecting physically active young women who are driven to excel in sports and who are pressured to fit into a specific athletic image. Since the passage by Congress of Title IX legislation in 1972, the numbers of girls and women participating in sports has increased dramatically. While training programs lead to improved fitness and well being for many individuals, the potential for diminishing returnsãoften with harmful resultsãalso exists.
TFAT Syndrome
The TFAT syndrome consists of three distinct but interrelated components: disordered eating, amenorrhea, and osteoporosis. This syndrome can have serious medical consequences, especially if all three components are present. While problems associated with over-training are often thought to affect only elite athletes, in fact TFAT frequently affects casual and amateur female athletes of various age groups. The exact prevalence of TFAT is unknown, in part because the behaviors involved, such as disordered eating, may be very secretive.
Who is at risk?
All physically active females are potentially at risk. This is especially true for those involved in sports in which "appearance" is an element, such as dance, ballet, figure skating, diving and gymnastics. TFAT is also found in women participating in endurance sports such as long distance running and cycling, as well as sports in which body contoured or revealing clothing is an element, including volleyball, swimming, or cheerleading.
Adolescents are most vulnerable to TFAT, due to a number of factors: physiological changes, peer and societal pressure to fit a body image which may be difficult if not impossible to attain, and a lack of identity outside of sports, leading to a "living and breathing" attitude towards sports programs. These issues may be reinforced by school/university programs which push a "win at all costs" mentality.
During puberty, males tend to gain muscle mass and are typically encouraged to gain weight to improve physical and athletic performance. In sharp contrast, girls gain body fat at this time, and they are often encouraged to lose weight for performance and appearance. Furthermore, adolescence is a critical time for laying down of peak bone mass, and this will not happen properly if disordered eating and amenorrhea are present.
Elements of TFAT
Each element of the triadãdisordered eating, amenorrhea, and osteoporosis may lead to short and long term morbidity. Possible consequences of TFAT include serious medical and psychological effects, such as depression and substance abuse, pathological fractures, irreversible bone loss, malnutrition and starvation, and, in rare cases, death from suicide or cardiac arrhythmia.
(1) Disordered eating is most often the result of societal and peer pressure. This may manifest itself in a variety of harmful behaviors. The spectrum may range from restrictions on food intake, prolonged fasting, the use of diet pills, occasional binge eating and purging, to the DSM IV diagnoses of bulimia nervosa and anorexia nervosa. When surveyed, many athletes believe that disordered eating practices are harmless, and that losing weight by whatever means will enhance performance. A vicious cycle is created when these beliefs are tied to athletes' desire for perfection, compulsiveness, and high expectations. Behaviors suggestive of disordered eating include a preoccupation with food, calories and weight as well as criticism of one's own body. Compulsive and excessive exercise that is not part of a routine training should also be considered a warning sign.
(2) Amenorrhea is the most easily recognized component of the triad. Cessation of menses as a result of athletic training has long been recognized. However, this should never be seen as a normal response to training programs. Amenorrhea may lead to acquiring a lower than normal Peak Bone Mineral Density and higher rates of bone loss. This process may be exacerbated in the TFAT patient by poor nutrition and low calcium intake. The end results of menstrual dysfunction on bone may be severe and long lasting, leading to higher incidence of fractures over time.
(3) Osteoporosis is in many respects a consequence of disordered eating and amenorrhea. This condition is marked by low bone mass and microarchitectural deterioration within the bone. As Mean Bone Mineral Density drops, the risk of fracture rises dramatically. Physicians should be alerted to the possibility of osteoporosis in athletes who have multiple stress fractures and exhibit amenorrhea for six or more months.
Summary
The Female Athlete Triad represents a potentially serious problem for many adolescents and young women, and it poses dramatic near and long-term consequences. Recognizing the syndrome may be difficult, since athletes with eating disorders may be very secretive about their behaviors. Ideally, girls and young women would undergo a physical examination prior to participation in sports programs. Whether conducted prior to athletic participation or thereafter, the examination and history should consider diet, exercise habits, menstrual history, signs and symptoms of starvation or purging, signs of hormonal abnormalities, and signs of other systemic illness.
Physicians should have a high degree of suspicion and concern when presented with female adolescents or young women who are deeply involved in athletics and who exhibit one or more element of the TFAT. Clinicians should adopt the mindset that this is a syndrome which needs to be treated and can be treated. Treatment can be accomplished through changes in training routines, dietary changes, supplemental estrogen when indicated, and counseling programs to support the patient as she implements the treatment plan.
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