Female Athlete Triad 

Updated: Aug 24, 2017
Author: Laura M Gottschlich, DO; Chief Editor: Craig C Young, MD 

Overview

Background

With the increase in female participation in sports (much of it attributable to Title IX legislation in the United States),[1, 2] the incidence of a triad of disorders particular, but not exclusive, to women—the so-called female athlete triad—has also increased.

The female athlete triad, though more common in the athletic population, can also occur in the nonathletic population. However, even though this triad was first described at the 1993 meeting of the American College of Sports Medicine (ACSM),[3, 4] associations between bone mineral density (BMD), stress fractures, eating disorders, and female athletics had been observed for decades before the syndrome was formally named.

The components of the female athlete triad, as put forth by the 1997 ACSM positional stand, consisted of disordered eating, amenorrhea, and osteoporosis.[5] Not all patients have all 3 components of the triad, and newer data suggest that even having only 1 or 2 elements of the triad greatly increases these females’ long-term morbidity.

In addition, a study by Burrows et al has suggested that the current triad components do not identify all at-risk women; rather, the authors suggest that criteria such as exercise-related menstrual alterations, disordered eating, and osteopenia may be more appropriate.[6]

Subsequent research on the female athlete triad culminated in an updated definition published by ACSM in 2007. The 2007 ACSM positional stand looks at each disorder as a point on a continuous spectrum rather than as a severe pathologic endpoint, as follows[7] :

  • “Disordered eating” has been replaced by a spectrum ranging from “optimal energy availability” to “low energy availability with or without an eating disorder”

  • “Amenorrhea” has been replaced by a spectrum ranging from “eumenorrhea” to “functional hypothalamic amenorrhea”

  • “Osteoporosis” has been replaced by a spectrum ranging from “optimal bone health” to “osteoporosis”

The 2007 ACSM positional stand also emphasizes that energy availability is the cornerstone on which the other 2 components of the triad rest.[7] Without correction of this key component, full recovery from the female athlete triad is not possible.

Often difficult to recognize, the female athlete triad can have a significant impact on morbidity and even mortality in a relatively young segment of the population. Indeed, the full impact of this syndrome may not be realized until these women reach menopause, when bone loss is accelerated.

Significant research of the triad has been ongoing. Recently, there have been a series of meetings that have resulted in consensus statements released in 2014 by the International Consensus Conference on the Female Athlete Triad, in 2014 by the International Olympic Committee (IOC) and in 2017 by a Committee Opinion from the American College of Obstetricians and Gynecologists (ACOG) on Adolescent Health Care. The Consensuses and ACOG Committee opinion reiterated the 2007 ACSM positional stand on the etiology and the need to view the components of the triad as a spectrum.[8, 9, 35] The main purpose of the consensus statements were to provide specific guidelines in treatment and return to play to providers of athletes at risk and/or diagnosed with the female athlete triad.[8, 9] The main purpose of the ACOG Committee Opinion was to discuss the obstetricians and gynecologists role in participating in the healthcare team for athletes with the FAT.[35]

Furthermore, the IOC has proposed changing the name of the female athlete triad to the "relative energy deficiency in sport" or "RED-S".[9] They believe the name change would more accurately describe the myriad of health issues affected by decreased energy availability, including "metabolic rate, menstrual function, bone health, immunity, protein synthesis, cardiovascular and psychological health" and include men, who can also be affected negatively by an imbalance in energy availability.[9]

Pathophysiology

Reduced energy availability

The first component of the female athlete triad, energy availability,[7, 10] is defined as “dietary energy intake minus exercise energy expenditure” and is intended to capture those athletes who, due to lack of education, may be inadvertently undereating or may have eating and weight concerns but do not have “significant psychopathology” and therefore do not meet the criteria for disordered eating.

The term disordered eating itself was coined to include pathologic eating behaviors that do not meet the strict Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) requirements for anorexia or bulimia; thus, it includes, but is not limited to, anorexia nervosa and bulimia nervosa.

Indeed, disordered eating includes a spectrum of behaviors ranging from simple failure to take in enough food to offset energy expenditure to preoccupation with eating and a profound fear of becoming fat (typically expressed by instituting measures such as food restrictions or the use of diet pills, laxatives, or diuretics).

Menstrual dysfunction

The second component of the triad, menstrual dysfunction,[7] describes the spectrum of menstrual function from eumenorrhea to amenorrhea and enables clinicians to capture a large portion of athletes who may have low estrogen levels but who still experience menstruation.

Menstrual dysfunction includes luteal suppression, anovulation, oligomenorrhea, and primary and secondary amenorrhea. Luteal suppression is marked by a shortened luteal phase and a prolonged follicular phase in which estradiol levels decrease. The cycle length usually does not change; the athlete will continue to ovulate—although it may be later in the cycle—and usually has regular menstruation.

Anovulation is marked by low levels of estradiol and progesterone, which deter follicular development, as well as by an absence of ovulation. Although the circulating hormone levels are decreased, female athletes will often menstruate, some experiencing shortened or prolonged cycles because of the stimulation of their uterine lining by the low levels of estradiol. Oligomenorrhea is defined as “greater than 35 days between cycles.”

Amenorrhea usually refers to secondary amenorrhea, though delayed menarche (primary amenorrhea) can occur in young athletes. By consensus, secondary amenorrhea is defined as the “absence of menstrual cycles lasting more than 3 months after menarche has occurred.” Physicians are cautioned that a full workup should be completed to rule out any other causes of menstrual dysfunction such as hormonal pathology, structural anomaly, medications, pregnancy, etc before such dysfunction is attributed to low estradiol levels stemming from low energy availability.[11, 35]

Impaired bone health

The final component of the female athlete triad, bone health,[7, 12] describes a continuum extending from optimal bone health to osteoporosis and focuses on bone strength, which consists of BMD (or bone mineral content) and bone quality.

Bone quality refers to factors related to bone turnover rates (eg, resorption versus formation, microarchitecture or trabeculae, time for maturation of the new bone matrix, and bone geometry and size). Our current inability to measure bone quality leaves one half of the equation for bone health empty and offers an explanation for why some athletes with the same poor BMDs as their colleagues may suffer more fractures. Therefore, dual-energy x-ray absorptiometry is used as a quantitative measure of bone health.

When reporting BMD, T-scores are used for the diagnosis of osteopenia and osteoporosis. However, the T-score measures the standard deviations (SDs) below the mean to predict fracture risks for postmenopausal woman. Concern over mislabeling of our premenopausal athletes, adolescents and children, led the International Society for Clinical Densitometry (ISCD) to issue a positional stand in 2004.[12]

The ISCD’s recommendation is to determine BMD by comparing chronologic age and sex using a Z-score distribution. The Society further recommends that the term osteopenia not be used in describing bone density and that the term osteoporosis be reserved for “low BMDs” with secondary clinical risk factors such as “chronic malnutrition, eating disorders, hypogonadism, glucocorticoid exposure, and previous fractures.”[12]

Athletes with a Z-score 2 SDs below the mean are to be termed “low bone density below the expected range for age” if they are premenopausal women and “low bone density for chronologic age” if they are children. The 2007 ACSM positional stand further defined “low BMD” as “a history of nutritional deficiencies, hypoestrogenism, stress fractures, and/or other secondary clinical risk factors for fracture together with a BMD Z-score between –1.0 and –2.0” and osteoporosis as “secondary clinical risk factors for fracture with a Z-score ≤ –2.0.”[7]

Because most athletes already have a higher BMD than nonathletes, the ACSM also recommends that physicians consider performing further workup for any athlete with a BMD Z-score below -1.0, even in the absence of fracture.[7]

The bones of the lower extremities, pelvis, and vertebrae are the ones most commonly affected by poor bone health in women with the female athlete triad; stress and frank fractures of these areas are the typical manifestations. Peak bone mass is obtained between the ages of 20 and 30 years, with peak bone mineral content reached between the ages of 9 and 20 years.

Menstruating athletes gain approximately 2-4% of bone mass per year, whereas amenorrheic athletes tend to lose 2% of BMD per year. Thus, it is easy to see why athletes who are involved in high-impact sports can still be more susceptible to fractures than their nonathletic and menstruating athletic counterparts. Often these fractures are due to the increased stress sustained by these bones in the course of physical activity. In this respect, athletes with the female athlete triad are not unlike their healthy counterparts. However, those who have the triad or portions of it are more susceptible to multiple fractures, and they are also more likely to sustain fractures in larger, less commonly affected bones (eg, femoral neck, pelvis, and vertebrae).

Other physiologic dysfunction

Ongoing research is looking at athletes diagnosed with the female athlete triad and the link to many other psychological and physiological dysfunctions affecting the cardiovascular, renal, hepatic, gastrointestinal, endocrine, reproductive, skeletal, and central nervous systems.[9] Issues including “anemia, chronic fatigue, increased risk of infection and illness, esophagitis, electrolyte imbalance, slowing of the metabolic rate, decrease production of growth hormone, unfavorable lipid panels, endothelial dysfunction, reduced muscle protein synthesis, unexpected pregnancy, possible long term reproductive repercussions, and depression” can all concurrently occur with the female athlete triad.[13, 14, 9]

Etiology

The theory behind the female athlete triad is that this syndrome is caused by an energy drain or caloric deficit (ie, the athlete’s energy expenditure exceeds her dietary energy intake).[7, 10] This low energy availability, whether subconscious or conscious, disrupts the hypothalamic-pituitary-ovarian axis, resulting in decreased gonadotropin-releasing hormone (GnRH) pulsatility and low luteinizing hormone (LH) and follicle-stimulating hormone (FSH) levels.[15]

These changes eventually lead to decreased estrogen production, causing menstrual dysfunction. The decreased estrogen levels, in turn, affect calcium resorption and bone accretion, causing decreased bone health.

Studies have indicated that 30 kcal/kg of lean body mass is a crucial threshold for maintaining menstrual function[7] ; they have also demonstrated that increasing exercise drastically while covering the energy expenditure with increased caloric intake did not result in disruption of LH pulsatility. Conversely, decreasing an athlete’s caloric intake to less than 30 kcal/kg within 5 days resulted in decreased LH pulsatility. All of these findings support the energy drain theory.

The hormone leptin, which is secreted by adipocytes, has also garnered increased interest. Leptin appears to influence the metabolic rate, and levels are proportional to body mass index (BMI). It may be a significant mediator of reproductive function, and many studies have demonstrated that low levels of leptin correlate positively with amenorrhea and infertility. Furthermore, leptin receptors have been found on hypothalamic neurons involved in the control of GnRH pulsatility and in bone, which may also affect osteoblastic function.

Athletes in some sports that are linked to an aesthetic component or a weight class are more likely to develop the female athlete triad. These athletes often attempt to reach unrealistic weight and body fat goals dictated by their sport, to the detriment of their health.[16, 17, 18, 19]

Emotional stressors can also often be identified as inciting factors in athletes with the triad. The death of a coach or a family member, growth spurts, an illness that prevents training, and other events that an athlete cannot control often lead to disordered eating and excessive training—areas of life that the athlete can control.

For many, moving to a university setting initiates the triad cascade. Some young women move far away from family and friends, and they may carry the added responsibilities of a sports scholarship and a demanding academic workload. Collegiate athletes have the additional pressure of performing to higher competitive standards with a new coach and trainer and alongside athletes who may have had 2-3 years more experience. Not surprisingly, the prevalence of the female athlete triad suddenly increases in college freshmen.

Epidemiology

As noted (see above), though all female athletes are at risk for the female athlete triad or any of its components, sports that have an aesthetic component (eg, ballet, figure skating, or gymnastics) or are tied to a weight class (eg, tae kwon do, judo, or wrestling) have a higher prevalence of affected female athletes.[7, 16, 17, 20, 21]

Obtaining exact epidemiologic data is difficult because of the lack of reporting or gathering of data from athletes. Like individuals with anorexia or bulimia, many athletes with the triad try to hide their symptoms or behavior from friends, family, trainers, or coaches. This is the main reason why diagnosis is so difficult. In fact, the vast majority of cases are diagnosed only after advanced symptoms become apparent. Milder cases may be extremely difficult to diagnose if the physician does not already have a high degree of suspicion.[7, 22, 23, 24, 25]

Many validated sources for evaluating for disordered eating in athletes exist: the Athletic Milieu Direct Questionnaire (AMDQ)[26] , the Female Athlete Screening Tool (FAST)[27] , and the American Physiological Screening Test for eating disorders among Female College Athletes (PST)[28] to name a few. The prevalence of low energy availability in female athletes is difficult to assess and until recently a validated source for evaluation did not exist. Multiple factors (eg, the difficulty of gathering accurate caloric intake data from athletes, inability to measure energy expenditure, uncertainty regarding which sports to include or which eating attitude survey to use, and varying definitions of eating disorders) compound the issue. In 2014, the Low Energy Availability in Females Questionnaire (LEAF-Q) was released to capture athletes who may be suffering from low energy availability and therefore are at risk for the female athlete triad.[29]

It is known, however, that an athlete is at increased risk for the spectrum of reduced-to-low energy availability, with or without an eating disorder, if she has a comorbid psychological disorder, such as anxiety, depression, or obsessive compulsive disorder (OCD). In some studies, the incidence of disordered eating in the female athletic population has been estimated to be as high as 62%, with the incidence of anorexia nervosa and bulimia (as defined in DSM-IV) estimated at 4-39%.

The prevalence of menstrual dysfunction is also difficult to assess. Over a number of studies, it has ranged from as low as 6% to as high as 79%, depending on the sport studied, the patient’s age, the definition and assessment of menstrual dysfunction, the use of oral contraceptives, the training volume, and the presence of subclinical menstrual disorders, such as luteal suppression and anovulation. Studies continue to be performed, and it is hoped that more and better data will become available.

The prevalence of impaired bone health, as indicated by reduced BMD, is likewise difficult to assess because of the prohibitively high cost of DXA scans. Osteopenia has been reported to occur in 22-50% of athletes, compared with 12% of nonathletes. Osteoporosis has also been reported in 0-13% of athletes, compared with 2.3% of nonathletes. Now that the ISCD has recommended using Z-scores instead of T-scores, more research will have to be done to obtain accurate data for athletes.

Although good epidemiologic data regarding the female athlete triad continues to mount, the 2014 Female Athlete Triad Coalition Consensus still maintains that preparticipation physical evaluations remain the first line for early detection.[8] Questionnaires should include inquiry about whether the athlete is satisfied with her current weight and about how much weight she would like to gain or lose, as well as a full menstruation history, dietary concerns/restrictions, and a bone health history.[8] Simple inquiries such as these may reveal the first warning signs of an athlete at risk or suffering from the female athlete triad.

A study that categorized athletes into low-, moderate-, and high-risk groups for bone stress injuries using the Female Athlete Triad Cumulative Risk Assessment score found that moderate-risk athletes were twice as likely to sustain a bone stress injury when compared to the low-risk group and high-risk were 4 times as likely. The study also found that bone stress injuries were most common in cross-country runners.[30]

 

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, although this set of symptoms had been noted for years before it was named.[3, 18, 31, 32] However, no long-term data on future problems are available. The first generation of athletes in whom this condition was diagnosed is still years away from menopause. Thus, it is unclear whether osteopenia/osteoporosis occurring at a younger age affects mortality or leads to more advanced osteoporosis later in life or to an increased risk of significant fractures (eg, hip fractures).[33]

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 fully regained.[33] Unfortunately, no long-term, double-blind, controlled studies are available (or even performable).

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.

Patient 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 may have a secretive nature, and by the time an athlete shows signs of disordered eating, education may not be enough to help these women seek help. If the general athletic population and the providers taking care of athletes are aware of the signs and symptoms of this disease, the female athlete triad has a better chance of being 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.

For patient education resources, see the Osteoporosis and Bone Health Center, the Exercise, Nutrition, and Weight Management Center, and the Women’s Health Center, as well as Anorexia Nervosa, Bulimia, and Amenorrhea.

 

Presentation

History

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 care 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. Athletes 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), the Athletic Milieu Direct Questionnaire (AMDQ),[26] the Female Athlete Screening Tool (FAST),[27] and the American Physiological Screening Test for eating disorders among Female College Athletes (PST),[28] are all questionnaires designed to help identify those with disordered eating. Also, in 2014, the Low Energy Availability in Females Questionnaire (LEAF-Q) was released to capture athletes who may be suffering from low energy availability and therefore are at risk for the female athlete triad.[29]

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.

Physical Examination

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, but labs may help uncover some of the physiological issues that often accompany the female athlete triad.[8, 9] 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 disordered eating or an eating disorder may try to hide their body weight loss. In addition, some athletes who present for the examination and then refuse to let the physician or anyone else examine them should also raise a red flag.

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 menstrual dysfunction and/or poor bone health and secondary physiologic issues of the triad. Athletes with the female athlete triad usually report signs or symptoms related to poor bone health (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 may be 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.

Complications

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.[34] 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 many other psychological and physiological dysfunctions affecting the cardiovascular, renal, hepatic, gastrointestinal, endocrine, reproductive, skeletal, and central nervous systems.[9] Issues such as anemia, chronic fatigue, increased risk of infection and illness, esophagitis, electrolyte imbalance, slowing of the metabolic rate, decreased production of growth hormone, unfavorable lipid panels, endothelial dysfunction (which is a strong predictor of coronary artery health and a possible increase in atherosclerotic disease and cardiovascular event rates), reduced muscle protein synthesis, unexpected pregnancy, possible long term reproductive repercussions, and depression can all concurrently occur with the female athlete triad.[13, 14, 9]

 

DDx

Diagnostic Considerations

Failure to diagnose the female athlete triad in a timely manner is probably the main medicolegal issue associated with this condition.

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 are paramount for avoiding lawsuits. Diagnosis of the female athlete triad can be delayed because in most cases, the stress fracture is diagnosed first, followed by the amenorrhea and finally by the eating disorder (the opposite of the order in which these components of the triad actually develop).

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.

In addition to the conditions listed in the differential diagnosis, other problems to be considered include the following:

  • Drug interactions

  • Hypogonadotropic hypoestrogenism

  • Hypothalamic disorders

  • Hyperthyroidism

  • Luteal-phase inadequacy

  • Nutritional deficiencies

  • Ovarian defect (eg, gonadal dysgenesis)

  • Pituitary disorders

Differential Diagnoses

 

Workup

Approach Considerations

Diagnosis of the female athlete triad is largely clinical; no test enables definitive diagnosis. Workup may include laboratory studies (including a pregnancy test), radiography (including dual-energy x-ray absorptiometry [DEXA]), magnetic resonance imaging (MRI) in selected cases, pelvic ultrasonography, bone scanning, electrocardiography (ECG), progesterone challenge, or endometrial biopsy.

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, thyroid-stimulating hormone [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

  • Follicle-stimulating hormone (FSH) and luteinizing hormone (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

Radiography

If the athlete presents with bone pain, as with a stress fracture, appropriate plain radiographs should be obtained.

Baseline DEXA scans can be obtained in all athletes with the female athlete triad to identify undiagnosed osteoporosis or subclinical stress fractures, as well as to provide a reference for future monitoring.

The American College of Sports Medicine (ACSM) and the American Academy of Pediatrics (AAP) recommend that an athlete’s bone mineral density (BMD) be evaluated if she has been amenorrheic for longer than 1 year, has a body mass index (BMI) lower than 18, or a history of a stress fracture. The recommendation is either a posteroanterior view of the spine or hip if the athlete is older than 20 years or a posteroanterior view of the spine and whole body if the athlete is younger than 20 years, with the diagnosis made on the basis of a Z-score.

According to the 2014 Female Athlete Triad Consensus Statement, guidelines for who should get a DXA include the following

See the list below:

  • ≥1 ‘High risk’ triad risk factors:

    • History of a DSM-V diagnosed ED

    • BMI ≤17.5 kg/m2, < 85% estimated weight, OR recent weight loss of ≥10% in 1 month

    • Menarche ≥16 years of age

    • Current or history of < 6 menses over 12 months

    • Two prior stress reactions/fractures, one high-risk stress reaction/fracture, or a low-energy nontraumatic fracture

    • Prior Z-score of <–2.0 (after at least 1 year from baseline DXA)

  • ≥ 2 “Moderate risk” triad risk factors:

    • Current or history of DE for 6 months or greater

    • BMI between 17.5 and 18.5, < 90% estimated weight, OR recent weight loss of 5–10% in 1 month

    • Menarche between ages 15 and 16 years

    • Current or history of 6–8 menses over 12 months

    • One prior stress reaction/fracture

    • Prior Z-score between –1.0 and –2.0 (after at least 1 year

    • interval from baseline DXA)

In addition, an athlete with a history of ≥1 nonperipheral or ≥2 peripheral long bone traumatic fractures (nonstress) should be considered for DXA testing if there are one or more moderate or high-risk triad risk factors. This will depend on the likelihood of fracture given the magnitude of the trauma (low or high impact) and age at which the fracture occurred. Athletes on medications for 6 months or greater that may impact bone (such as depot medroxyprogesterone acetate, oral prednisone and others), should also be considered for DXA testing.

Further recommendations for follow up DXA scans depend on the severity of disease, the success of treatment of the female athlete triad and the ongoing status of the athlete. If there is concern, DXA scans every 1-2 years may be necessary to evaluate the ongoing bone health of the athlete and treatment strategies.[8]

Other Imaging Studies

If the results of laboratory studies indicate abnormal pituitary function, thin-section MRI 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.

In the future, following endothelial dysfunction via ultrasonographic measurement of flow-mediated vasodilatation of the brachial artery may be recommended.[13, 14]

Electrocardiography

A resting ECG should be obtained in any athlete whose resting heart rate is lower than 50 beats/min. Many physicians believe that a baseline ECG should be performed in all athletes at risk for the female athlete triad. As with so many aspects of this disease, exact epidemiologic data are not yet available. Experience with anorexia and bulimia, for which a baseline ECG is usually recommended, suggests that proceeding with this noninvasive test may be a safe choice.

Progesterone Challenge

A progesterone challenge test can be used to determine if the uterine endometrium has been primed with estrogen and thus is ready to be shed, as in normal menstruation. A 10-day course of 5 or 10 mg of oral progesterone 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 estrogen in amounts sufficient to sustain endometrial growth.

Endometrial Biopsy

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 inserting a thin tube, usually a disposable pipette, through the cervical os into the uterine cavity. Suction is then applied to the tube, and endometrial tissue is drawn into it. This sample is then histologically examined to help determine the stage of growth of the endometrial tissue and, thus, the effects or presence of estrogen and progesterone.

 

Treatment

Approach Considerations

When identified, main focus should be correcting the cornerstone of the female athlete triad, decreased energy availability, through a multispecialty team of providers.[8, 9] This team may include a team physician, a sports dietician, a mental health professional, an athletic trainer, an exercise physiologist and medical consultants if concomitant medical issues exist as previously discussed.[8] Depending on where the athlete is in his or her season and the severity of the issue, this may involve increasing caloric intake and/or decreasing energy expenditure, with a goal of increasing energy availability.[8, 9] It is recommended that an athlete aim for a “20%-30% increase in caloric intake with a goal of 0.5 kg weight gain every 5-7 days."[8] Normalization of body weight will aid in normalization of menstruation and increase bone health and help with the nonpharmacological treatment of the other components of the female athlete triad.[8, 9]

Recommendations by the 2014 Female Athlete Triad Consensus for treatment of low energy availability is as follows[8] :

  1. If the cause of low EA is inadvertent undereating, then referral for nutritional education is sufficient. Nutrition education ideally should include a sports dietitian. Either a sports dietitian or an exercise physiologist should complete an assessment of energy expenditure and EA.

  2. If the cause of low EA is DE, the referral should be to a physician and for nutritional counseling with a sports dietitian.

  3. If the cause of low EA is intentional weight loss without DE, then referral for nutritional education is likely sufficient.

  4. If the cause of low EA involves clinical ED, treatment should include evaluation and management with a physician, nutritional counseling with a sports dietitian, and referral to a mental health practitioner for psychological treatment. In this case, the reversal of low EA will be not possible without psychological treatment.

Success though is dependent on participation of the athlete. If nonpharmacological treatments of low energy availability, disordered eating or an eating disorder are not successful with the team’s physician, dietician and mental health provider, antidepressant medication may be useful in aiding treatment.[8]

If nonpharmacologic treatment of menstrual disruption and BMD is not successful, oral estrogen has not been shown to be beneficial in increasing BMD (in some studies it may only stop further bone loss or further compromise bone health by further lowering IGF-1) and may mask treatment of energy availability with withdrawal bleeds giving providers and the athlete a false sense of normalization.[8, 9]

Transdermal estradiol with cyclic progesterone does not suppress IGF-1 and in multiple studies was shone to increase BMD.[8, 9]

Bisphosphonates should be used with extreme caution due to their teratogenicity and long half-life and should only be used on a case to case basis.[8, 9] In the 2014 Female Athlete Consensus, it is also recommended that then not be used unless a board certified endocrinologist or a specialist in metabolic bone diseases is on board.[8] Below are their recommendations for starting pharmacologic agents in an athlete:

BMD z-scores less than or equal to -2.0 with a clinically significant fracture history and lack of response to at least 1 year of nonpharmacological therapy and

*BMD z-scores between -1.0 and -2.0 with a clinically significant fracture history and >=2 additional triad risk factors and lack of response to at least 1 year of nonpharmacological therapy.

Transdermal estradiol replacement with cyclic progesterone may be considered in young athletes between 16 and 21 years of age with FHA to prevent further bone loss during this critical window of optimal bone accrual if they have the following:

  • BMD z-scores less than or equal to -2.0 without a clinically significant fracture history and at least one additional Triad risk factor (in addition to FHA) and lack of response to at least 1 year of nonpharmacological therapy.

   Lack of response to therapy has been defined as

  • A clinically significant reduction in BMD z-scores after at least 1 year of nonpharmacological therapy or
  • Occurrence of new clinically significant fractures during nonpharmacological treatment over the course of 1 year.

Calcium supplementation should be between 1300 and 1500 mg/day and Vitamin D between 1500 and 2000 mg/day with a goal of a Vitamin D level of 32-50 ng/ml.[8, 9]

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

Initial 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. Physical therapy may be appropriate for a fracture or stress fracture, depending on the type of injury. Unless a fracture or stress fracture requires surgical intervention, surgery is usually not indicated.

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.

Special concerns

Because the female athlete triad affects a specific subpopulation, it raises a few special concerns.

Pregnancy is not usually an issue, because of the amenorrhea involved with the triad. Even if the athlete is lacking this portion of the triad, she is still less likely to become pregnant, 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. The vast majority of patients are affected in their early teens to late 20s. Historically, this disease is not one that affects the geriatric population. This may change as women who grew up in the post–Title IX era age. The triad can 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.

Lifestyle and Dietary Modifications

Acute phase

In addressing dietary and lifestyle modifications, a restrained, understated manner often works to the physician’s advantage. For many people with disordered eating, this 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. The physician may use a “Cumulative Risk Assessment” to help measure the extent that participation of the athlete might need to be restricted.[35]

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 already be overemphasized in the patient’s mind. Weight measurements should be taken as seldom 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 (or trainer) and physician must agree that the athlete will not return to the team or to competition until her weight has reached a minimum value through lifestyle changes.

A team member or fellow athlete may also help with treatment, if desired by the athlete. Often athletes with the female athlete triad either are loners or have only 1 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 multiorgan dysfunction due to extreme weight loss. The decision to hospitalize must be made on an individual basis, ideally 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 certain, even with optimal treatment.

Recovery phase

In the recovery phase, nutritional modifications can continue, 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.

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 a consultant, it may be advisable to remove her temporarily from the team or sport. 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.

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

Return to play

The 2014 Female Athlete Triad Consensus put forth guidelines for clearance, return to play and structured follow-up for athletes suffering from the female athlete triad with the IOC Consensus guidelines being very similar.[8, 9]

It provides a very simple scoring grid for the following risk factors:

  1. Low EA with or without DE/ED

  2. Low BMI

  3. Delayed menarche

  4. Oligomenorrhea and/or amenorrhea

  5. Low BMD

  6. Stress reaction

Low risk in each category gets 0 points, moderate risk gets 1 point each, high risk gets 2 point each.[8] Based on the “magnitude of the risk” recommendations for clearance and return to play are made.[8] Full clearance for 0-1 points, Provisional or limited clearance for 2-5 points and restricted from training and competition for >_ 6 points.[8] “Athletes with a diagnosis of anorexia nervosa, who have a BMI < 16 kg/m2 or with moderate to severe bulimia (purging > 4 times per week) be categorically restricted from competing until their ED is better controlled – i.e. BMI >18.5, cessation of binging and purging and close follow-up with the multidisciplinary team.”[8] Moderate risk athletes will sign a contract agreeing to participation with the multidisciplinary team.[8] Participation in their sport will be contingent on fulfilling the plan put forth by the team.[8] Athletes in the high risk category will also work with the team and return to play will be on a case to case basis.[8]

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. Like 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. Allowing the athlete to continue activity with her peers or coaches may encourage her not to resist treatment.

Unless it proves necessary, mandatory withdrawal from activity should not be used as punishment for noncompliance or lack of objective improvement. This may disrupt the trust that has been built up between the clinician and the athlete and thereby trigger 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 because of physical limitation, 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 have to be kept in place for a longer-than-usual period to permit complete healing in the osteoporotic bone.

Pharmacologic Therapy

Medical treatment is of secondary importance in the treatment of the female athlete triad, after changes in the eating and exercise habits of the athletes affected with this condition (see above). Some medicines can be used in conjunction with behavior modifications. The medications mainly consist of those used for hormone replacement and dietary supplementation.

Calcium, vitamin D, and potassium supplementation may help minimize the osteoporosis that can occur with the triad, especially in athletes with strict or unusual dietary restrictions. Doses of 1200-1500 mg of elemental calcium, 400-800 IU of vitamin D, and 60-90 mg of potassium are 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.

In accordance with the 2007 positional stand of the American College of Sports Medicine (ACSM), hormone replacement therapy and oral contraceptive pills are not commonly used in athletes with the female athlete triad.[7] Rather, restoration of menstrual function generally focuses on correcting the low energy availability by meeting the athlete’s caloric needs. This will restore gonadotropin-releasing hormone (GnRH) and luteinizing hormone (LH) pulsatility, as well as menstruation. If nonpharmacologic treatment does not work, transdermal estradiol with cyclic progesterone does not suppress IGF-1 and in multiple studies was shone to increase BMD.[8, 9]

Bisphosphonates should be used only with extreme caution in premenopausal woman, because of their long half-life and their potential teratogenic effects on an unborn fetus.

Some physicians recommend selective serotonin reuptake inhibitors (SSRIs) in individual cases. The advantage to using such agents is that they treat obsessive-compulsive disorder (OCD), depression, and anxiety; the main disadvantage is that some individuals lose weight. Thus, whether to use SSRIs is a judgment call.

Emerging data on folic acid supplementation have shown reversal of endothelial dysfunction in athletes diagnosed with the triad.[13, 14] Initial studies were with 10 mg/d for 4 weeks.[14] Research is ongoing to further evaluate dosing and duration.[13, 14]

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. 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. Some coaches maintain strict guidelines based on height or body type and specify 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 fails to consider how well the athlete has been performing. For example, the best athlete on the team may be someone who is 5 lb over the weight limit.

The situation can be made worse when overweight athletes are “punished” by being made to run or perform pushups or by being forced to weigh in in front of the team. As a beginning step, the team physician should discourage such public weigh-ins and punishments 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 female athlete triad. Because of the difficulty of diagnosing this condition, a high index of suspicion should be maintained for all athletes, females and males. Many preparticipation questionnaires now include questions about 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 questions of this type are not a part of the preparticipation 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 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.

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 a person to whom she can always go to with questions.[7] Continued close contact with consultants should be maintained.

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 Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (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 SSRIs in individual cases.

A nutritionist, especially one with experience in sports nutrition, is of great help. Many larger universities and professional teams employ nutritionists to care for athletes. Even if an athlete does not belong to such an organization, the training or medical staff of these institutions may be able to provide the physician with useful contacts. The nutritionist can help medical staff assess the patient’s caloric intake and output and advise them on modifications that will have a maximal impact on the disease while causing minimal upset to the athlete.

A cardiologist may have 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 classic 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 nonoperatively; however, femoral neck stress fractures or compression vertebral fractures may require consultation with a specialist. If casts or braces are needed, they may have 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 performed by a physician who is 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 alone when the rest of the team is eating together, and exercising in addition to scheduled practices are all behaviors that should be reported to the medical staff.

 

Medication

Medication Summary

Medical treatment is of secondary importance in the treatment of the female athlete triad, after changes in eating and exercise habits of the athletes affected with this condition. Some medicines can be used in conjunction with behavior modifications. The medications mainly consist of those used for hormone replacement (eg, oral contraceptives) and dietary supplementation.

Vitamins, Fat-soluble

Cholecalciferol (Vitamin D3, Bio-D-Mulsion Forte, Delta D3)

Cholecalciferol stimulates the absorption of calcium and phosphate from the small intestine and promotes the release of calcium from bone into blood. It is use for the treatment of vitamin D deficiency or prophylaxis of vitamin D deficiency. Supplementation with 400-800 IU of vitamin D is suggested for young adults with menstrual dysfunction.

Electrolytes

Class Summary

Calcium supplementation restores serum calcium levels. Supplementation may help minimize the osteoporosis that can occur with the triad, especially in athletes with strict or unusual dietary restrictions. Doses are 1200-1500 mg of elemental calcium.

Calcium carbonate (Oystercal, Caltrate, Oysco 500, Tums E-X, Children's Pepto)

Calcium carbonate is indicated to restore and maintain normocalcemia when hypocalcemia is not severe enough to warrant rapid replacement. It is used orally as supplementation to IV calcium therapy. Calcium carbonate moderates nerve and muscle performance by regulating the action potential excitation threshold. Amounts of elemental calcium in calcium carbonate tablets are as follows: Tums, 200 mg; Rolaids, 220 mg; Os-Cal, 500 mg.

Calcium citrate (Calcitrate, Cal-Citrate 225, Cal-Cee)

Calcium citrate is an oral formulation usually used as supplementation to IV calcium therapy. Calcium moderates nerve and muscle performance by regulating the action potential excitation threshold and facilitating normal cardiac function. Give the amount needed to supplement dietary intake, so as to reach recommended daily amounts. The amount of elemental calcium in 1000 mg of calcium citrate is 210 mg.

Potassium acid phosphate (K-Phos)

Potassium is essential for transmission of nerve impulses, contraction of cardiac muscle, maintenance of intracellular tonicity, skeletal and smooth muscles, and maintenance of normal renal function. Gradual potassium depletion occurs via renal excretion, through gastrointestinal loss, or because of low intake. Potassium depletion sufficient to cause a 1-mEq/L drop in serum potassium requires a loss of about 100-200 mEq of potassium from the total body store. Approximately 60-90 mg of potassium is recommended.

Estrogen and Progestin Combination

Oral Contraceptives

Oral contraceptive agents can be used in athletes older than 16 years whose bone mineral density (BMD) continues to decline during treatment for the female athlete triad despite a normalized caloric intake and weight.

Hormone, Parathyroid

Teriparatide

Recombinant human parathyroid hormone rhPTH(1-34), which has identical sequence to 34 N-terminal amino acids (biologically active region) of 84-amino acid human parathyroid hormone (PTH). Acts as endogenous PTH, thus regulating calcium and phosphate metabolism in bone and kidney. Works primarily to stimulate new bone by increasing number and activity of osteoblasts (bone-forming cells). Additional physiological actions include regulation of bone metabolism, renal tubular reabsorption of calcium and phosphate, and intestinal calcium absorption.

When administered with calcium and vitamin D, teriparatide increases bone mineral density and decreases risk of fractures in patients with osteoporosis.