Chapter 5 - The Female Athlete
Triad: Disordered Eating,
Amenorrhea, and Osteoporosis
Jacalyn J. Robert-McComb, PhD,
FACSM
Learning Objectives
After viewing this slideshow, you should have an
understanding of:
 the American College of Sports Medicine (ACSM)
position stand on the female athletic triad;
 the difference between disordered eating and eating
disorders;
 the progressive nature of menstrual disturbances in
athletes;
 the difference between osteopenia and osteoporosis;
Learning Objectives Continued
the inter-relatedness of disordered eating,
amenorrhea, and osteoporosis;
athletes at greatest risk for developing signs and
symptoms associated with the triad; and
the growing health concern of the triad for allied
health professionals.
ACSM’s Position Stand on the
Female Athletic Triad
• In 1997, ACSM published its Position Stand on the Female
Athletic Triad (Otis C, Drinkwater B, Johnson M, et al. 1997).
• The Female Athlete Triad is a serious syndrome consisting
of disordered eating, amenorrhea, and osteoporosis. The
components of the Triad are interrelated in etiology,
pathogenesis, and consequences. These disorders occur
not only in elite athletes but also in physically active girls
and women participating in a wide range of physical
activities. The Triad can result in declining physical
performance, as well as medical and psychological
morbidity’s and mortality.
The Difference Between Eating
Disorders and Disordered Eating
• The term disordered eating includes a
spectrum of abnormal eating behaviors that
range from mild restricting behaviors and
occasional binging and purging to those that
meet the diagnostic criteria for Eating
Disorders in the Diagnostic and Statistical
Manual of Mental Disorders-DSM-IV-TR .
Eating Disorders
• The primary types of eating disorders are
Anorexia Nervosa (AN) and Bulimia
Nervosa (BN). American Psychiatric
Association. Diagnostic criteria for these
disorders can be found in the DSM-IV-TR.
DSM-IV- TR Diagnostic Criteria for Anorexia
Nervosa (American Psychiatric Association, 2000)
• Refusal to maintain body weight at or above a minimally
normal weight for age and height (e.g., weight loss leading
to maintenance of body weight less than 85% of that
expected; or failure to make expected weight gain during
period of growth, leading to body weight less than 85% of
that expected).
• Intense fear of gaining weight or becoming fat, even
though under-weight.
DSM-IV- TR Diagnostic Criteria for Anorexia
Nervosa (American Psychiatric Association, 2000)
• Disturbance in the way in in which one’s body weight or
shape is experienced, undue influence
of body weight or shape on self-evaluation, or denial of the
seriousness of the current low body weight.
• In postmenarcheal females, amenorrhea, i.e., the absence
of at least three consecutive menstrual cycles. (A woman is
considered to have amenorrhea if her periods occur only
following hormone, e.g., estrogen, administration.)
DSM-IV-TR Diagnostic Criteria for Bulimia
Nervosa (American Psychiatric Association, 2000)
• Recurrent episodes of binge eating. An episode of binge
eating is characterized by both of the following:
• eating in a discrete period of time (e.g., within any 2hour period), an amount of food that is definitely larger
than most people would eat during a similar period of
time and under similar circumstances
• a sense of lack of control over eating during the episode
(e.g., a feeling that one cannot stop eating or control
what or how much one is eating)
DSM-IV-TR Diagnostic Criteria for Bulimia
Nervosa (American Psychiatric Association, 2000)
• Recurrent inappropriate compensatory behavior in order to
prevent weight gain, such as self-induced vomiting; misuse
of laxatives, diuretics, enemas, or other medications;
fasting; or excessive exercise.
• The binge eating and inappropriate behaviors both occur,
on average, at least twice a week for 3 months.
• Self-evaluation is unduly influenced by body shape and
weight.
• The disturbance does not occur during episodes of
Anorexia Nervosa.
Definitions of Amenorrhea (somewhat arbitrary)
• Primary Amenorrhea
• Acyclic at age 16 with secondary sex
characteristics (seems to be general agreement)
• Secondary Amenorrhea
• The International Olympic Committee defines
secondary amenorrhea as having one or fewer
menstrual cycles a year.
• The ACSM position stand on The Female
Athletic Triad defines amenorrhea as the
absence of at least 3-6 menstrual cycles a year.
Oligomenorrhea (again, definitions are
somewhat arbitrary).
• Defined by some as:
• cycles that occur at intervals longer than
35 days.
• Others define amenorrhea as:
• cycle length from 45-90 days with fewer
than 6 menses a year.
The Progressive Nature of Menstrual
Disturbances in Athletes
• 1. Regular cycles with a shortened luteal phaseprogesterone production stops early
• 2. Regular cycles with inadequate progesterone
production
• 3. Regular cycles with failure to develop and
release an egg (ovulation)
• 4. Irregular cycles but still ovulating
• 5. Irregular cycles and anovulation
• 6. Absence of menses and anovulation
Differentiating Osteoporosis from
Osteopenia
The diagnostic criteria for low bone mass as defined by the
World Heath Organization is as follows:
normal: bone mineral density (BMD) that is no more than 1
Standard Deviation (SD) below the mean of young adults;
ostopenia: BMD between 1 and 2.5 SD below the mean of
young adults;
osteoporosis: BMD more than 2.5 SD below the mean of
young adults; and
severe osteoporosis: BMD more than 2.5 SD below the mean
of young adults plus one or more fragility fractures.
The Inter-Relatedness of Disordered Eating,
Amenorrhea, and Osteoporosis
One disorder leads to another: (1) disordered
eating  (2)amenorrhea  (3)osteoporosis .
1
2
3
Girls who participate in the
following sports are most susceptible
• Sports where
performance is
subjectively judged
• Sports where athletes
wear revealing
clothing
• Sports with weight
categories
• Sports where a prepubescent body is
emphasized
The Growing Health Concern of the
Triad for Allied Health Professionals
• Many colleges and high schools do not use
a medical history form that asks questions
which might help determine if athletes are
at risk of developing the signs and
symptoms associated with disordered
eating, amenorrhea, and osteoporosis.
Responsibility is in our hands
• Therefore, it is up to allied health
professionals such as athletic trainers,
school nurses, team physicians, physical
therapists, nutritionists and exercise
physiologists to implement such a screening
device.
Denial is common so questions
should be subtle.
Examples of eating/weight history questions
• What is your desired weight?
• Do you weigh yourself often?
• Does worrying about weight take up a significant
amount of your time?
Examples of menstrual history
questions
• At what age did you have your first period?
• When was your last period?
• How many periods have you had in the last
12 months?
Examples of stress fracture history
• Have you ever had a stress fracture or a stress
reaction?
• Have you ever had x-rays to rule out a stress
fracture or a stress reaction?
• Have you ever had a bone scan or a bone density
test?
Sample questions come from the University of Colorado Sports
Medicine Department at Colorado Springs (with permission)
The following Instruments can be found in the
Appendices in the text, The Active Female:
Health Issues Throughout the Lifespan.
Body Image Concern Inventory
Eating Attitudes Test (EAT-26)
Bulimia Test - Revised (BULIT-R)
Student-Athlete Nutritional Health Questionnaire
Female Athlete Screening Tool
Thank You