The Importance of Female Athlete Triad Screenings in Athletic Training
California University of Pennsylvania
Many athletes, as well as certified athletic trainers, are unaware of the effects, signs, and symptoms, and methods
of prevention and treatment of the Female Athlete Triad. The purpose of this paper is to outline the components
of the triad, the methods used for screening the triad, and the importance of surveying in athletic training.
Background of the Female Athlete Triad
The female athlete triad is a growing problem in female athletics. Many athletes, as well as certified
athletic trainers, are unaware and uneducated as to the effects of the female athlete triad, signs and symptoms,
and the use of screening for preventing and treating the triad. The triad consists of three components: eating
disorders or disordered eating, amenorrhea, and osteoporosis (West, 1998). Because the American College of Sports
Medicine’s (ACSM) Women’s Task Force identified these three health concerns in 1992, the medical and
scientific communities have attempted to alert those individuals who have contact with female athletes to become
more informed of the seriousness of these conditions (Warren, 1990).
The prevalence of eating disorders has been rising steadily
for the past five decades and is quickly becoming a significant public health concern in female athletics (MacMullen, 2005).
An eating disorder, in athletes is characterized by a wide spectrum of maladaptive eating and weight control behaviors
and attitudes including concerns about body weight and shape and poor nutrition or inadequate caloric intake (Green, 2005).
An eating disorder or disordered eating can range from a mild case such as only engaging in these behaviors a few times
a week to very severe case such as not eating for days at a time, or vomiting. Athletes may be self-motivated or
pressured by their coaches, peers, or parents to meet unrealistic body weight or body fat levels, resulting in an eating
disorder or some form of disordered eating (Rumball, 2005).
Amenorrhea is the absence of menstrual bleeding and
can be classified as either primary or secondary amenorrhea. Primary amenorrhea refers to a female who has not yet had
a menstrual cycle by the age of 16 or who is without sexual development by the age of 14. Secondary amenorrhea refers
to a female who has had an absence of menstrual bleeding for either six months or the length of time equivalent to a total
of at least three of her pervious cycle lengths (Simpson, 1998). Athletes who begin training before menarche are often
more likely to have incidences of amenorrhea than those who begin training after menarche (Pantano, 2009). Amenorrhea
is deficient, absent, or inappropriately secreted pulsatile gonadotropin-releasing hormone (GnRH) (Simpson, 1998). Abnormal
GnRH secretion is said to occur for two reasons. Adrenal axis activation during exercise inhibits the hypothalamic GnRH
pulse activator, and/or low caloric intake combined with increased caloric expenditure may result in low energy (Simpson,
Osteoporosis, third component
of the triad, refers to inadequate bone formation and premature bone loss and can result in increased risk of fracture. The
average person experiences bone loss at a rate of 0.5 percent per year. Osteoporosis in young athletes can increase
that rate to anywhere between 2 percent and 6 percent per year, with complete loss reaching 25 percent of the total bone
mass (Pantano, 2009). A correlation has been found between athletes with amenorrhea and decreased bone mineral density
(BMD) that supports the connection between these two components of the triad (Simpson, 1998).
Methods of Screening
Screenings for the female athlete triad is
becoming more common in female athletics. Because little was known about the triad until recently, there
are very few methods of screening available. The most common ones are for eating disorders as the apparent main
factor of the triad, as well as physical and physiological screenings. Screening may also aid in prevention,
a possible key in minimizing the occurrences of the female athlete triad.
The most often used method of prevention of the triad
in athletic training is the use of pre-participation exams, medical history forms, surveys, and questionnaires (Black,
2003). Athletes are questioned or monitored for disordered eating behaviors, eating habits, nutritional intake, energy
level, and history of menses during pre participation screening examination. These strategies are important for
treating and preventing low energy availability, which can lead to menstrual dysfunction and low BMD (Rumball, 2005). The
pre-participation examination and medical history form provide an excellent opportunity to screen for triad disorders,
to establish a rapport with the athletes, and build a complete medical history on the patient (Black, 2003).
The most widely used test for eating disorders or disordered eating is the Eating Disorders Inventory-2 (Pantano,
2009). This Inventory is a self-report measure of 91 items that questions athletes on age, actual weight, desired
weight, height, menstrual history, and exercise habits (Manore, 2007). The Eating Disorders Inventory-2 includes
11 subscales; the three subscales that receive the greatest considerations are the Bulimia, Body Dissatisfaction,
and Drive-for-Thinness subscales because they are the core subscales for screening eating disorders. These three
subscales measure the athlete’s tendency to engage in binge eating or purging, unhappiness with body image,
and concern about height and weight (Pantano, 2009). Some of the other areas tested in the questionnaire
are Ineffectiveness, Interpersonal Distrust, Perfectionism, Maturity Fear, Interceptive Awareness, Impulse Regulation,
Social Insecurity, and Asceticism (Manore, 2007).
Along with pre-participation screenings, education and
knowledge about the female athlete triad is a key contributor to prevention. Athletes, coaches, certified athletic
trainers, and any other person working with the athlete needs to be educated as to the causes, signs, symptoms, and results
of the female athlete triad (Warren, 1990). Uneducated athletes may not realize the severity of the condition and
in turn not go to their certified athletic trainer if a problem arises. Recognition of signs and symptoms then become
The only part of the female athlete triad that can be
recognized simply through signs and symptoms is an eating disorder. An athlete who suffers from an eating disorder
may not necessarily be abnormally thin; however, they may present with bradycardia, hypotension, lanugo hair, and/or a
history of fainting. Parotid swelling, erosion of tooth enamel, a large amount of dental work, and Russell’s
sign, which is finger and nail changes on the first and second digits of the dominant hand, are all signs of bulimia (Simpson,
Improving an athlete’s
overall energy availability may be the key to reversing menstrual dysfunction and low bone density in female athletes.
Increasing total daily energy intake in moderate increments may be the easiest approach when treating an athlete
with the female athlete triad. In short, focus on a good diet may serve any prevention and/or treatment plan. The
use of screening is very important in the profession of athletic training. Certified athletic trainers are responsible
for the prevention, recognition, and treatment of any condition their athletes may face, including the female athlete
triad. The use of screenings would help certified athletic trainers recognize a problem early and prevent
the occurrence of more serious medical problems.
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