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Female Athlete Triad: Follow-up
Updated: May 30, 2008
Follow-up
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In mild to moderate cases of the female athlete triad, many athletes continue to participate in their activity even while in treatment. Activity modifications should be in place, however, and the time that the patient spends exercising should be closely monitored. When inquiring about exercise times, the physician should ask about formal practice sessions as well as exercise away from the structured environment. Often, the extra activity burns much of the athlete's caloric intake.
When the physician discusses exercise restrictions, the athlete often finds it easier to accept a restriction of her private workouts rather than her practice time with a team or coach. As with anorexia and bulimia, the triad is a secretive disorder. Just as the athlete may want to hide evidence of the disease, she may also try to hide evidence of the treatment. By allowing her to continue activity with her peers or coaches, she may not resist treatment.
Unless necessary, withdrawal from activity should not be used as a form of punishment for noncompliance or lack of objective improvement. This can often result in loss of the trust that has been built up between the clinician and athlete and can lead to the athlete's resumption of self-directed exercise. Instead, the physician should work with the athlete to try to make her understand the necessity of the restrictions that are being set. This should minimize the likelihood of the athlete stopping therapy or being lost to follow-up.
If the athlete has been restricted from athletics because of poor compliance with the proscribed regimen or due to physical limitation (eg, stress fracture), a slow resumption of exercise should be attempted. In advanced or difficult cases, resumption of activity should not be allowed until the athlete is within 10-15% of the suggested body weight. Even in cases in which the athlete meets the weight goal, only slow resumption should be attempted. If a physical limitation is required (eg, to let a stress fracture heal), the limitation may be needed for longer than usual to permit complete healing in the osteoporotic bone.
Complications
Continued bone loss leading to irreversible osteoporosis is the most worrisome complication of the triad. Some evidence exists to suggest that 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.
Multiple stress fractures or complete fractures can, of course, lead to increased incidence of osteoarthritis, depending on the site of the fractures. Other fractures may heal without any long-term sequelae. Careful monitoring of these fractures should be provided, as 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 rate 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.
Prevention
Because of the difficulty in diagnosing the female athlete triad and in treating patients with the condition, prevention is fundamental in reducing morbidity and mortality rates. Early detection reduces symptoms and decreases the likelihood of serious long-term consequences.
There is substantial debate between physicians and the coaching community regarding the role of weigh-ins for sports. Some coaches or instructors have strict guidelines based on height or body type, and they set maximal weights for eligibility for competition. This regimented approach often places increased stress on the athlete and sends the wrong message about the importance of weight. It also does not account for how well the athlete has been performing in her sport (eg, a situation in which the best athlete on the team is also 5 lb over the weight limit).
The situation can be made worse when overweight athletes are "punished" with running or performing push-ups or when they are forced to weigh in in front of the team. As a beginning step, the team physician should discourage such public weigh-ins and punishment and emphasize specific athletic achievement instead of weight.
The preparticipation physical examination presents an ideal opportunity to screen all female athletes for signs or symptoms of the triad. A high index of suspicion should be maintained for all female athletes because of the difficulty in diagnosing this disease. Many preparticipation questionnaires now include questions concerning the athlete's menstrual history and contentment with her current body weight. These questions often bring otherwise asymptomatic individuals to the attention of the medical and training staff. If these questions are not a part of the questionnaire, the physician should consider making them part of his or her routine examination. Most women will not volunteer this information unless asked; therefore, a proactive approach should be used in routine history taking.
Better education of team physicians, other healthcare providers, trainers, coaches, parents, and the athletes themselves should reduce the yearly incidence of the female athlete triad. Many young women consider oligomenorrhea or amenorrhea during the season or at times of peak activity a sign of hard work and dedication. Not long ago, the medical community considered athletic amenorrhea a benign condition and treated it as such. If both the athlete and physician are aware of the potential damage that can occur as a result of menstrual dysfunction, they may be able to prevent this insidious disease.
Prognosis
For many athletes, the long-term prognosis is good. Few athletes with the female athlete triad are admitted to the hospital for inpatient treatment, and few die from their disease. However, significant long-term morbidity may affect these women later in life.
The diagnosis of the female athlete triad was established in the early 1990s, and this constellation of symptoms had been noted for years before a name was given to it.3,20,22,23 However, no long-term data about future problems are available. The first generation of athletes in whom this condition was diagnosed is still years away from menopause. Therefore, whether osteoporosis that occurs at a younger age affects mortality or leads to more advanced osteoporosis later in life or an increased risk of significant fractures (eg, hip fractures) is unknown.
For mild to moderate cases of the female athlete triad, some improvement in bone health is thought to occur. The lost BMD is unlikely to be replaced in its entirety, and the bone mass that should have been accumulated during this important time in bone development may or may not be regained. However, many case reports show that bone density does not increase, and the losses may be permanent. Unfortunately, no long-term, double-blinded, controlled studies are available (and cannot be performed).
As more information about the female athlete triad and its complications is gathered, everyone involved may better understand the significant morbidity that can occur years or decades after the disease is diagnosed and treated.
Education
Educating athletes may lead to earlier detection of the female athlete triad. If women know that amenorrhea is not a positive sign of hard work but a harbinger of disease, they may seek treatment sooner. Of course, the triad has a secretive nature, and once an athlete is showing signs of disordered eating, education may not be enough to help these women seek help. If the general athletic population is aware of the signs and symptoms of this disease, the female athlete triad might be caught in its early stages.
Physicians need to do better in educating trainers, coaches, and parents (as well as the athletes themselves). These are the people who will have daily contact with the athlete, and they may be the persons who first raise concerns about a particular individual. Taking the time to talk to the athletic staff about the warning signs may help in preventing the disease or catching it in its early stages.
Related eMedicine topics:
Amenorrhea
Eating Disorder: Anorexia
Eating Disorder: Bulimia
Menstruation Disorders
Stress Fractures
Related Medscape topics:
Resource Center Eating Disorders
Resource Center Exercise and Sports Medicine
Resource Center Nutrition
CME Bone Density Evaluation in Teens Prevents Future Osteoporosis
The Female Athlete Triad: Do Female Athletes Need to Take Special Care to Avoid Low Energy Availability
Miscellaneous
Medicolegal Pitfalls
- The main medicolegal complication is most likely the failure to diagnose the female athlete triad in a timely manner.
- Because the diagnosis was formalized in the past decade or so, the direction the legal community has decided to take regarding the triad is still being established.
- Medical malpractice suits are likely to follow patterns established in the diagnosis of anorexia and bulimia.
- Although the diagnosis of the female athlete triad is relatively new, legal-civil penalties could be harsh because of the severity of the disease and the population it affects.
- As with most diseases, timely diagnosis and initiation of treatment is paramount in avoiding lawsuits. Diagnosis of the female athlete triad can be delayed because the stress fracture is diagnosed first, followed by the amenorrhea and, lastly, the eating disorder.
- What may make civil litigation difficult are the secretive nature of the disease and the significant rate of patient noncompliance with treatment.
- Even with rapid diagnosis and treatment, bad outcomes are possible.
Related Medscape topic:
Resource Center Medical Malpractice and Legal Issues
Special Concerns
- The female athlete triad affects a specific subpopulation, and as such, this disease poses a few special concerns to consider.
- Pregnancy is usually not an issue because of the amenorrhea involved with the triad. If the athlete is lacking this portion of the triad, pregnancy is still unlikely because of the physical and nutritional stresses she is experiencing. If the athlete does become pregnant while exhibiting other signs of the triad, a more aggressive treatment approach must be pursued in decreasing her activity levels and in addressing her nutritional changes.
- The female athlete triad rarely affects women older than 40-50 years. By far, most women are affected in their early teens to late 20s. This disease is simply not one that affects the geriatric population. It can, however, affect girls who have not yet experienced menarche. In these patients, differentiating primary amenorrhea from congenital abnormalities or hormonal imbalances during the initial workup becomes significantly more important.
Related Medscape topics:
Resource Center Adolescent Medicine
Specialty Site Women's Health
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 |
| « Previous Page |
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Further Reading
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
