eMedicine Specialties > Sports Medicine > Introductory Topics in Sports Medicine

Female Athlete Triad: Treatment & Medication

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

Treatment

Acute Phase

Rehabilitation Program

Physical Therapy

If a fracture or stress fracture is present, physical therapy may be appropriate, depending on the type of injury.

Medical Issues/Complications

In the acute phase, treatment is aimed at addressing the secondary complications of the female athlete triad. This treatment may involve immobilizing any stress fractures or prescribing a period of rest from athletic activities to allow the body to heal as much as possible.

Many initial laboratory and radiologic studies can be ordered at this time to aid in clinical decision making. For some tests, the patient may need to be referred to regional facilities or larger laboratories, and this time should be used to begin forming a relationship with the athlete. A restrained, understated manner often works to the advantage of the physician. For many people with disordered eating, their behavior represents a way of controlling at least one aspect of their lives. In the case of collegiate or professional athletes, many of their daily decisions are being made for them; they have control of only their eating habits and how they feel about their self-image.

The goal is to help the athlete to make the best decisions, especially in the initial visits. The athlete should not feel as though the medical staff is trying to take away her control. If a heavy-handed approach is used, many athletes may ignore or reject the advice given.

Although the physician may be able to restrict the patient's participation in organized practice and competition, most athletes also work out on their own, and they may continue to do so against medical advice. In early discussions with the athlete, the physician should persuade her to adhere to modest exercise reductions (eg, 10-20% reduction per week until acceptable goals are reached). More serious cases involving weight loss of more than 20% below the ideal body weight may require more aggressive activity cessation or even inpatient therapy, but fortunately, these cases are not as common as less severe cases.

The focus should be on lifestyle modifications. The athlete’s weight should not be used as the absolute indication of treatment success because body weight may be overemphasized already. Weight measurements should be taken as few times as possible, and once the patient has stopped losing weight, routine measurements should be stopped.

Dietary changes can also be made at this time, or a nutritionist may be consulted to address these issues. Again, modest changes should be attempted until a trusting relationship has been established. Sometimes the coach/trainer/physician must agree that the athlete will not return to the team or to competition until the weight reaches a minimum value (ie, the weight increases through lifestyle changes).
 
A team member or fellow athlete may also help with treatment. Most athletes with the female athlete triad are either loners or have only one friend on the team.

Hospitalization may be required at any time during the treatment process if it is determined that the athlete is continuing to harm herself or if she shows signs of multi-organ dysfunction due to extreme weight loss. The decision is highly individualized and should be made in consultation with a trained psychiatrist who is willing to treat such patients. Hospitalization for affected patients is often a long-term process, and months-long hospital stays are not uncommon. A good prognosis is far from ensured, even with optimal treatment.

Related Medscape topics:
Resource Center Eating Disorders
Resource Centers Patient-Provider Relations in Psychiatry & Mental Health
Specialty Site Psychiatry & Mental Health
Specialty Site Women's Health

Surgical Intervention

Unless a fracture or stress fracture requires surgical intervention, surgery is usually not indicated.

Consultations

A multidisciplinary approach should be used in the treatment of the female athlete triad. A team approach to care of the athlete with the team physician or primary care physician coordinating care is vital, not only to ensure that all details are covered but also to provide the athlete with an individual to whom she can always go to with questions.⁷

A psychologist or psychiatrist familiar with eating disorders should be contacted for assistance with psychosocial issues. The consultant should be aware that most athletes do not meet the strict DSM-IV criteria for bulimia or anorexia and that these individuals are most likely to have disordered eating. Psychotherapy for behavior modification is often useful in adjusting habits that may be detrimental to the athlete’s health. Antidepressants or antipsychotic medications are rarely indicated for these patients. Some physicians do recommend selective serotonin reuptake inhibitors (SSRIs) in individual cases. The advantage is treatment of the comorbid depression, anxiety, and or OCD that may exist; however, a disadvantage is that some individuals lose weight. Therefore, the use of SSRIs is a judgment call.

A nutritionist, especially one with experience in sports nutrition, is of great help. Many larger universities and professional organizations employ a nutritionist to care for its athletes. Even if the athlete being treated is not a member of one of these organizations, the training or medical staff of these institutions may be able to provide the physician with a contact for assistance. The nutritionist should be able to help the medical staff in assessing the patient's caloric intake and output and to advise them about how to help the patient make modifications that will have a maximal impact on the disease while causing the least amount of trepidation by the athlete.

A cardiologist may need to be consulted if cardiac arrhythmias are present. Cardiac arrhythmia is the leading cause of death in patients with anorexia and often starts as simple sinus bradycardia. Prompt referral should be made at the earliest sign of a cardiac abnormality. Few patients with anorexia complain of the classical chest pain or shortness of breath until late in the course of the disease.

If the athlete develops a fracture or stress fracture that requires surgical intervention, referral to an orthopedist is needed. Many such injuries can be managed conservatively; however, femoral neck stress fractures or compression vertebral fractures may require consultation with a specialist. If casts or braces are needed, they may need to be used for a longer period than usual because of the patient's altered nutritional status.

If the team physician is not comfortable with performing pelvic examinations, he or she should refer the athlete to her primary care provider or gynecologist. Endometrial biopsy is sometimes necessary as part of the workup for the triad, and this should be preformed by a physician experienced with these procedures.

Close contact with the coach and medical staff should be maintained to monitor the athlete's attitude, affect, practice regimen, eating patterns. Especially with athletes who travel for competition or who are part of an organized athletic squad, the athletic trainer may be able to report any unusual behavior. Skipped meals, meals taken by herself when the rest of the team is eating together, and exercising in addition to scheduled practices are all behaviors that should reported to the medical staff.

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Resource Center Adolescent Medicine
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Other Treatment

Other treatments can be directed at secondary musculoskeletal problems that may arise, but the focus should remain on the underlying problem of the triad.

Recovery Phase

Rehabilitation Program

Physical Therapy

Physical therapy can be continued, if needed.

Medical Issues/Complications

Treatment should quickly move into the recovery phase to minimize further damage. This phase can involve the use of multiple medications and supplements directed at various systems in the athlete’s body.

Nutritional modifications can continue at this point, with the assistance of a sports nutritionist. Caloric intake should be increased slowly to avoiding compound the patient’s fear of becoming fat. A food diary and 24-hour recall can be used to monitor intake. If the athlete is part of a large college or university, its nutritional staff can prepare special diets and monitor the patient's intake. The athlete should be encouraged to eat with friends and during accepted eating times. Eating alone makes it easier for the patient to leave larger portions of the diet uneaten. A "food buddy" can make sure the athlete attends all meals and does not simply load her plate with lettuce and carrots and later define this as an adequate diet.

Activity modifications can help reduce the energy drain that may be contributing to the triad. Again, modest reductions in activity levels help prevent the athlete from ignoring the physician's recommendations. If the restrictions are too severe, the athlete may completely ignore them, with the justification that they are unreasonable. If necessary, a contract may be used to set the guidelines for exercise.

If the patient ignores the recommendations of the physician or one of the consultants, the athlete's temporary removal from the team or sport may be imposed. This approach is obviously more difficult to enforce in athletes who have acquired the triad as part of an individual sport or outside organized sports. Moreover, this approach may change the athlete’s attitude toward the medical staff to a more adversarial tone, which can lead to noncompliance or therapy failure.

Calcium, vitamin D, and potassium dietary supplementation may help to minimize the osteoporosis that can occur with the female athlete triad, especially in athletes who have strict or unusual dietary restrictions. A dose of 1200-1500 mg of elemental calcium, 400-800 IU of vitamin D, and 60-90 mg of potassium is suggested for young adults with menstrual dysfunction. Although only a few studies have been conducted to investigate the effects of calcium supplementation in women with the female athlete triad, the low cost and benign nature of this mineral makes it a safe suggestion.

Again, a reduction and not cessation of activity should be emphasized early in the course of treatment. As previously suggested, a 10-20% activity reduction per week may be appropriate until acceptable goals are reached.

Consultations

Continued close contact with consultants should be maintained.

Medication

Medical treatment is of secondary importance after changing the eating and exercise habits of the athletes affected with the female athlete triad. Some medicines can be used in conjunction with behavior modifications. The medications mainly consist of those used for hormone replacement and dietary supplementation.
 
Some physicians recommend SSRIs in individual cases. The advantage in using such agents is treatment of OCD, depression, and anxiety; however, a disadvantage is that some individuals lose weight. Therefore, the use of SSRIs is a judgment call.

Contraceptive, Oral

Oral contraceptive agents can be used in athletes >16 years old whose BMD continues to decline during treatment for the female athlete triad despite a normalized caloric intake and weight.

Medroxyprogesterone acetate (Cycrin, Amen)

For hormonal cycling and reestablishment of the hypothalamic-pituitary axis. Administer cyclically 12 d/mo to prevent the endometrial hyperplasia that unopposed estrogen may cause.

In young women, regular withdrawal bleeding is preferable, because even young women with premature ovarian failure have a 5-10% chance of spontaneous pregnancy (unlike postmenopausal women).

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