Choosing Wisely: Management of Female Athlete Triad

By Caitlyn Mooney, MD

Choosing Wisely is an initiative of the American Board of Internal Medicine and supported by multiple medical societies, including the American Medical Society for Sports Medicine. Each society was asked to contribute five diagnostic tests or treatments that both physicians and patients should question. The highlight this quarter is the AMSSM’s “number three” recommendation:

Don’t prescribe oral contraceptive pills as initial treatment for patients with amenorrhea or menstrual dysfunction due to the female athlete triad (defined as low energy availability with or without disordered eating, menstrual dysfunction, and low bone mineral density).

The female athlete triad is a complex medical condition seen in physically active women and girls that includes a spectrum of conditions related to three inter-related components including: 1. Low energy availability (which may or may not include disordered eating or clinical eating disorders) 2. Menstrual dysfunction including amenorrhea 3. Low bone mineral density including osteoporosis. Early identification and medical management is important as athletes with any component of the triad are at risk for serious complications including eating disorders, stress fractures, osteoporosis/risk of low bone mineral density for life, reproductive dysfunction, as well as various other complications.

As the underlying cause of both menstrual dysfunction as well as low bone mineral density is less available energy than is required by the body for functioning the treatments that are most successful aim to eliminate this gap in energy. The goal of initial treatment is to reverse recent weight loss and both increase energy intake and decrease energy expenditure to eliminate the deficit. If an eating disorder is also present this will need to be treated as well. The goal is to have resumption of menses as this appears to be also required to normalize bone mineral levels, as estrogen also needs to be normalized to optimally increase the bone mineral density.

Oral contraceptives can be used to produce menses however it does not change the factors in the body that lead to the abnormal menstruation as well as the low bone mineral density. Thus while an athlete may resume having periods, she will continue to have metabolic factors that impair bone health. Thus treating the energy deficit and restoring spontaneous menstruation is the goal for treating the female athlete triad. If after a year of treatment aimed at increasing available energy through non- pharmaceutical interventions does not result in improvement, an oral contraceptive can be added to the initial management. Oral contraceptives alone have not been shown to increase bone mineral density and thus should not be used initially to address menstrual dysfunction in athletes, as it does not correct the underlying cause of the dysfunction that is an energy deficit.

Visit www.femaleathletetriad.org for more information about the symptoms, prevention, and management of this common condition. Additional information for medical professionals can be found in the ACSM’s 2007 Position

Statement on the Female Athlete Triad as well as the 2014 Female Athlete Triad Coalition Consensus Statement on Treatment and Return to Play of the Female Athlete Triad.

Visit Choosing Wisely for more information on this campaign.

AMSSM Member Authors
Caitlyn Mooney, MD