Female Athlete Triad Treatment Guidelines

What is the female athlete triad?

Physical activity is beneficial for women and girls of all ages. Yet, some female athletes may adopt restrictive eating patterns or overtrain to achieve a specific body weight or lean appearance. Such behaviors can have serious health implications, including irreversible damage and, in severe cases, increased mortality risk. Additionally, they can hinder athletic performance and may even require the athlete to reduce or halt exercise.

The female athlete triad (triad), first identified in 1992, describes a medical condition of three interrelated health issues that can affect female athletes (De Souza et al., 2014):

1. Low energy availability (with or without disordered eating): Low energy availability occurs when an athlete’s energy intake (calories consumed) is insufficient to support the energy expended through physical activity and the body’s basic metabolic functions.
2. Menstrual dysfunction: Menstrual dysfunction in female athletes ranges from irregular menstrual cycles (oligomenorrhea) to the complete absence of menstruation (amenorrhea). Low energy availability disrupts the normal production of hormones critical for reproductive health, especially estrogen. As estrogen levels decline, menstrual cycles may become irregular or cease, which can have long-term implications for bone health and cardiovascular health.
3. Low bone mineral density (BMD): It is a reduction in the density and strength of bone tissue, increasing the risk of fractures and conditions like osteopenia and osteoporosis. In the female athlete triad, low BMD often results from both inadequate nutrition and reduced estrogen levels due to menstrual dysfunction.

Female athletes frequently exhibit one or more components of the triad, making early intervention crucial to prevent progression to severe outcomes, such as clinical eating disorders, amenorrhea, and osteoporosis.

Female Athlete Triad Treatment Guidelines

Given the triad's complexity and interconnected nature, treatment requires a comprehensive and multidisciplinary approach. A set of recommendations for its treatment was developed following the 1st and 2nd International Symposia on the Female Athlete Triad, held in San Francisco, California, and Indianapolis, Indiana, respectively.

The guidelines aim to provide healthcare providers, including physicians, athletic trainers, and other professionals, with an evidence-based framework for effectively managing and treating this condition.

Carepatron has created an easy-to-use Female Athlete Triad Treatment Guidelines handout you can use as a reference when formulating treatment plans for young athletes with the triad. The template includes information on:

• Non-pharmacological treatment options
• Pharmacological treatment strategies
• Pharmacological treatment considerations
• Therapies that can be offered
• Other information regarding the treatment of the female athlete triad

This handout compiles the treatment recommendations as slated in the 2014 Female Athlete Triad Coalition consensus statement on treatment and return to play of the female athlete triad: 1st international conference held in San Francisco, California, May 2012 and 2nd international conference held in Indianapolis, Indiana.

To access our template, just click "Use template" and open it using the Carepatron app. For a PDF copy, click "Download."

Screening and diagnosis

Early identification of athletes at risk is essential for preventing the progression of the female athlete triad. Screening for the triad should be integrated into the pre-participation physical evaluation (PPE) and include questions covering all aspects of the triad spectrum.

Although evidence on the effectiveness of specific screening questions is limited (Mencias et al., 2012), annual triad-specific self-reports are recommended for female athletes. Athletes identified as having or being at risk for any component of the triad should undergo a more comprehensive evaluation.

According to De Souza et al. (2014), risk factors to assess for the triad include a history of menstrual irregularities and amenorrhea, stress fractures, and critical comments about eating or weight from parents, coaches, or teammates. Additional factors are a history of depression, dieting, personality traits such as perfectionism and obsessiveness, pressure to lose weight, and frequent weight cycling. An early start in sport-specific training, overtraining, recurrent or non-healing injuries, and inappropriate coaching behavior are also important considerations.

After initial screening, diagnosing any component of the female athlete triad requires a comprehensive evaluation by a physician alongside a skilled multidisciplinary healthcare team. This team should ideally include a physician, a sports dietitian (preferably a registered dietitian with certification in sports dietetics), and a mental health professional, particularly if the athlete shows signs of disordered eating or a clinical eating disorder. Additional team members may include an exercise physiologist, a certified athletic trainer, and relevant medical specialists.

Complications related to the female athlete triad syndrome

If left untreated, the triad can lead to long-term health complications (American College of Sports Medicine, 2007):

• Sustained low energy availability, with or without disordered eating, can lead to psychological problems such as low self-esteem, depression, and anxiety disorders.
• Eating disorders and low energy availability can have significant cardiovascular and endocrine consequences, including impaired heart function and hormonal imbalances.
• Amenorrheic women face infertility due to a lack of ovarian follicular development and ovulation, while athletes with luteal deficiency may also experience infertility due to poor follicular development or implantation failure.
• One of the most concerning effects of the female athlete triad is the decline in BMD, which increases the risk of a stress fracture. As the number of missed menstrual cycles increases, BMD continues to decline, and these losses may not be fully reversible.
• Amenorrheic athletes may experience impaired fertility due to hypoestrogenism, which also affects vascular and muscle function. Although some athletes may ovulate before their menstrual cycles are fully restored, this can lead to unexpected pregnancies if reliable birth control is not used.

Early recognition, intervention, and comprehensive management are essential to preventing these complications and ensuring the long-term health and well-being of female athletes.

References

American College of Sports Medicine. (2007). The female athlete triad. Medicine & Science in Sports & Exercise, 39(10), 1867–1882. https://doi.org/10.1249/mss.0b013e318149f111

De Souza, M. J., Nattiv, A., Joy, E., Misra, M., Williams, N. I., Mallinson, R. J., Gibbs, J. C., Olmsted, M., Goolsby, M., & Matheson, G. (2014). 2014 Female Athlete Triad Coalition consensus statement on treatment and return to play of the female athlete triad: 1st international conference held in San Francisco, California, May 2012 and 2nd international conference held in Indianapolis, Indiana, May 2013. British Journal of Sports Medicine, 48(4), 289–289. https://doi.org/10.1136/bjsports-2013-093218

Mencias, T., Noon, M., & Hoch, A. Z. (2012). Female athlete triad screening in National Collegiate Athletic Association Division I athletes. Clinical Journal of Sport Medicine, 22(2), 122–125. https://doi.org/10.1097/jsm.0b013e3182425aee