Female Athlete Triad: Understanding the Interrelationship between Energy Availability, Menstrual Function, and Bone Health

Abstract

The Female Athlete Triad (FAT) is a complex medical condition characterized by three interrelated components: low energy availability (EA) with or without disordered eating, menstrual dysfunction, and decreased bone mineral density (BMD). This syndrome is particularly prevalent among female athletes who engage in sports that prioritize leanness, endurance, and aesthetic performance, such as gymnastics, dance, and long-distance running. Prolonged exposure to inadequate caloric intake relative to energy expenditure can disrupt hormonal regulation, leading to irregular or absent menstrual cycles (amenorrhea) and compromising bone health. This cross-sectional study aims to investigate the prevalence and impact of low EA on menstrual function and BMD among 180 female athletes aged 18-30 years. Participants were divided into three menstrual status categories: eumenorrhea, oligomenorrhea, and amenorrhea. The study also categorized athletes into sports groups (aesthetic, endurance, and power sports) to identify patterns across different disciplines. Data collection included dietary intake records, exercise logs, menstrual history questionnaires, and DEXA scans to measure BMD at the lumbar spine and hip. Results indicate that 67% of participants exhibited low EA (< 30 kcal/kgFFM/day), which was significantly associated with menstrual dysfunction (p < 0.001). Among participants, 25% reported oligomenorrhea (irregular cycles), and another 25% experienced amenorrhea (absence of menstruation for more than three months). BMD analysis revealed that 30% of the athletes had osteopenia, while 5% were diagnosed with osteoporosis, highlighting the long-term risks associated with chronic low EA and menstrual irregularities. Notably, athletes engaged in aesthetic sports had the highest prevalence of low EA (80%) and menstrual dysfunction (45%), followed closely by those in endurance sports. These findings underscore the urgent need for targeted interventions to promote energy balance, safeguard reproductive health, and prevent bone deterioration among female athletes. Educational programs focusing on nutritional counseling, regular monitoring of menstrual health, and multidisciplinary care involving coaches, sports dietitians, and healthcare providers are essential to mitigate the risks of the Female Athlete Triad. Future research should further explore psychological factors influencing energy availability, including body image concerns and disordered eating patterns, to develop comprehensive prevention strategies.