Prevalence of Individual and Combined Components of the Female Athlete Triad JENNA C. GIBBS, NANCY I. WILLIAMS, and MARY JANE DE SOUZA Women’s Health and Exercise Laboratory, Noll Laboratory, Department of Kinesiology, Pennsylvania State University, University Park, PA ABSTRACT GIBBS, J. C., N. I. WILLIAMS, and M. J. DE SOUZA. Prevalence of Individual and Combined Components of the Female Athlete Triad. Med. Sci. Sports Exerc., Vol. 45, No. 5, pp. 985–996, 2013. Purpose: The female athlete triad (Triad) is a syndrome linking low energy availability (EA) with or without disordered eating (DE), menstrual disturbances (MD), and low bone mineral density (BMD) in exercising women. The prevalence of Triad conditions (both clinical and subclinical) has not been clearly established. The purpose of this review is to evaluate the studies that determined the prevalence of clinical or subclinical Triad conditions (low EA, DE, MD, and low BMD) in exercising women and in women participating in lean (LS) versus nonlean sports (NLS) using self-report and/or objective measures. Methods: A review of publications using MEDLINE and PubMed was completed. Randomized controlled trials and observational studies that evaluated the prevalence of clinical and subclinical Triad conditions (MD, low BMD, low EA, and DE) in exercising women were included. Results: Sixty-five studies were identified for inclusion in this review (n = 10,498, age = 21.8 T 3.5 yr, body mass index = 20.8 T 2.6 kgIm j2 ; mean T SD). A relatively small percentage of athletes (0%–15.9%) exhibited all three Triad conditions (nine studies, n = 991). The prevalence of any two or any one of the Triad conditions in these studies ranged from 2.7% to 27.0% and from 16.0% to 60.0%, respectively. The prevalence of all three Triad conditions in LS athletes versus NLS athletes ranged from 1.5% to 6.7% and from 0% to 2.0%, respectively. LS athletes demonstrated higher prevalence rates of MD and low BMD (3.3% vs 1.0%), MD and DE (6.8%–57.8% vs 5.4%–13.5%), and low BMD and DE (5.6% vs 1.0%) than the NLS athletes. Con- clusions: Although the prevalence of individual/combined Triad conditions is concerning, our review demonstrates that additional research on the prevalence of the Triad using objective and/or self-report/field measures is necessary to more accurately describe the extent of the problem. Key Words: LOW ENERGY AVAILABILITY, MENSTRUAL DISTURBANCES, LOW BONE MINERAL DENSITY, EXERCISING WOMEN T he female athlete triad (Triad) was first recognized two decades ago based on the association of disor- dered eating (DE), functional hypothalamic amen- orrhea (FHA), and osteoporosis observed in recreational and elite-level exercising women (41). In 2007, the American College of Sports Medicine published a position stand (41) with updated scientific information and recommendations for screening, diagnosis, prevention, and treatment of the Triad. The most recent conceptual model of the Triad is a syndrome linking low energy availability (EA) (with or without DE), menstrual disturbances (MD), and low bone mineral density (BMD) across a continuum of healthy (opti- mal EA, normal and regular menstrual cycles, and optimal BMD) to unhealthy and increasingly severe clinical pre- sentations of each component (41). The Triad is a detri- mental consequence of the failure to ingest adequate energy to compensate for energy expended during exercise, a condition called low EA. As such, the Triad is commonly observed in exercising women (14,41), particularly those women involved in leanness, aesthetic, and/or endurance sports and activity (63). Low EA with or without DE may be induced for a variety of reasons to include the following: 1) intentional, i.e., modifying body size and composition to achieve appearance or performance goals; 2) compulsive, i.e., demonstrating DE and/or pathological weight control behavior; or 3) inadvertent, i.e., failing to match energy intake to exercise-induced energy expenditure (37). Low EA often results in an energy deficiency, which when sustained for prolonged periods of time translates to meta- bolic and reproductive suppression (72). The result is the development of both subclinical (luteal phase defects [LPD] and anovulation) and clinical MD (FHA and oligomenorrhea), musculoskeletal complications, e.g., low BMD and stress fractures (41), and other clinical sequelae, that is, endothelial dysfunction (29,45). A large body of literature exists wherein the prevalence of individual disorders of the Triad has been determined (MD, low BMD, and DE/eating disorders). Several publi- cations have reported the prevalence of clinical MD (FHA Address for correspondence: Mary Jane De Souza, Ph.D., FACSM, Women’s Health and Exercise Laboratory, Department of Kinesiology, Pennsylvania State University, 104 Noll Laboratory, University Park, PA 16802; E-mail: mjd34@psu.edu. Submitted for publication July 2012. Accepted for publication November 2012. 0195-9131/13/4505-0985/0 MEDICINE & SCIENCE IN SPORTS & EXERCISE Ò Copyright Ó 2013 by the American College of Sports Medicine DOI: 10.1249/MSS.0b013e31827e1bdc 985 APPLIED SCIENCES Copyright © 2013 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.