Physiological aspects and clinical sequelae of energy deficiency and hypoestrogenism in exercising women

Amenorrhoea associated with reduced caloric intake and strenuous exercise leads to hypoestrogenism and is associated with clinical manifestations that include disordered eating, stress fractures, osteoporosis, and, as recently reported, a potential increase in the risk of premature cardiovascular disease. Disordered eating, menstrual irregularities and bone loss comprise the clinical condition known as the 'female athlete triad'. The aetiology of the triad is linked to a high prevalence of disordered eating and cognitive restraint. This results in inadequate caloric intake for high exercise energy expenditures that leads to energy deficiency. This in turn stimulates compensatory mechanisms, such as weight loss or energy conservation, subsequently causing a central suppression of reproductive function and concomitant hypoestrogenism. Because the aetiology of menstrual disturbances and the female athlete triad is causally linked to energy deficiency, there is no justification for fears that exercise itself is unhealthy for women. However, improved detection, monitoring, and treatment of all components of the triad in exercising women should be emphasized. This paper critically reviews the physiological aspects and clinical sequelae of energy deficiency and hypoestrogenism associated with the female athlete triad in exercising women.