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Female Athlete Triad: Differential Diagnoses & Workup

Author: Laura M Gottschlich, DO, Assistant Professor of Family and Community Medicine, Medical College of Wisconsin; Consulting Staff, St. Joseph Family Medicine Residency Program
Coauthor(s): Craig C Young, MD, Professor, Departments of Orthopedic Surgery and Community and Family Medicine, Medical Director of Sports Medicine, Sports Medicine Fellowship Director, Medical College of Wisconsin; Boone Barrow, MD, Consulting Staff, Department of Family Medicine, Scott and White Clinic
Contributor Information and Disclosures

Updated: May 30, 2008

Differential Diagnoses

Other Problems to Be Considered

Androgen excess (endogenous or exogenous)
Depression
Drug interactions
Generalized anxiety disorder
Hypogonadotropic hypoestrogenism
Hypothalamic disorders
Hypothyroidism or hyperthyroidism
Luteal-phase inadequacy
Nutritional deficiencies
Ovarian defect (eg, Turner syndrome, gonadal dysgenesis)
Pituitary disorders
Polycystic ovary disease
Premature ovarian failure

Workup

Laboratory Studies

Obtain the following laboratory studies in a female suspected of having the female athlete triad:

  • Urine or plasma pregnancy test to rule out pregnancy
  • Urinalysis with specific gravity to establish volume status
  • Complete blood cell (CBC) count to rule out anemia
  • Erythrocyte sedimentation rate (ESR) to check for inflammation or infection: A C-reactive protein (CRP) test may be ordered for verification, although this is usually not necessary because such a clinical problem is likely to have been present for months or years.
  • Complete metabolic panel to evaluate liver function, electrolyte levels, and kidney function
  • Thyroid panel to rule out hyperthyroidism and hypothyroidism: A thyrotropin (ie, TSH) test is standard to rule out these diseases, and a free thyroxine (T4) test can be performed to confirm the results. The standard thyroid panel used in most laboratories is now outdated, and the thyrotropin and T4 tests are the standard.
  • FSH and LH tests to evaluate pituitary function and possible premature ovarian failure
  • Prolactin test to evaluate pituitary function
  • Testosterone and dehydroepiandrosterone sulfate (DHEAS) tests to evaluate androgen excess and possible adrenal or ovarian tumors: Some forms of these tumors may be nonvirilizing and therefore difficult to diagnose without a laboratory test.
  • Direct estradiol measurements

Related Medscape topic:
Specialty Site Pathology & Lab Medicine

Imaging Studies

  • If the athlete presents with bone pain, as with a stress fracture, appropriate plain radiographs should be obtained.
  • Baseline dual-emission x-ray absorptiometric (DEXA) scans can be obtained in all athletes with the triad to identify undiagnosed osteoporosis or subclinical stress fractures, as well as to provide a reference for future monitoring. The ACSM and the American Academy of Pediatrics recommend that an athlete's BMD be evaluated if she has been amenorrheic for longer than 1 year, has a BMI less than 18, or a history of a stress fracture. The recommendation is a posteroanterior view of the spine and/or hip, if the athlete is >20 years old and a posteroanterior view of the spine and whole body, if the athlete is <20 years old, with the diagnosis made by a Z-score.
  • If the results of laboratory studies indicate abnormal pituitary function, thin-section magnetic resonance imaging of the head should be performed through the sella turcica.
  • In athletes with primary amenorrhea who lack a uterus (as determined at physical examination), pelvic ultrasonography can be used to verify the finding and to evaluate the presence and morphology of the ovaries. Hand images should also be obtained in these patients to establish their bone age.
  • When a 3-phase bone scan depicts a stress fracture, further imaging evaluation is usually not indicated. The presence of multiple stress fractures in an at-risk athlete is a warning sign for the female athlete triad.

Other Tests

  • The diagnosis is largely clinical, and no test enables definitive diagnosis of the female athlete triad.
  • As mentioned earlier, a resting ECG should be obtained in any athlete with a resting heart rate of less than 50 bpm. Many physicians believe that a baseline ECG should be performed in all athletes at risk for the triad. As with so many aspects of this disease, exact epidemiologic data are not yet available. Drawing on experience with anorexia and bulimia, for which a baseline ECG is usually recommended, proceeding with this noninvasive test may be a safe choice.
  • A progesterone challenge test can be used to determine if the uterine endometrium has been primed with estrogen and thus be ready to be shed, as in normal menstruation. A 10-day course of 5 or 10 mg of oral progesterone (Provera; Pfizer Inc, New York, NY) can be used to induce menstrual bleeding. Lack of menses indicates that the uterine endometrium has not been adequately exposed to estrogen since the last menses. A positive test result is confirmed when menstrual flow occurs; this finding provides indirect confirmation of the presence of adequate amounts of estrogen to sustain endometrial growth.

Procedures

  • During the workup for amenorrhea, an evaluation of the endometrium may be necessary.
  • The team physician can perform an endometrial biopsy, or a consultation with the primary care physician or gynecologist should be requested.
    • Endometrial sampling is performed by using a thin tube, usually a disposable pipette, inserted through the cervical os into the uterine cavity.
    • Suction is then applied to the tube, and endometrial tissue is drawn into it.
    • This sample can then be histologically examined to help determine the stage of growth of the endometrial tissue and, thus, the effects or presence of estrogen and progesterone.

More on Female Athlete Triad

Overview: Female Athlete Triad
Differential Diagnoses & Workup: Female Athlete Triad
Treatment & Medication: Female Athlete Triad
Follow-up: Female Athlete Triad
References
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Further Reading

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Keywords

FAT, sports amenorrhea, sports-related amenorrhea, amenorrhea, female athletes, disordered eating, anorexia, bulimia, osteoporosis, energy availability, low energy availability in the female athlete, menstrual dysfunction, menstruation disorders, bone health, functional hypothalamic amenorrhea

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Contributor Information and Disclosures

Author

Laura M Gottschlich, DO, Assistant Professor of Family and Community Medicine, Medical College of Wisconsin; Consulting Staff, St. Joseph Family Medicine Residency Program
Laura M Gottschlich, DO is a member of the following medical societies: American Academy of Family Physicians, American College of Sports Medicine, American Medical Association, American Medical Society for Sports Medicine, and American Osteopathic Association
Disclosure: Nothing to disclose.

Coauthor(s)

Craig C Young, MD, Professor, Departments of Orthopedic Surgery and Community and Family Medicine, Medical Director of Sports Medicine, Sports Medicine Fellowship Director, Medical College of Wisconsin
Craig C Young, MD is a member of the following medical societies: American Academy of Family Physicians, American College of Sports Medicine, American Medical Society for Sports Medicine, Phi Beta Kappa, and Wilderness Medical Society
Disclosure: Nothing to disclose.

Boone Barrow, MD, Consulting Staff, Department of Family Medicine, Scott and White Clinic
Boone Barrow, MD is a member of the following medical societies: American Academy of Family Physicians, American College of Sports Medicine, American Medical Association, American Medical Society for Sports Medicine, and Texas Medical Association
Disclosure: Nothing to disclose.

Medical Editor

Leslie Milne, MD, Assistant Clinical Instructor, Department of Emergency Medicine, Harvard University School of Medicine
Leslie Milne, MD is a member of the following medical societies: American College of Sports Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Russell D White, MD, Professor of Medicine, Department of Community and Family Medicine, University of Missouri-Kansas City School of Medicine, Truman Medical Center Lakewood
Disclosure: Nothing to disclose.

CME Editor

Jon B Whitehurst, MD, Clinical Instructor of Surgery, University of Illinois College of Medicine; Partner and Executive Board Member, Rockford Orthopedic Associates; Orthopedic Chairman, Rockford Memorial Hospital
Jon B Whitehurst, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Society for Sports Medicine, and Arthroscopy Association of North America
Disclosure: Nothing to disclose.

Chief Editor

Craig C Young, MD, Professor, Departments of Orthopedic Surgery and Community and Family Medicine, Medical Director of Sports Medicine, Sports Medicine Fellowship Director, Medical College of Wisconsin
Craig C Young, MD is a member of the following medical societies: American Academy of Family Physicians, American College of Sports Medicine, American Medical Society for Sports Medicine, Phi Beta Kappa, and Wilderness Medical Society
Disclosure: Nothing to disclose.

 
 
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