Understanding and Identifying the Female Athlete Triad in Adolescents

Reprinted from the Winter 2020 Issue of The Ohio Family Physician

By: Molly McDermott, DO, PGY-2, Cleveland Clinic Family Medicine Residency Program

As an adolescent female, there are unique obstacles and pressures from academic institutions, family members, and peer groups placing them at risk for significant mental and physical harm. Of all people, I should know. Now retired, I reflect on the hardships of becoming a Division I collegiate athlete and recall young women intentionally or unintentionally overlooking their health in pursuit of their athletic dreams.

With the increasing prevalence of female athletes participating in sports, so too has the number of athletes suffering from the ‘Female Athlete Triad’ (Triad). Previously recognized as amenorrhea, osteoporosis, and disordered eating, the Triad has evolved to encompass a spectrum of conditions, which includes low energy availability (EA) with or without disordered eating, menstrual dysfunction, and low bone mineral density (BMD).¹ This spectrum is a continuum rather than separate disease processes as athletes may present with one or all of the components. If unrecognized and improperly treated, it could have long-term health effects such as postmenopausal osteoporosis, increased risk of fractures in adulthood, and risk of cardiovascular disease.²

Decreased Energy Availability
As a driving force for the underlying consequences of the Triad, decreased EA can occur as a result of inadequate caloric intake to compensate for the rigorous training completed by athletes.¹ While this can occur from specific behaviors such as dieting or disordered eating, many times inadequate EA is unintentional. According to the American Academy of Pediatrics, “Optimal EA has been identified to be 45 kcal/kg fat-free mass per day in female adults, but may be even higher in adolescents who are still growing and developing.” ² Low EA ultimately affects menstrual function and can lead to deficits in BMD.

Menstrual Dysfunction
Adolescents suspected to have the Triad can present with an array of menstrual irregularities such as primary or secondary amenorrhea, oligo-menorrhea, and problems with ovulation.^1,2 As adolescent females notably have menstrual irregularities regardless of sport participation, recognizing menstrual abnormalities as part of the Triad can be especially difficult.

Decreased Bone Mineral Density
Of particular concern to the adolescent population, abnormal bone development and decreased rate of bone acquisition are associated with the Triad as 90% of adult bone mass is obtained by the end of adolescence.^1,2 This can have long-term effects as adolescence is critical for the development of optimal peak bone mass and prevention of osteoporosis. To combat this, weight-bearing exercise and appropriate nutritional intake can positively influence BMD.

Assessment and Treatment
As family physicians, it is crucial to be able to identify the signs and symptoms of the Triad as early intervention can prevent long-term health consequences. Screening should be completed at yearly well-child checks or pre-participation physical evaluations with special attention to the athletes in sports that emphasize leanness such as gymnastics, long distance running, and figure skating. According to Thein-Nissenbaum and Hammer, there are multiple screening tools that can be utilized including the Low Energy Availability in Females Questionnaire, RED-S Risk Assessment Model, and the Female Athlete Triad: Cumulative Risk Assessment.³

In assessing a patient exhibiting symptoms of the Triad, a complete history should be taken with a focus on sport and exercise routine, nutrition, menstrual history, and previous injuries. Physical examination including vital signs should evaluate for bradycardia, orthostatic hypotension, low body mass index value, and signs of disordered eating. Oftentimes, this examination will largely be normal, especially in those that do not restrict their diet.² Laboratory evaluation may include initial testing as seen in Table 1.

Additional laboratory testing for further evaluation of menstrual dysfunction, including endocrine disorders, should be done on an individualized basis. BMD in adolescents is typically evaluated using a dual-energy radiograph absorptiometry (DXA), which should be expressed as Z-scores to compare age- and sex-matched controls.³ A Triad risk stratification instrument can be completed by the physician, according to the 2014 Female Athlete Triad Coalition Consensus statement, to identify when to order DXA screening.⁴

Management of an individual with suspected Triad includes a multidisciplinary team, which is optimally comprised of a physician, dietician, behavioral health clinician, certified athletic trainer, coaching staff, and family members.² Initial treatment should focus primarily on improving EA with the goal of obtaining a positive energy balance. This, however, can be challenging and a partnership with an experienced dietician and/ or a sports psychologist is critical. The resumption of menses should be attempted with cautious use of combined oral contraceptives as this can give a false sense that EA has been restored.¹ In regard to low BMD, Vitamin D (600 IU/day) and calcium (1300 mg/ day) supplementation should be optimized.^1,2 Ultimately, it is important to note that treatment should be individualized for each female athlete and that recovery of each part of the triad occurs at varying rates.

References available online.