The Female Triad

The Female Triad is the name given to a unique combination of circumstances commonly found in female athletes that significantly increases their chance of developing a serious injury or illness.

The Female Triad is used to explain the relationship between how much energy is available, menstrual function and the effect these have on bone density. This can range from being healthy to developing a physical or psychological disease and needs to be recognised by healthcare professionals.

The Female Triad is the correlation between:

  • Energy availability (ranging from high to low levels)

  • Bone mineral density (ranging from high levels to osteoporosis)

  • Menstrual function (ranging from healthy to complete absence of cycles)

Any of these three above areas can be seriously affected if the other two aren’t properly maintained. If all are properly maintained, then normal healthy function is achieved.

As a podiatrist, I commonly see female athletes presenting with overuse injuries as a direct result of The Female Triad being present. Some common overuse injuries that we see as a result of this includes:

  • Bone Stress Reaction

  • Stress Fractures

  • Recurrent Stress Fractures  

  • Medial Shin Pain

  • “General aches and pains” in the feet when exercising

  • Recurring tendonitis injuries to existing or new areas

Energy Availability

Energy availability is defined as dietary energy intake minus exercise energy expenditure. This directly results in skeletal (muscle and bone) and menstrual health.

When energy availability is too low, physiological functions in the body are impaired to reduce the amount of energy being used. These functions can include cellular maintenance, growth, reproduction and body temperature regulation. This is usually a direct result of not consuming enough calories, which can commonly come from a range of eating disorders.

Ladies, if you train regularly, you have to eat enough food in order to keep your hormonal levels and reproductive functions performing normally.

Menstrual Function

Eumenorrhea is defined as normal menstrual function whereas amenorrhea is the absence of menstrual cycles for more than three months. When amenorrhea is present, it is obviously very dangerous to your health. Severe dietary restriction alone can disrupt the menstrual cycle however, the more physically active you are, the less dietary restriction is required to cause low energy availability. The physical ‘stress’ of exercise is not the cause of the disruption to menstrual function, low energy availability is. It should be noted that for some individuals, a decrease in energy expenditure from exercise is required to help restore energy balance.  However, for most, an increase in dietary energy intake to better meet the energy demands of exercise is sufficient to restore menstrual function.

Whenever an active female presents with any of the mentioned injuries, we (podiatrists and other health professionals) have to ask about your menstrual cycle. So girls, if you are seeing someone for your foot pain and they ask about your menstrual cycle…be honest. It may hold the key to 1) diagnosing your pain and 2) getting you better.

Bone Mineral Density

Young active females with any of the above two issues are up to 15% more likely to develop a bone density issue such as osteoporosis. Although rare and severe, females in their late 20s can potentially develop osteoporosis if the above two signs are left untreated.

A regular menstrual cycle and normal energy levels directly impact on bone density. It can take a long and complicated physiological explanation as to why this is the case, but rest assured, it is vital this is considered if the above two are present. A decrease in bone density greatly increases the chances of an injury occurring or reoccurring. Especially to bones, muscles, joints and tendons.

In summary, if you are a young and active female who is currently experiencing any of these symptoms:

  • Potential eating disorder (no matter how mild or severe)

  • Irregular menstrual cycle

  • Any of the above injuries mentioned earlier

Then it is important to go and speak to a health professional so they can guide you on the best course of treatment and put you in touch with the right medical professionals to help manage The Female Triad.

Ryan Twist is a Sports Podiatrist practising out of Bayswater Foot and Ankle Clinic in Melbourne's outer east. He founded the clinic 5 years ago after returning home from working at Sports Podiatry Clinic in Canberra, where he gained valuable experience working with athletes at the Australian Institute of Sport. He has a passion for triathlons having competed in 7 Ironman’s and 10 Half Ironman’s - and qualifying for the World Ironman Championships in Hawaii. Some may say he is crazy, but let's not tell him that!

www.bayswaterpodiatry.com.au

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