In 1996 WomenSport International convened an International Forum on the Female Athlete Triad: Eating Disorders, Amenorrhea, and Osteoporosis in Atlanta, just prior to the 4th Olympic Scientific Congress. The Forum was designed to bring world-wide attention to the Triad and resulted in the appointment of a WSI Task Force that worked with the IOC Medical Commission to address this issue.
The joint Task Force was chaired by Barbara Drinkwater (WSI) and included a mix of medical doctors and academics. WSI members included Naama Constantini, Israel; Ruth Highet, New Zealand; Jorunn Sundgot-Borgen, Norway; and Jane Wilson, UK. IOC representatives were Arne Ljungqvist, Sweden; Ken Fitch, Australia; and W.D. Montag, Germany.
Read more about the Forum, including the definitions of terms, consequences of the Triad and suggestions for what can be done to prevent it.
A Female Athlete Triad Summit was convened in Chicago in 2002 to coordinate the many organizations trying to eliminate the Triad among female athletes. WSI was represented by WSI Task Force Chair, Barbara Drinkwater. The Summit produced a Mission Statement, Goals and 4 recommended projects focused on Public Education, Collaboration/Sponsorship, Advocacy/Political Strategies and Professional Education. Read more about this Summit.
The Task Force produced the following summary statement about the Female Athlete Triad.
Summary Statement
The Female Athlete Triad 
Under intense pressure from coaches, parents, teammates – often even themselves – to lose weight, many young athletes slip into disordered eating which can lead to menstrual irregularities and bone loss, jeopardizing their health and placing them at risk for premature osteoporosis. WomenSport International has appointed a Task Force to educate athletes and those responsible for their welfare about the dangers of this Triad of health problems.
Weight loss does not necessarily ensure improvement in athletic performance. Muscle mass as well as fat is lost during extreme dieting and performance may actually deteriorate. Other side-effects of poor nutrition such as fatigue, anemia, electrolyte abnormalities, and depression can also contribute to a poor performance. Although many coaches now realize that body composition measurements provide better information than body weight alone, most do not realize that these measures are far from precise and that holding all athletes to a single standard for body fat can have serious repercussions. Pressuring athletes to achieve an unrealistic weight loss ignores individual variability in body habitus and often leads to disordered eating.
Although not all athletes with eating problems meet the strict criteria for bulemia or anorexia, the number of females who exhibit restrictive eating behavior is estimated to range between 15 and 62% depending on the sport. There appears to be a continuum of disordered eating within the athletic population ranging from poor nutrition to clinical pathology. All points along this continuum can have serious consequences for the athlete’s health. For those athletes who progress to anorexia or bulemia those consequences include serious medical complications and even death.
While a common symptom of anorexia nervosa in women is amenorrhea (absence of menses), menstrual irregularities can occur in the absence of an eating disorder. As a result of the high energy demands of exercise, athletes may be energy deficient even while consuming meals considered normal for healthy nonathletes. While the precise etiology of amenorrhea and oligomenorrhea (irregular menses) has yet to be determined, it is possible that even seemingly minor deficits between caloric expenditure and caloric intake may play a role. Stress, such as the pressure to meet impossible weight standards, may also be a factor. What is certain is that the prevalence of amenorrhea among athletes is high, ranging from 10 to 45% depending on the sport, and the consequences can be serious.
Amenorrhea is usually an overt sign of a decrease in estrogen production. In most amenorrheic athletes estrogen levels drop to postmenopausal levels and there is a significant decrease in bone mass. This loss of bone mineral density (BMD) is usually first observed in the spine but, if the amenorrhea is prolonged, bone loss can occur in other parts of the skeleton as well. Early studies suggested that with the resumption of menses some of the bone could be regained, but more recent studies report that recovery of bone is limited and some of the loss may be irreversible. The spinal density of some young athletes is similar to that of women in their 70’s and 80’s and may never return to normal. Evidence is mounting that these athletes are at increased risk for stress fractures and more serious fractures of the pelvis, hip, and spine. What the future holds for these women is uncertain, but there is great concern about the potential for premature osteoporotic fractures as these women age.
Girls and women should be encouraged to realize the full physiological, social, and psychological benefits of sport and physical activity and should be encouraged to strive for excellence. However, pressure to meet unrealistic weight standards which ignores the consequences for the athlete should not be tolerated. Among the priorities of the WSI Task Force are the education of athletes, coaches, parents, and sports governing bodies about the Female Athlete Triad, distribution of guidelines for physicians to follow in the preparticipation physical examination of female athletes, establishment of standards of conduct for those responsible for coaching and training, women, and encouragement of research into the etiology of the amenorrhea associated with sport.