Female Athlete Triad Treatment & Management

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

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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.

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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]

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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.

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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.

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