Subspecialist Consult

Tackling the Hurdles of the Female Athletic Triad


First be on the lookout for an adolescent girl in your practice who might have the "female athletic triad," which is characterized by disordered eating, amenorrhea, and osteoporosis.

Many girls are involved in sports these days, which is fantastic. But there are some girls and/or their families or coaches who take training to the extreme. Some patients are driven to be the best in their sport or to win an athletic scholarship, whether it’s in track, ice skating, or gymnastics. Some of these girls purposely do not eat right and develop disordered eating to maintain a body weight that they believe is optimal for their sport.

By Dr. Elizabeth M. Alderman

Maintain a high index of clinical suspicion. Adolescence is a crucial time of bone and body development, a time when healthy girls reach their optimal adult height. A really important message to deliver to your athletic patients is that a negative energy balance – that is really what this is about – puts their body and health at risk.

A simple way to start screening for the female athletic triad is to ask all adolescent girls about their periods. Inquire during each visit, whether it’s an annual checkup or routine physical examination. Consider further evaluation if she reports any recent menstrual changes. The benefits of such a screening go beyond diagnosis of the triad – a regular period every month really connotes health in many ways.

If a girl is not getting her period at all, rule out an endocrinologic problem. Girls who have a hyperactive thyroid might not have regular periods and can lose a lot of weight because their bodies are hypermetabolic. So keep this and other endocrinologic disorders in your differential diagnosis of the female athletic triad.

A comprehensive nutrition and exercise history is essential. Ask your patient to complete a 24-hour diet recall. When you take an exercise history, determine exactly what the adolescent girl is doing. Is she training for a specific event? How frequently does she train and for how long?

Once you diagnose female athletic triad in a patient, you can perform her medical management if you feel comfortable doing so. Generally there is a team approach. I often refer patients to a nutritionist – ideally a sports nutritionist – and consider a mental health referral for some girls.

A nutrition specialist can provide general counseling about why the girl has to eat right to maintain her body in a healthy way. Most of the time these patients do not have a sense of what they need to eat to maintain caloric intake and prevent significant weight loss and subsequent amenorrhea. In some cases, patients will report frequent fainting following their weight loss.

You can also refer your patient to an adolescent medicine specialist, who, in some cases, can address the nutritional aspects as well. A consult also can evaluate your patient for risk of anorexia nervosa, particularly if she has lost a tremendous amount of weight.

When you counsel these girls, particularly if they seem reluctant to change their diet or cut back on training, warn them about the long-term risk for osteoporosis. While it’s true that most adolescents with the female athletic triad do not have frank osteoporosis, they might have osteopenia and be at elevated risk for osteoporosis in the future. The few patients who do have osteoporosis often experience bone fractures, even during the teenage years.

Although risk of osteopenia and osteoporosis is part of the triad, I generally don’t order a DXA scan unless a girl has a history of fractures or has missed her periods for close to 1 year. Maintaining proper intake of calcium and vitamin D is important for bone health, and strength exercises also help.

Many girls need supplementation of vitamin D, so obtaining a level might guide treatment. Calcium supplementation also is important because dietary intake is generally not sufficient.

Dr. Alderman is an adolescent medicine specialist at the Children’s Hospital at Montefiore and professor of clinical pediatrics at Albert Einstein College of Medicine, both in New York. She said she had no relevant financial disclosures.

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