Female Athlete Triad Clinical Presentation

When an athlete is identified as being at risk for the female athlete triad, a detailed screening history should be obtained. The purpose of the screening process is to gather information about the patient’s medical history and dietary and exercise behaviors and to evaluate the athlete for existing psychopathology and medical complications.

The team physician should not undertake every aspect of the evaluation and care of a woman with female athlete triad; rather, a multidisciplinary approach should be used. If available and deemed necessary, consultation with a psychiatrist or clinical psychologist with experience in disordered eating, an orthopedic surgeon, a gynecologist, a cardiologist, a sports nutritionist, and the athlete’s athletic trainer should be added to the treatment team to augment the physician’s personal knowledge of the athlete and team.

Past medical history

Particular attention should be given to any other endocrine disorders, such as thyroid abnormalities, panhypopituitarism, and diabetes. A careful and thorough history of past stress fractures and complete fractures should be elicited, and the history should be verified with trainers, coaches, or parents, if possible.

Menstrual history

Menstrual history should include age of menarche, length of menses, and menstrual cycle, as well as any missed menses and the menstrual pattern during the season or time period in which the athlete is exercising the most. Athletes playing certain sports in which strength is important may be using anabolic steroids, which are a potential cause of secondary amenorrhea. Pregnancy, however, is the most common cause of secondary amenorrhea in young females, and this possibility should always be discussed and ruled out.

Psychosocial history

At the first visit, routine questions should be asked, such as those pertaining to tobacco or alcohol use. As trust is built up over the next few visits, further details about the patient’s background should be elicited, such as illegal drug use, sexual or physical abuse, depression, anxiety, previous eating disorders, suicidal behavior, recent trauma or illness, change in coaches, failure at school or work, or other significant personal events.

The lack of a familial or social support system is a risk factor for the female athlete triad. Women just entering college are often in a new environment that is physically distant from their friends and family. This move, already potentially difficult, can be made more traumatic when the pressure to perform as a collegiate athlete is added. Sometimes, these women fall back on athletics—one of the few things that may have remained constant since high school—to gain acceptance from coaches and fellow athletes.

Exercise history

The number of hours that the athlete spends practicing and exercising each day should be determined. The examiner should make a point of asking how much time is spent in formal practice with the team or coach and how much additional time apart from scheduled workouts is spent on other related activities (eg, conditioning, running, and lifting). The athlete should also be asked if this workout pattern changes during the off-season or if it continues year round.

Nutritional assessment

Even when an athlete is consuming what would otherwise be considered a normal number of calories per day, she may not be consuming enough calories for her particular lifestyle. Women who exercise for hours every day are likely to need more than the 1600-2000 kcal that their body weight would indicate.

The Eating Disorder Inventory (EDI), for example, is a questionnaire designed to help identify those with disordered eating. Although the EDI is not a precise instrument for identifying eating disorders, it can be used to identify people at risk for anorexia or bulimia.

Some athletes with the triad adopt restrictive diets, and they may sometimes use personal convictions or religious beliefs to justify their behavior. Often, the athlete develops a recognizable pattern of disordered eating in which they establish and exceed progressively restrictive dietary boundaries. For example, a diet that eliminates red meat may progress to vegetarianism and then to veganism over the course of months.

The athlete’s convictions may be subconscious excuses reflecting what is socially acceptable to her peers and authority figures. Of course, not every athlete with a diet that restricts certain foods has the female athlete triad, and not every athlete is consciously participating in disordered eating. For many athletes, the low energy availability is due to lack of education about caloric needs for their exercise or training. This is yet another reason why the diagnosis is difficult to establish.

Current medications

The patient’s history should include the use of any prescription medications, including contraceptive medications, any over-the-counter (OTC) medications, and any herbal medicines or dietary supplements.

Many people do not consider OTC medicines to be “real” medicines, and athletes with the triad commonly use or abuse dietary supplements or ergogenic aids. For example, athletes may take the common stimulant ephedrine in order to lose weight or to burn fat; however, ephedrine is known to cause mild tachycardia and has been at least temporally associated with several deaths in the athletic population. This tachycardia could potentially mask the bradycardia found in athletes with advanced eating disorders.

Attention should also be directed toward any present or past use of hormones because these substances can also cause menstrual irregularities.

In general, a complete screening physical examination should be performed. As with the patient history, it may be appropriate to postpone some parts of the physical examination until a relationship has developed between the athlete and physician.

For example, a gynecologic and breast examination may be better suited for a second or third visit. An exception to this rule is made if the amenorrhea is primary—that is, if the athlete has never had normal menses. In this case, pelvic examination to verify the presence of a uterus should be performed at the first visit. Pelvic ultrasonography can aid in this determination.

The diagnosis is largely clinical, and no test enables definitive diagnosis of the female athlete triad. Many times, the physician first diagnoses a stress fracture, then menstrual dysfunction, and finally low energy availability, with or without an eating disorder. However, this sequence is the reverse of the order in which the female athlete triad develops.

Female athletes who come to a summertime preparticipation physical examination wearing many baggy clothes or sweatpants and sweatshirts should raise concern. Athletes with the female athlete triad may try to hide their body weight loss. In addition, some athletes may present for the examination and then refuse to let the physician or anyone else examine them. This is often the case with 14- to 16-year-old athletes who participate in high school sports.

Anthropometric data and vital signs should be obtained without any comments about weight or weight-to-height ratios. Body mass index (BMI) charts are calibrated for the general population and may not be suitable for the athletic subpopulation. If possible, the patient’s percentage of body fat should be determined. Pediatric growth charts are often helpful in teenagers or college students.

The remainder of the physical examination is directed toward other causes of amenorrhea or osteoporosis and secondary signs of the triad. Athletes with the female athlete triad usually report signs or symptoms related to osteoporosis (eg, fracture, stress fracture) before they report menstrual abnormalities.

The thyroid should be palpated for possible goiter. The parotid glands should be palpated for evidence of hypertrophy. This is sometimes found after chronic purging.

Bulimia can cause bloodshot eyes and petechiae of the sclera or cheeks. Dental examination can show dental caries or pitting from the regurgitation of stomach acid through the oropharynx. If a finger is used to induce vomiting, the knuckles may be scarred from the patient biting down on them during regurgitation. The Russell sign is typical callous formation on the distal extensor surface of the long finger that is used to induce vomiting.

Anorexia may cause cachexia, bradycardia, and hypotension later in the course of the disease. Although many well-conditioned athletes may have a resting heart rate below that of the general population, an electrocardiogram (ECG) should be obtained if the athlete’s resting heart rate is lower than 50 beats/min.

Sinus bradycardia is an early cardiac sign in eating disorders, but conduction abnormalities (eg, atrioventricular conduction blocks, ventricular tachycardia) may become evident in more advanced cases. A baseline ECG may also be obtained for future comparison.

Dermatologic examination sometimes reveals lanugo or the dry or yellow skin that is sometimes found in those with anorexia.

Continued bone loss leading to irreversible osteoporosis is the most worrisome complication of the triad. Some evidence exists to suggest that bone mineral density (BMD) can be regained to a small degree, but it is doubtful that a significant loss can be completely corrected, even with years of therapy.

A cross-sectional study that evaluated the associations between BMD and exercise performed in women with a history of anorexia nervosa found that currently ill participants had a lower BMD than recovered patients.^[26] The authors concluded that excessive moderate loading exercise may put these patients at higher risk of low BMD. Recovering patients may benefit from high bone-loading exercise by provoking bone accrual.

Multiple stress fractures or complete fractures can lead to an increased incidence of osteoarthritis, depending on the site of the fractures. Other fractures may heal without any long-term sequelae. These fractures should be carefully monitored; they may take longer to heal than one would expect. The negative nutritional balance often leads to slowed or delayed healing of fractures.

End-stage eating disorders can result in more serious complications, such as prolonged hospitalization, cardiac arrhythmias, or even death. Anorexia nervosa has an estimated mortality of 15% once the diagnosis is made. Compared with other individuals, athletes are less likely to meet the criteria for anorexia or bulimia, but significant morbidity and mortality can occur.

As research continues and long-term data are followed, possible other complications may include an increase in endothelial dysfunction, which is a strong predictor of coronary artery health and a possible increase in atherosclerotic disease and cardiovascular event rates.^{[8, 9]}