Women face 'triad' of danger

Sports can be a win-win activity for young women. Research shows that exercise builds strong bones, helps control weight and improves mood. And it reduces the risk of developing serious illnesses such as heart disease and breast cancer.

But it also comes with risks. If female athletes consume too few calories for their level of activity, they might stop menstruating for months, which can lead to bone loss and an increased risk of osteoporosis.

This trio of interrelated problems -- insufficient calories, bone loss and disrupted menstrual cycles -- have been dubbed the "female-athlete triad" by the American College of Sports Medicine.

"I have seen girls who had been in their 20s who had been amenorrheic (not menstruating) for several years who had the bones of a 70- or 80-year-old woman," says Seattle-based research physiologist Barbara Drinkwater, a former president of the sports medicine group.

The problem has caught the attention of the International Olympic Committee Medical Commission, which recently developed a consensus statement on dangers and possible treatments, and the National Collegiate Athletic Association, which published a coaches handbook on the topic.

Not just the elite

The female-athlete triad is not limited to college or elite athletes.

It occurs in high school and middle-school girls as well as other women who are physically active, says psychologist Ron Thompson, who co-wrote the NCAA handbook. Any woman, even if she's in her 40s, who has disordered eating and becomes amenorrheic will lose bone, Drinkwater says.

Bone loss also can occur in men who have eating disorders, she says. Those at risk are athletes in sports in which body weight is important, such as running, wrestling and ski jumping, she says. "But men haven't been studied as well as women," she says, and there is no triad for them at this point.

The triad should serve notice to parents "to be aware of any pressure put on young athletes to be thin, whether from coaches, teammates or the athlete herself," Drinkwater says.

The problem often begins with "disordered eating," a broad term used to describe a range of eating problems. They range from frequent dieting to anorexia nervosa, or self starvation, a low weight and fear of being fat, to bulimia nervosa, the binge-and-purge disorder.

When young women do not consume enough calories for their activity levels, their energy deficits may disrupt their menstrual cycles. Estrogen, which is critical for preserving bone, drops to the level of postmenopausal women, Drinkwater says. At the same time, inadequate nutrition leads to other hormonal changes that inhibit the ability to build bone. With restrictive dieting, women often limit calcium-rich dairy products and other important nutrients for bone health, she says.

Trouble signs early

Such behaviors are especially harmful during the teen years up until about age 21 because women at those ages are still building bone, she says. "So it's a two-prong problem: They are losing bone and not developing it at a critical age."

In the most severe cases, young women may develop osteoporosis, the crippling loss of bone mass often associated with older, postmenopausal women.

The weakened skeletons of young athletes can lead to fractures, especially in the legs, hips and pelvis, Drinkwater says. "If you happen to be a ballet dancer, it can be the end of your career. If you are trying for the Olympics and you have a hip fracture, that's the end of a dream."

Katherine Beals, a researcher at the University of Utah in Salt Lake City, investigated the triad in 112 female college athletes. She found three who had all three problems; only one met the strictest definition for osteoporosis. However, many others had disordered eating, amenorrhea and/or low bone-mineral density for their ages, says Beals, author of the book Disordered Eating Among Athletes. She recommends that young women who have not been menstruating regularly have a bone-mineral density test.

Drinkwater says no one knows how long women can go without menstruating before they experience bone loss. That is because techniques for gauging bone density are not sensitive to small changes. But going more than three months without a period is not good, she says.

There is no magic pill to fix the loss once it occurs. Medications prescribed to older women to build bone such as Actonel and Fosamax have not been tested in premenopausal women and are not recommended for them, she says.

Amenorrhea often can be reversed with an increase in calories or a decrease in physical activity. Says Drinkwater: "The best treatment is getting to a nutritionist and solving the problem of inadequate intake."

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