female athlete triad (FAT)

Last reviewed 05/2021

The "female athlete triad" (FAT) has long been recognised as a syndrome that has the potential to affect female athletes and consists of three inter-related disorders (1):

• osteoporosis
• disordered eating
• menstrual disorders

Note though that others suggest the triad is (2)

• (a) disordered eating
• (b) amenorrhoea, and
• (c) osteopaenia

The three corners of the triad are inter-related through psychological and physiological mechanisms

• psychological pressures to perform to an optimal standard, and thus often a perceived requirement to maintain a low body mass, result in a high volume of training
  • high volume of training and low energy intake, in addition to stress hormones produced by psychological stress, may lead to a physiological alteration in the endocrinological control of the menstrual cycle, which may ultimately lead to the athlete becoming amenorrhoeic (loss of cycle after menarche)
• prevalence of FAT in different sports varies from 0% to 1.36% (2)
  • in contrast, the isolated components, i.e., disordered eating, menstrual dysfunctions, and bone dysfunctions, vary from 16.8% to 60%, 9.8% to 40%, and 0% to 21.8%, respectively (2)
• presence of one or more component of FAT may decrease athletic performance and cause morbidities or even death (3)
  • reduction in performance is associated with energetic restriction and loss of muscular mass and body fat, predisposing the previous termathletesnext term to precocious fatigue, anaemia, and hydroelectrolytic disturbances
    • food restriction related to energy or a nutrient may contribute to the development of menstrual disorders, such as primary and secondary amenorrhea, oligomenorrhea, decreased luteal phase, and anovulation
    • presence of disordered eating associated with extenuating physical training favours low percentages of body fat related to the development of menstrual dysfunctions
    • type and duration of menstrual dysfunction, low percentage of body fat, inadequate food intake, changes in weight, and reduction of plasma estrogen level in women are directly related to alterations in bone mineral density (BMD)
      • wmen with low plasma oestrogen levels present a fast loss of bone due to a decrease in bone formation and an increase in bone reabsorption
        • low plasma oestrogen level during the crucial period for bone deposition may damage the peak of bone mass after a certain age
          • thus, even after the resumption of menstrual cycles, these athletes may not reach the expected peak of bone mass and may precociously develop osteoporosis (4)

Reference:

• 1) Birch K. Female athlete triad. BMJ 2005;330(7485):244-6
• 2) Schtscherbyna A et al. Female athlete triad in elite swimmers of the city of Rio de Janeiro. Brazil Nutrition 2009;25(6): 634-639.
• 3) American College of Sports Medicine. Position stand: the female athlete triad, Med Sci Sports Exerc 2007;39:1-9.
• 4) Warren MP, Stiehl AL. Exercise and female adolescents: effects on the reproductive and skeletal systems. J Am Med Womens Assoc 1999;54:115-120.