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Female Athlete Triad: What You Need to Know

Female Athlete Triad is common in sports like gymnastics, ballet, diving, figure skating, and running.

What is it?

Essentially, low energy availability affects the menstrual status which directly affects bone health. It often presents as menstrual irregularity, a stress fracture or chronic fatigue. Functional hypothalamic amenorrhoea (FHA) in athletes secondary to low energy availability (EA) is a diagnosis of exclusion.

What to ask on history?

  1. Menstruation: ask about menarche, last period, how many in the last 12 months, OCP use
  2. Dietary: recent changes in weight, asked to lose weight, worry about weight, avoiding foods
  3. Bone health: history of stress fractures or previous low bone density


  1. Labs – FSH, LH, prolactin, bHCg, TSH, free T4, Estradiol, testosterone (free and total), DHEAS+/- AM progesterone, progesterone challenge test
  2. Imaging: pelvic US for utererine pathology, disorders of sexual differentiation.
  3. DEXA if ↑ risk (1 of: history of eating disorder, BMI ≤5, recent 10% weight loss, menarche ≥16)

Sites for DEXA- NOTE: Z-score should be used. Repeat every 1-2 years.

  1. Adult women ≥20 year: Weight-bearing sites (spine, total hip, femoral neck)
  2. Children, adolescents and young women <20 years: lumbar spine bone mineral content, whole body less head, adjust for growth delay, use paediatric reference data if possible


  • FHA- diagnosis of exclusion, bloodwork likely normal
  • Endocrine disorder – abnormal TSH, prolactin, AM progesterone, DHEAS
  • Primary ovarian insufficiency – no ovulation with progesterone challenge, ↑ gonadotropins
  • PCOS- ↑ free/total testosterone


  • Approach must address the underlying cause of the Triad, that is, low EA
  • Nutritional education should ideally include a sports dietitian
  • If low EA is caused by an eating disorder, cognitive behavioural therapy (CBT) has been demonstrated to be an effective treatment approach
  • Weight gain and subsequent resumption of menses are key to prevent further loss of bone mass
  • Weight-bearing exercise is a primary non-pharmacological strategy for increasing/maintaining BMD
  • Total calcium intake between 1000 and 1300 mg/day, daily intake of 600 IU Vitamin D
  • Role for pharmacologic intervention is controversial
  • OCP doesn’t seem to restore bone mass (does not normalize metabolic factors impairing bone health)
  • No evidence to review efficacy or safety of bisphosphonates, teriparatide, testosterone, DHEA, leptin or rhIGF-1

Return to Play

  • There are no clear guidelines on return to play. Cumulative Risk Assessment may help guide.
  • There is some suggestion that athletes at high risk for, or with the triad, be restricted from training and competition

Summary taken from 2014 Female Athlete Triad Coalition Consensus Statement on Treatment and Return to Play of the Female Athlete Triad (DeSouza et al. Br J Sports Med 2014)

Article written by: David White, BSc, MSc, MD, CCFP

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