The female athlete triad

Abstract

Female athlete triad (Triad) consists of spectrums of energy availability, menstrual function, and bone mineral density. Male athlete triad similarly is a syndrome that consists of decreased energy availability, functional hypogonadotropic hypogonadism, and low bone mineral density with or without bone stress injury In Triad, the energy deficit leads to functional hypothalamic amenorrhea through the reduced release of gonadotropin-releasing hormone and the resultant hypoestrogenic state caused by decreased levels of FSH and luteinizing hormone. The third component of the triad is decreased bone mineral density, which results from the energy deficit which may also include a hypoestrogenic state. Adolescent and young adult athletes should be screened for Triad at well child visits, preparticipation physicals or when they present with amenorrhea, bone stress injuries, or recurrent injuries. The Cumulative Risk Assessment tool can be used to determine an athlete's risk of having female athlete triad. Initial evaluation for female athlete triad should include a thorough history and physical exam. If an athlete has one or more components of Triad then further evaluation includes laboratory tests with additional workup if the athlete has amenorrhea. In athletes with one high-risk factor or two moderate-risk factors, bone mineral density should be examined with a dual-energy X-ray absorptiometry (DXA). Treatment should include a multidisciplinary approach with cooperation between the family, medical team, registered dietitian, athletic trainer, coach, and when needed, a mental health professional. Treatment should focus on correcting the energy deficit. Pharmacologic treatment can be considered for those not responding to nonpharmacologic treatment. Options include estrogen patches and cyclical progesterone in the amenorrheic athlete with low bone mass, and rarely, other pharmacological management in consultation with an osteoporosis expert. While there are no set guidelines, the Cumulative Risk Assessment score can be used to guide participation and return to play decisions.