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Female Athlete Triad

BASICS

  • Syndrome of three interrelated clinical entities:
  • Low Energy Availability (LEA) ± Disordered Eating (DE)
  • Menstrual Dysfunction (MD)
  • Low Bone Mineral Density (LBMD)
  • LEA is the fundamental cause; recovery depends on correction of energy availability.
  • Related concept: Relative Energy Deficiency in Sport (RED-S) expands to broader physiologic effects and males.

EPIDEMIOLOGY

  • Prevalence varies by criteria:
  • All 3 criteria: 0-16%
  • Two criteria: 3-27%
  • One criterion: 16-60%
  • Secondary amenorrhea prevalence up to 60% in female athletes vs 2-5% general population.
  • LBMD (osteopenia) ranges 0-40% in athletes vs ~12% in general population.
  • Higher prevalence in lean sports (swimming, cross country).

ETIOLOGY AND PATHOPHYSIOLOGY

  • LEA defined as energy intake minus exercise energy expenditure.
  • LEA causes suppression of LH pulsatility → menstrual dysfunction via ovulatory suppression and hypoestrogenemia.
  • Hypoestrogenemia leads to decreased bone formation, increased resorption → LBMD.
  • Triad elements lie on a spectrum from health to dysfunction and are interrelated.
  • RED-S highlights additional effects on immunity, metabolism, cardiovascular and psychological health.

RISK FACTORS

  • History of menstrual irregularities, stress fractures, dieting, depression.
  • Participation in lean physique or weight-class sports with intense training, frequent weigh-ins.
  • Personality traits: perfectionism, obsessiveness.
  • Lack of social/family support, psychological comorbidities.
  • Younger athletes more susceptible (teens).

GENERAL PREVENTION

  • Education of athletes, coaches, trainers, parents, physicians.
  • Screening at preparticipation exams and annual physicals using validated questionnaires.
  • Screen athletes with red flags: fractures, fatigue, amenorrhea, syncope, electrolyte abnormalities.
  • Assess and counsel on nutrition, menstrual health, bone density risks.

COMMONLY ASSOCIATED CONDITIONS

  • Eating disorders (anorexia nervosa, bulimia, ARFID).
  • Psychological issues: anxiety, depression, low self-esteem.
  • Increased risk of stress fractures, osteopenia/osteoporosis.

DIAGNOSIS

History

  • Menstrual history including contraceptive use.
  • Dietary intake and eating behaviors.
  • Fracture history.
  • Psychological assessment and weight changes.

Physical Exam

  • BMI <17.5 kg/m², ≥10% weight loss in 1 month.
  • Signs: bradycardia, orthostatic hypotension, lanugo, parotid enlargement, epigastric tenderness, Russell sign.
  • Pelvic exam to assess estrogen status and rule out outflow obstruction in amenorrhea.

Differential Diagnosis

  • Rule out pregnancy, endocrine causes (thyroid, Cushing), hypothalamic/pituitary causes, ovarian dysfunction, uterine causes.
  • Screen for eating disorders via DSM-5 criteria.

Diagnostic Tests

  • Labs: CMP, CBC, ESR, TSH, vitamin D, calcium, FSH, LH, prolactin, urinalysis.
  • Pelvic ultrasound if hyperandrogenism suspected.
  • ECG to exclude prolonged QT.
  • Bone mineral density testing (DEXA) for high-risk patients or those with fractures.

TREATMENT

  • Multidisciplinary team approach: physician, dietitian, behavioral health, trainers, family.
  • CBT may aid in LEA treatment.
  • Goal: restore energy balance → normalize menses and improve bone density.
  • Nutrition: real food prioritized over supplements, calcium 1000-1300 mg/day, vitamin D ≥600 IU (may require up to 1500-2000 IU).
  • Address disordered eating and psychological comorbidities.

Medications

  • First line for persistent dysfunction or fractures: transdermal estrogen with oral cyclic progestin.
  • Bisphosphonates and denosumab not recommended in reproductive-age women due to teratogenicity.
  • Experimental: rhIGF-1, metreleptin (limited data).

ADMISSION

  • Indications: severe eating disorders, life-threatening bradycardia, orthostatic hypotension, electrolyte disturbances, arrhythmias.

ONGOING CARE

  • Regular follow-up by multidisciplinary team.
  • Gradual return to training encouraged; intermittent training programs may reduce exacerbation risk.
  • Use consensus-based clearance and return-to-play guidelines (TC and RED-S clinical assessment tools).

PATIENT EDUCATION

  • Importance of balanced nutrition, calcium/vitamin D, and weight-bearing exercise.
  • Risks of untreated triad: bone loss, menstrual irregularities, fractures.

PROGNOSIS

  • Amenorrheic women lose 2-3% bone mass/year without treatment.
  • Early diagnosis and intervention improves outcomes.
  • Long-term consequences if untreated include persistent bone loss and reproductive issues.
  • Disordered eating often requires long-term management.

REFERENCES

  1. Mountjoy M, Sundgot-Borgen J, Burke L, et al. The IOC consensus statement: beyond the Female Athlete Triad-Relative Energy Deficiency in Sport (RED-S). Br J Sports Med. 2014;48(7):491-497.

CODES

  • ICD10:
  • F50.9 Eating disorder, unspecified
  • N91.2 Amenorrhea, unspecified
  • R53.83 Other fatigue

CLINICAL PEARLS

  • LEA is the core factor in the triad; menstrual and bone health depend on energy availability.
  • Multidisciplinary early intervention is key to restore menstrual cycles and bone density.
  • Screening athletes at risk improves early detection and management.
  • The triad exists on a spectrum from healthy to dysfunctional states, requiring individualized care.