The Female Athlete Triad (Guest Post – Andy Bruce)

For this post, we invited Andy Bruce of ACB Coaching, a strength and conditioning coach specialising in eating disorders to write about a particularly pertinent topic in female athletes – The Female Athlete Triad.
After a recent discussion on a Youth S&C Coaches facebook page, I was contacted by Rob asking if I would like to write a guest post for coaches to raise awareness of the Female Athlete Triad. Since the Female Athlete Triad is considered a condition that can have adverse and long term effects on both the health and performance of an individual, athletic coaches who work with this population have a both a professional and ethical obligation to understand what the Female Athlete Triad is, how to recognise it, and what to do about it if they suspect it.

So if you are reading this, a coach to a female athletes, and are still unsure as to what the Female Athlete Triad is, you are not alone. A recent paper by Mukherjee et al. (2016) in the International Journal of Sports and Coaching Science investigated the awareness, perceptions and knowledge of 106 coaches in Singapore via a specially designed questionnaire. They reported that of the 106 coaches questioned, a staggering 90 (85%) of coaches hadn’t heard of the Female Athlete Triad. Only 2, yes, thats TWO!!!! of 106, were able to identify the three components of the triad correctly. I can only hope that the results would not be as frighteningly poor as this if were they to survey coaches elsewhere. What is clear, is that the Female Athlete Triad is not well understood by most coaches/practitioners and with such a potentially harmful condition, we owe it to our athletes, collectively, to do better than this.
A Brief History of the Female Athlete Triad
Before we get into the details, a bit of context is probably appropriate as I believe it can help inform how we approach to the topic. Perhaps a part of the reason why things are not well understood by coaches is that there is considerable debate within the community as to the best way to approach the surrounding issues. The notion of the Female athlete triad was first discussed in the early 80s with the official term coined in 1992. The American College of Sports Medicine released their first position stand on the topic in 1997, and revised this in 2007. In April 2014 however, the International Olympic Committee (IOC) released a consensus statement suggesting that term Relative Energy Deficiency in Sport (RED-S) was a more appropriate umbrella term to describe the physiological and pathophysiological effects of energy deficiency in female AND male athletes. This was quickly rebutted by the main coalition of triad researchers suggesting that RED-S currently lacked the scientific evidence to supplant nearly 30 years of specific research on the Female Athlete Triad. They felt that this new term, would confuse and potentially mislead, rather than enlighten an already complex research landscape.  In December 2014 the main group of Female Athlete Triad researchers also released their own consensus statement on the Female Athlete Triad. Confusing stuff, but however complicated the issues are, as coaches our responsibilities remain. Regardless of the debate, the Female Athlete Triad remains a recognised syndrome, and somewhat different to RED-S. RED-S currently lacks evidence, but that doesn’t mean it always will. Since we’re focusing on the Female Athlete Triad, let’s dive in.
What is the Female Athlete Triad?
The Female Athlete Triad is a medical condition seen in physically active girls and women that involves 3 interrelated components:

These can be displayed alone or together and are considered on a spectrum of increasing severity:

Optimal energy availability	Reduced energy availability with or without an eating disorder	Low Energy availability with or without an eating disorder
Eumenorrhoea	Subclinical menstrual disorders	Functional hypothalamic amenorrhoea
Optimal Bone health	Low bone mineral density	Osteoporosis

Low energy availability is the causal factor here. When energy availability is reduced, the human body will prioritise essential mechanisms such as brain function, locomotion and general metabolism over things like reproductive function. This begins with the suppression of luteinizing hormone, and subsequent blunting of oestrogen production. Oestrogen has multiple functions within the body, one of which is to inhibit bone resorption. Once the pulsatile nature of oestrogen is compromised in a low energy environment, bone health is also compromised. Bottom line is, once energy availability is low, hormonal function is impacted, and bone health follows suit! Not good.
Previously, the female athlete triad was just a clear-cut triple whammy of eating disorders, amenorrhoea, and osteoporosis. Which effectively was much further down the road of ill health than the new more encompassing spectrum. While some may consider it problematic that the new terminology of the spectrum will now capture more individuals within its definitions, since we are primarily concerned with the health of our athletes – this provides and earlier opportunity to make a positive impact on their health.
So now we know what the Female athlete triad is, how do we recognise it?

1. Low Energy Availability with or without an eating disorder

As far as this is concerned we can consider energy balance at approximately 45kcal per kg of fat free mass per day.  There is a very loose and debated threshold in the literature where we might classify low energy availability which can be anywhere between 10-20kcal per kg of fat free mass per day.
It is important to recognise that sometimes there will be entirely intentional and valid reasons to temporarily reduce energy availability.  However, there will also be many misguided, but equally deliberate efforts to ‘diet down’. It’s also worthwhile to consider that sometimes, low energy availability might be quite unintentional. It is important to take into account both the sport and the culture that the athlete is in.
If you suspect there is low energy availability, open up a discussion with your athlete try to identify if this due to insufficient intake, or too great an energy expenditure? Is it deliberate or unintentional? Food diaries can be useful here, because if it is being manipulated by intake, nutrient and vitamin availability can also be compromised, further challenging the health of the athlete. This all starts with a conversation, and any detailed analysis of a food diary on which action is taken should be handled by a qualified and trained professional.
As far as eating disorders are concerned, this is another vast topic with multiple subclinical presentations that also require professional help. While there are a variety of questionnaires that can be used here, since many eating disorders are characterised by a strong sense of ambivalence, those suffering might not openly think there is a problem. Best bet is to know the warning signs, especially of restrictive and purging types of eating disorder. Have they lost weight or eat much less than they used to? Do they make a fuss around things like dressings on salad or butter on vegetables? Do they complain frequently about feeling fat? Have they become obsessive around exercise? Are they deliberately ‘dieting’? Are they withdrawn or withdrawing from social environments? Do they get angry if you or friends press the point with regards to eating behaviour? Of course none in isolation are cast iron signs that something is wrong. I’m sure many readers can identify on a personal level with many of the above questions. Generally, as a concerned coach – if you think there might be something wrong, there probably is! If so, seek specialist help! You can definitely say the ‘wrong’ thing when it comes to disordered eating, no matter how positive your intention.
2. Menstrual function
Officially, a normal menstrual cycle is 28 days. But this can actually it can be anywhere between 21-35 days. Within this window is termed as Eumenorrhoea. There are also a few further key terms worth understanding to provide a better background:
Menstruation or shedding of the uterine lining signifies day 1 of the menstrual cycle. (oestrogen and progesterone are low)
Ovulation occurs on approx..day 14 (peak high oestrogen, low progesterone)
Follicular phase – from menstruation up to ovulation
Luteal phase -from ovulation through to menstruation (lowered oestrogen compared with ovulation but still higher than at menstruation, high progesterone).
Oligomenorrhea – an irregular menstrual cycle that takes either less or more time than 21-35 days
Amenorrhoea – the absence of menstruation. This can either be ‘primary’ which is the failure of menses to occur by age 16 years (the expected onset of menarche) or ‘secondary’ where the menstrual cycle is occurring normally but stops for 6 months or longer.
Effectively, what we need to be on the look out for here are significant changes from the norm. Of course there will also be oral contraceptive users in this group, who will be manipulating hormonal levels and the subsequent pattern of menstruation. Either way, changes in menstrual function are an indicator of hormonal disturbances and longer term fertility issues also come into play.
It should not be taboo to discuss menstruation, that includes male coaches. In my experience, assuming appropriate levels of sensitivity and trust are present, female athletes are comfortable to discuss this topic. More often than not, I think men feel that they have to steer clear of this. Please don’t, again, the health of your athlete might be at risk.
3) Bone health 
Bone health is easy to measure via Dual energy x-ray absorptiometry (DXA). However, we don’t normally have DXA scanners sitting around in our gyms/schools. A fracture, stress fracture or stress reaction will however be easily identifiable. Multiple occurrences of stress fractures would certainly raise alarm bells, but co-occurence of other aspects of the triad would certainly warrant further testing from a medical professional.

Implications
While the treatment of these issues depends largely on their nature, in general, the female athlete triad can have broad and diverse implications.  Low energy availability will likely go hand in hand with nutritional deficiencies, electrolyte imbalance increased tiredness, irritability and anxiety.  Energy deficiencies can normally be addressed and remedied in a number of days or weeks. Menstrual status might take several months to improve, and bone mineral density can take several years to alter.
Hopefully, having read this you will now be in a better position to understand, recognise and act on signs of the Female Athlete Triad. Before we even consider performance, the health and well-being of our athletes must take absolute priority.
If you want to know more, I’d certainly recommend a listen to Laurent Bannock’s Guru performance podcast episode on the Female Athlete Triad featuring Dr. Kirsty Elliot-Sale (http://guruperformance.com/episode-57-the-female-athlete-triad-and-red-s-with-kirsty-elliot-sale-phd/)
Needless to say, in order to prevent what might be a very long road to recovery, the need for early preventative action is clear! This always starts with an honest conversation in a safe environment with the athlete concerned, followed by referral to an appropriately qualified professional.

I’d like to thank Andy for writing a valuable post on this topic. Please feel free to leave any comments or questions you may have regarding this topic. If you’d like to learn more about Andy, please have a look at his own site: ACB Coaching 
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