A Clinical Update on the Female Athlete Triad

August 1, 2016

A Clinical Update on the Female Athlete Triad

  1. Alain Joffe, MD, MPH, FAAP

Treatment should address increasing energy availability and decreasing training volume.

  1. Alain Joffe, MD, MPH, FAAP

The components of the female athlete triad involve three physiologic processes: (abnormal) menstrual function, (decreased) bone mineral density (BMD), and (low) energy availability.

A clinical report from the American Academy of Pediatrics (AAP) reviews key features of this condition likely encountered by pediatricians:

  • About 1% of high school athletes have all 3 components, 4–18% have two, and 16–54% have one.

  • Athletes participating in sports in which leanness, aesthetics, endurance, or weight class grouping are emphasized are at increased risk for triad disorder, as are those specializing in one sport at an early age and those who diet.

  • Disordered eating leads to low energy availability (EA; dietary energy intake minus daily exercise energy expenditure corrected for fat-free mass). Optimal EA is 45 kcal/kg fat-free mass, and EA <30 disrupts luteinizing hormone secretion and bone mineralization.

  • Menstrual dysfunction can manifest solely as a disruption in luteinizing hormone secretion; oligomenorrhea and amenorrhea are more overt manifestations.

  • Some data show that endurance runners have lower BMD compared with other athletes (e.g., sprinters, basketball players, and gymnasts). This may be due to suppression of bone accumulation, perhaps linked to menstrual irregularities, disordered eating, or decreased calcium intake.

  • Endothelial dysfunction (a marker for increased coronary artery disease risk) is shown to be correlated with low BMD, menstrual dysfunction, and low estrogen levels in some athletes.


The AAP recommends screening for this triad at all pre-participation physical examinations, using all but 4 of the 12 questions in the Female Athlete Triad Coalition's screening instrument (http://www.femaleathletetriad.org/~triad/wp-content/uploads/2008/11/ppe_for_website.pdf). Educate parents and teenagers that oligomenorrhea or amenorrhea should never be dismissed as secondary to training. Increasing EA and/or decreasing training volumes are the key components of treatment. Using oral contraceptives may produce regular menses but is unlikely to reverse the other factors at play.

Editor Disclosures at Time of Publication

  • Disclosures for Alain Joffe, MD, MPH, FAAP at time of publication Editorial boards Adolescent Medicine: State of the Art Reviews; JAMA Pediatrics; Neinstein’s Textbook of Adolescent and Young Adult Health Care (Associate Editor)


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