More females play sports than ever before. Just before Title IX was passed, approximately 300,000 female athletes played sports in the United States. By 2010, that number had jumped to well over 3 million. Unfortunately, young women can develop a syndrome called female athlete triad.

This condition is classically thought to consist of three interrelated disorders –amenorrhea (absence of menses), disordered eating, and osteoporosis. Now the condition encompasses relative deficiencies in those three areas.

Based on a recent paper in the Journal of the American Academy of Orthopaedic Surgeons, this article offers some insight into this difficult problem.

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Sports medicine stats: Female athlete triad
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Women's volleyball

Who is most likely to suffer female athlete triad?

All females who participate in sports or who exercise could develop it. It commonly develops in females who participate in sports that require lean bodies, like cross-country and other endurance sports. It can also occur in athletes who participate in sports with judging, like gymnastics and diving.

Does an athlete have to show all three components to have female athlete triad?

The diagnosis has been expanded to include athletes with one or two components. Physicians and other healthcare providers should assess the athlete for the presence of disordered eating, menstrual irregularity, and low bone density if one or two of the other symptoms exist.

How common are stress fractures in athletes with female athlete triad?

Stress fractures are common in athletes with any of those risk factors. One study showed that athletes with one risk factor had a 15% to 21% increased risk of stress fractures. Two risk factors increased the risk of stress fracture 21% to 30%. Three risk factors caused up to 50% increased risk.

How common are menstrual irregularities in female athletes?

At the high school level, rates of menstrual dysfunction between 18% and 54% have been shown.

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Sports medicine stats: Stress fractures in high school athletes

How common is disordered eating in female athletes?

It has been estimated that between 11% and 25% exhibit some aspect of disordered eating. Up to 14% could have a true eating disorder, like anorexia nervosa or bulimia nervosa.

Are anorexia or bulimia required for the diagnosis?

True eating disorders can be present in an athlete with female athlete triad, but they are not required. An athlete can have a lack of adequate caloric intake from trying to consume fewer calories or by burning more through physical activity. Proper education about nutritional requirements for athletes is key.Young female runner at risk for female athlete triad

What can doctors and healthcare providers do to detect athletes at risk?

During the pre-participation physical exam, ask about the athlete’s diet and if she is trying to lose weight. Ask about her menstrual cycles. Also study her training regimen. Often changes on physical exam are present as well.

Why is bone mineral density important for young females?

On average, 90% of peak bone mineral density develops by age 18. Most of that bone development occurs in early adolescence. If girls have low bone mineral density as teenagers, they might never reach optimal bone density, since a person doesn’t increase bone density once peak levels have been achieved in the late teens and early 20s. That is why it can be important to consider screening for low bone mineral density in female athletes with a stress fracture or stress reaction.

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How can the affected athlete be treated?

Treatment requires healthcare professionals in a number of specialties. An orthopedic surgeon might treat the stress fracture but not the other issues. A dietitian can assess the athlete’s diet and make changes. A primary care physician or OB-GYN can help with menstrual dysfunction. A psychologist or psychiatrist can help with disordered eating. And the team of medical professionals should involve coaches and parents to try to prevent these issues.


Reference: Matzkin E, Curry EJ, Whitlock K. Female Athlete Triad: Past, Present, and Future. J Am Acad Orthop Surg 2015;23: 424-432.