Issue: June 2018
June 14, 2018
3 min read

How should the female athlete triad be addressed in adolescent female athletes?

Issue: June 2018
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Click here to read the Cover Story, "Youth sport superspecialization: A path to injuries, burnout."


Ask the right questions

Marci A. Goolsby, MD
Marci A. Goolsby

Female athlete triad refers to the abnormal menses and affected bone health, such as increased risk of stress fractures and osteoporosis, that comes from an imbalance between an athlete’s nutrition and exercise (referred to as low energy availability). The negative consequences of the female athlete triad can be significant and can impact an athlete’s performance, risk of injury, long-term risk of osteoporosis, fertility and overall health. The best way to treat the female athlete triad is through prevention and education. It is important that there is a positive culture around weight and body image in our young female athletes and that signs and symptoms of the female athlete triad are addressed promptly. There are a number of useful and validated questionnaires to identify these risks. Some of the things that can be evaluated include injuries, particularly stress fractures, history of or current abnormal periods and weight loss or other signs of eating disorder. To go further in depth, there are a number of questions to identify those with current risk factors for an eating disorder. The treatment for the female athlete triad is a team approach and often multiple members of the health care team, including nutrition, medical and psychological services, are involved. Studies have shown that the longer the duration of the female athlete triad, the more negative consequences are likely to develop, particularly to bone health. Athletes may present to the doctor’s office with a stress fracture and it is imperative the physician asks the necessary questions to identify risk factors. When risk factors of the female athlete triad are identified, treatment will be focused on education and counseling in order to prevent the short-term and long-term consequences.

Marci A. Goolsby, MD, is a primary care sports medicine physician at the Women’s Sports Medicine Center at Hospital for Special Surgery in New York.
Disclosure: Goolsby reports no relevant financial disclosures.



Early identification is key

Rachel M. Frank, MD
Rachel M. Frank

The critical step is to screen and try to appropriately identify at-risk athletes. This can be difficult, particularly in the adolescent patient population because signs and symptoms of any of the components of the female athlete triad may not be obvious and it may be difficult to identify who is at risk. Health care providers, in particular sports medicine physicians, need to be aware of the type of athletes who may be at risk for any of the components of the triad and need to try to identify them early, because some of the long-term effects of the female athlete triad can result in serious health consequences and can be exceedingly difficult to reverse. In particular, treating decreased bone mineral density, as well as attempting to treat amenorrhea/oligomenorrhoea, can be challenging and so identifying athletes at risk and intervening early is critical. It is important for providers to have the ability within their sports medicine system to be able to screen and identify these athletes and then provide resources to help, which can take some time.

We have to remember, as sports medicine surgeons, we often see patients for medical and surgical injuries, but a major component to the female athlete triad is psychologic. When we identify these patients, offering them appropriate counseling and an opportunity to work with a psychologist or psychiatrist is critical. Specifically, to get athletes back to sport safely, it is critical for them to not only be cleared medically but also psychologically in an effort to avoid returning to a potentially high-risk environment that may result in recurrence of symptoms. While as sports medicine physicians we are often considered the “quarterbacks” of our athletes’ health care needs, in these cases, we typically need to enlist the help of a variety of specialists to provide a multidisciplinary approach to care, including a psychiatrist or psychologist, endocrinologist and nutritionist, among other specialists. The ultimate goal is to create an environment for the athlete that optimizes healthy eating and fitness habits, improves bone mineral density and improves menstrual function, all in an effort to help these patients become healthier athletes, both on and off the field.

Rachel M. Frank, MD, is an assistant professor in the department of orthopedic surgery at the University of Colorado School of Medicine, Aurora, Colorado.
Disclosure: Frank reports no relevant financial disclosures.