Spectrum of Menstrual Function

The 1997 Triad Position Stand included only the extreme end point of menstrual dysfunction (ie, amenorrhea) [2]. The proposed revised triad uses the term menstrual dysfunction to depict more accurately the spectrum of menstrual irregularities that can plague female athletes, including luteal suppression (or shortened luteal phase), anovulation, oligomenorrhea, primary amenorrhea, and secondary amenorrhea [2,33]. In contrast to disordered eating and bone strength, menstrual irregularities do not exist on a continuum. An athlete

Table 3

Health performance consequences of disordered eating behaviors

Weight control behavior Physiologic effects and health consequences

Fasting or starvation Promotes loss of lean body mass, a decrease in metabolic rate, and a reduction in bone mineral density. Increases the risk of nutrient deficiencies. Promotes glycogen depletion, resulting in poor exercise performance Typically function by suppressing appetite and may cause a slight increase in metabolic rate (if they contain ephedrine or caffeine). May induce rapid heart rate, anxiety, inability to concentrate, nervousness, inability to sleep, and dehydration. Any weight lost is quickly regained when use is discontinued Weight loss is primarily water, and any weight lost is quickly regained when use is discontinued. Dehydration and electrolyte imbalances are common and may disrupt thermoregulatory function and induce cardiac arrhythmia Laxatives or enemas Weight loss is primarily water, and any weight lost is quickly regained when use is discontinued. Dehydration and electrolyte imbalances, constipation, cathartic colon (a condition in which the colon becomes unable to function properly on its own), and steatorrhea (excessive fat in the feces) are common. May be addictive, and athlete can develop resistance, requiring increasingly larger doses to produce the same effect (or even to induce a normal bowel movement) Self-induced vomiting Largely ineffective in promoting weight (body fat) loss. Large body water losses can lead to dehydration and electrolyte imbalances. Gastrointestinal problems, including esophagitis, esophageal perforation, and esophageal and stomach ulcers, are common. May promote erosion of tooth enamel and increase the risk for dental caries. Finger calluses and abrasions are often present

Fat-free diets May be lacking in essential nutrients, especially fat-soluble vitamins and essential fatty acids. Total energy intake still must be reduced to produce weight loss. Many fat-free convenience foods are highly processed, with high sugar contents and few micronutrients unless the foods are fortified. The diet is often difficult to follow and may promote binge eating Saunas Weight loss is primarily water, and any weight lost is quickly regained when fluids are replaced. Dehydration and electrolyte imbalances are common and may disrupt thermoregulatory function and induce cardiac arrhythmia Excessive exercise Increases risk of staleness, chronic fatigue, illness, overuse injuries, and menstrual dysfunction

Data from Beals KA. Disordered eating among athletes: a comprehensive guide for health professionals. Champaign (IL): Human kinetics; 2004.

may or may not progress through subclinical menstrual disturbances before developing amenorrhea [34]. Conversely, an athlete may experience subclinical menstrual disturbances for years without ever experiencing a complete cessation of menstruation [34]. A brief description of the major categories of menstrual dysfunction is presented.

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Luteal suppression

Also called luteal phase deficiency or shortened luteal phase, luteal suppression is generally an asymptomatic (ie, no overt symptoms) condition, characterized by a shortened luteal phase of the menstrual cycle (between ovulation and menstruation), which may be accompanied by a prolonged follicular phase (between menstruation and ovulation); the total cycle length remains relatively unchanged. Because there are no overt symptoms, luteal suppression can be diagnosed only by measuring ovarian steroid hormone concentrations in the blood or urine over an entire menstrual cycle [34]. Women with luteal suppression generally display low estradiol levels in the early follicular phase along with a slightly decreased luteinizing hormone (LH) pulse frequency and significantly increased pulse amplitude. The rate and extent of follicular development are reduced, ovulation occurs later, and the amount and duration of progesterone secretion during the luteal phase is reduced or shortened [34].


Anovulation is the absence of ovulation and is generally caused by impairment of follicular development resulting from altered hormonal status. More specifically, estrogen and progesterone levels are reduced; however, estrogen production is sufficient to stimulate some proliferation of the uterine lining, and bleeding often occurs. As a result, women with anovulation often do not realize that they are have a menstrual irregularity. In some instances, alterations in cycle length can occur, including very short cycles (<21 days) or overly long cycles (35-150 days) [34].


Literally translated, the term oligomenorrhea means ''irregular menses.'' In practice, oligomenorrhea is used to describe a prolonged length of time between cycles (ie, >35 days) [33].


The term amenorrhea connotes the absence of menstruation and can be subdivided into two categories: primary and secondary. Primary amenorrhea, also referred to as delayed menarche, has been redefined by the American Society of Reproductive Medicine as the absence of menstruation by age 15 years in girls with secondary sex characteristics [35]. The age was lowered from 16 years due to the fact that age at menarche declined by 5 years in developed countries after the middle of the nineteenth century and is declining rapidly in developing countries. When amenorrhea occurs sometime after menarche, it is referred to as secondary amenorrhea. Generally, secondary amenorrhea requires the absence of at least three consecutive menstrual cycles [2].

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