Q: What is the female athlete triad, and why should every female athlete know about it?

A: It’s a myth that it’s normal for young women to not get a regular monthly period during times of intense physical activity such as exercise or athletics. Actually, the menstrual cycle is a vital sign, just like blood pressure and heart rate. If a female athlete does not have a regular monthly menstrual cycle, it could indicate a health concern, such as a condition called the female athlete triad.

The female athlete triad is comprised of three parts: low energy, either with or without disordered eating; menstrual dysfunction; and low bone density.

Healthy athletes have optimal balance between these three components. But an athlete does not need to have all three components to have this condition.

Low energy availability happens when an athlete doesn’t realize that she is not taking in sufficient calories for the energy she is expending. In many cases, an athlete is unaware that she is not meeting nutritional needs. In other cases, low energy availability can result from disordered eating — a spectrum of abnormal eating behaviors, ranging from dieting to clinical eating disorders such as anorexia nervosa. Consulting with a mental-health provider who has experience treating eating disorders is recommended.

Adolescents typically present with menstrual dysfunction ranging from infrequent or irregular cycles, to never having a menstrual cycle at all. Normal menstrual cycles should occur in an adolescent every 21 to 45 days. A teen whose menstrual cycle is occurring outside of this range warrants further evaluation. An evaluation is also necessary if a teen hasn’t had a menstrual cycle by age 15, or within three years of breast development. Menstrual dysfunction warrants complete assessment with a thoughtful patient history. A laboratory evaluation and physical exam might also be indicated. An absent cycle might be due to the female athlete triad, a hormonal issue, medication, or pregnancy.

Teenage patients who present with the female athlete triad might not have a regular monthly menstrual cycle due to a problem in the hypothalamus — the part of the brain that sends important hormones around the body. In this case, it results in decreased estrogen levels. Estrogen plays a key role in bone being reabsorbed and built. Peak bone mass is accrued during adolescent years. Long-term effects of unrecognized low bone density can result in stress fractures and osteoporosis.

In addition to negative bone effects, if the female athlete triad is not treated early, it can impact other systems in the body and harm psychological health with risks for depression, low self-esteem, and anxiety.

Athletes who engage in sports in which low body weight is considered ideal (i.e., runners, gymnasts, and dancers) are more likely to suffer from this condition. However, it’s important to recognize that it can occur in any athlete.

The good news is that if the problem is diagnosed early, intervention is possible through lifestyle modifications. It can be treated by either adjusting energy expenditure (the amount of exercise) and/or energy availability (caloric intake). Athletes who are unaware of their energy needs should consult a sports nutritionist. For teens who have an eating disorder, cognitive behavioral therapy and/or family-based therapy are recommended. The strongest predictor for the recovery of normal menstrual function in college athletes is weight gain. Once optimal weight is restored, teens will likely resume having a regular monthly cycle.

Working with the athlete’s coach can help to reduce athletic activity level until a positive energy balance is achieved. Restricting activity can sometimes be met with hesitation. However, this is a temporary measure to restore optimal health. Treatment includes a team-based approach among the athlete, parents, coach, physician, and nutritionist.

Screening all athletes for the female athlete triad during physicals and well visits is important. Prevention is best achieved through awareness and education.

Rachael L. Polis is a pediatric and adolescent gynecologist at Crozer Health.