Review

The female athlete triad: It takes a team

Jaya Mehta, MD, Bithika Thompson, MD and Juliana M. Kling, MD, MPH
Cleveland Clinic Journal of Medicine April 2018, 85 (4) 313-320; DOI: https://doi.org/10.3949/ccjm.85a.16137

Article Figures & Data

Figures

  • Figure 1
    Figure 1

    The components of the female athlete triad are linked. Energy availability and menstrual dysfunction play causative roles in bone mineral density pathology. Within each component of the triad a spectrum of dysfunction exists, with all 3 components exhibiting serious health end points including low energy availability, functional hypothalamic amenorrhea, and osteoporosis.

Tables

  • TABLE 1

    Eating disorders: Restrictive and binging/purging

    Restrictive eating disorder
    Symptoms
     Amenorrhea
     Constipation
     Headaches
     Fainting
     Dizziness
     Fatigue
     Cold intolerance
    Physical findings
     Acrocyanosis
     Dry skin
     Hair loss
     Bradycardia
     Orthostatic hypotension
     Loss of muscle mass and subcutaneous fat
     Lanugo
    Binging/purging eating disorder
    Symptoms
     Bloating
     Fullness
     Lethargy
     Gastroesophageal reflux disease
     Abdominal pain
     Sore throat
    Physical findings
     Knuckle calluses
     Dental enamel erosion
     Salivary gland enlargement
     Cardiomegaly (in setting of ipecac toxicity)
  • TABLE 2

    Diagnostic tests for the female athlete triad

    Low energy availability
    Overt signs:
     body mass index < 17.5 kg/m2
     or body weight < 85% of expected
    Calculation (with aid of daily food logs and accelerometer): Embedded Image
    Resting metabolic rate
    Triiodothyronine (T3) level
    Low bone mineral density
    Dual-energy x-ray absorptiometry (DEXA) if any of the following:
     Oligomenorrhea or amenorrhea ≥ 6 months
     Disordered eating or an eating disorder ≥ 6 months
     Stress fracture or other fracture from minimal trauma
    Interpretation:
    Low bone mineral density
     Ages 5–19: Z score ≤ –2.0
     Age ≥ 20: Z score between –1.0 and –2.0 with a history of nutritional deficiency, hypoestrogenism, stress fracture, or other secondary risk factor fracture
    Osteoporosis
     Ages 5–19: Z score ≤ –2.0 plus clinically significant fracture
     Age ≥ 20: Z score ≤ –2.0 plus secondary cause of osteoporosis
    Menstrual dysfunction
    Rule out pregnancy and outflow tract obstruction
    Oligomenorrhea: > 35 days between menses
    Amenorrhea: Absence of menses
    Laboratory tests to consider:
     Follicle-stimulating hormone
     Prolactin
     Progesterone challenge
     Thyroid-stimulating hormone, thyroxine (T4)
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