Female Athlete Triad: Five Key Takeaways

Female athletes are participating in sports at record levels. Anatomic and physiological differences exist between female and male athletes includingthe Female Athlete Triad. The sports medicine teamshould consider both the short- and long-term effects of the triad when treating female athletes of all ages and abilities.

Meet Susan

Susan is a 15-year old high-school cross-country and track athlete, who is a running prodigy having won several national events while in junior high school. She is part of a high-level local running development club and is mentored by a former Olympic runner. She trains 50 weeks out of the year, and is a top prospect forseveral Division 1 colleges.

Susan has struggled with shin pain each season throughout her high school career, but during her sophomore year she has been sidelined from competition and all road races due to a stress fracture of the right tibia. Her scholarship hopes are on the line

What is the Female Athlete Triad?

The female athlete triadis the relationship originally observed between three related clinical conditions: eating disorders, menstrual irregularities, and bone health. This concept has evolved since its initial description in 1992 and now includes the spectrum between optimal and non-optimal states of these components. Often, the female athlete moves along these spectra throughout her lifetime and competitive history.³

The three components of the triad are highly interrelated, and are believed to be strongly linked to energy availabilitythe lynchpin of the Triad. The triad may be related to long-term pathology, including permanent loss of bone mineral density.

For example, our athlete Susan may have moved from a state of optimal bone health to a state of low bone mineral density, leading to the stress fracture in her right tibia. But why did this happen? Is it solely due to her demands of sport and progression over time?Is it optimal for Susan to continue to train as she has been?

Without further information, it is not possible to know whether her menstrual or nutritional status (energy availability) have contributed. Inmany women with the triad, purposive or inadvertent low energy availability negatively affects both menstrual status and bone health. Amultidisciplinary approach to evaluation and treatment should be usedwith athletes who may have facets of the triad.²

Many women have no idea that cessation of menstruation is a warning sign! Athletes like Susan must be examined and screened by aphysical therapist forthe components of the triad. Then, any existing dysfunctions can be addressed appropriately. Simply treating her stress fracture or assessing her musculoskeletal system is not enough!

FiveKey Takeaways

1. The triad is often denied, unrecognized, or under-reported

All sports medicine personnel should learn to recognize and prevent it. As vital members of the sports medicine team, physical therapists and athletic trainers should have working knowledge of the facets of the triad.

2. Be ready to evaluate for risk of the triad

Don't be leery of asking the right questions that deal with menstruation and eating and eating disorders.

• During the examination, seek the athlete's menstrual history and current function withsimple questions: How old were you when you began to menstruate? and Do you have a monthly period?

• Ask questions about their nutrition and diet or screen for an eating disorder.¹ The Triad Consensus Panel recommends asking the following screening questions at the time of the sport pre-participation evaluation.

• Note: With minors, have the parent present.

3. Refer to the appropriate medical or allied health provider if even ONE component of the triad is present

You will need to develop referral strategies with professionals qualified to evaluate and treat athletes with the triad, including:

• Family medicine or internal medicine physician

• Endocrinologist

• Sports psychologist

• Registered dietician (with expertise in sports nutrition)

Dont be alarmist, but dont hesitate!

4. Educate coaches and parents about the triad

Avoid pressuring athletes! Deconstruct weight and performance myths such as the less you weigh the better you will perform. A better-informed community can help with prevention.

5. Educate athletes about the warning signs and risks of the triad

Offer a recipe for success in athletics and physical performance, including healthy training strategies, optimal nutritional support, rest, and varied activities (avoidance of specialization). You can usethispublicly available document for Education of Parents, Athletes, and Coaches from the Female Athlete Triad Coalition.

Best care of the female athlete includes knowledge, assessment, and readiness to treat the female athlete triad. Every physical therapist and athletic trainershould know the three components of the triad and have referrals for managing the aspects beyond our scope of practice. Finally, educate your peers, your communities, and female athletes fromall walks of life.