Caring for the female athlete: 5 clinical strategies

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Since the passage of Title IX of the Education Amendment of 1972, the number of girls competing in high school sports has increased from 295,000 to nearly 3.2 million — with more women playing collegiate sports than ever before.

As these numbers continue to rise, and girls and young women become more empowered through sports, awareness of health issues specific to female athletes has become increasingly important. One issue, the Female Athlete Triad (Triad), has gained increasing awareness as more athletes have come forward about their struggle with the condition.

Dr. Kathryn Ackerman, medical director of Boston Children’s Female Athlete Program, offers the following clinical strategies for avoiding the Triad and keeping athletes healthy.

Female athlete triad

The Triad is a condition of three intertwined health issues: (1) low energy availability, (2) menstrual dysfunction and (3) poor bone health. According to Ackerman, patients may present with one or more of these components at varying levels of severity. Athletes can take an active role in preventing the Triad by:

  • Taking in enough quality calories to account for energy expenditure from daily activities and exercise
  • Monitoring/maintaining normal monthly menstrual cycles
  • Participating in weight bearing exercise to achieve bone density that is equal to or better than non-active adolescents and teens

The Female Athlete Program performs initial evaluations and risk assessment for this condition, with many patients benefitting from receiving this evaluation and gaining awareness of the issue. Other moderate- and high-risk athletes may require more in-depth care. Ackerman says, “a sports medicine physician who can provide the expertise and multidisciplinary resources to help manage more complex cases can be a nice adjunct to the athlete’s primary care team.”

Managing the menses

It’s important to encourage all female athletes to keep track of their periods. “In the Female Athlete Program, we always ask about menstrual cycles and want to make sure athletes are staying on their growth curve,” Ackerman says. “We care about periods largely because of the female athlete triad, so keeping track and noticing pattern changes and the athlete’s own performance changes with menses can be helpful.”

The hormonal milieu

Maintaining an energy balance is important for normal hormonal functioning in athletes. Changes in normal hormone concentrations occur as energy is diverted away from biological processes that are not necessary for survival.  This includes reproduction, an energetically costly process, and leads to menstrual disturbances.

Many of the hormones involved in reproduction and menstrual function are important for bone and muscle growth. For example, low energy availability can lead to an estrogen deficiency that can affect bone metabolism. Many hormones can be affected by low energy availability, causing downstream effects to different body systems. It’s important to monitor hormone levels in athletes suspected of the Triad to avoid any potential short and long term effects.

Nutrition, nutrition, nutrition

Nutritional guidance can be invaluable to the female athlete. A lot of young athletes try different diets, but it’s important that they are properly fueling their bodies as they continue to grow. Unfortunately, giving good nutritional guidance is something that is not often a focus of medical school courses.

“With the Female Athlete Program, athletes are getting a professional sports-trained dietician who can educate athletes on how to fuel themselves,” Ackerman says. “It’s equally important for clinicians to make sure their athletes are not skipping out on the iron, calcium and vitamin D that will impact their overall health.”

Bone density

When athletes overtrain, they develop sustained fatigue and are at an increased risk of stress fractures and premature osteoporosis. Paying careful attention to training regimens and maintaining a positive energy balance can help athletes maximize their bone health and overall energy.

Handling societal pressures

Being aware of societal pressures is key, because this is a time when body changes occur and teens begin to feel the effects of peer pressure. According to Ackerman “we need to be sending girls and women positive messages about strong, healthy bodies.”

We need to be sending girls and women positive messages about strong, healthy bodies, and block the noise about an ‘ultra-thin ideal.’”

When discussing weight, female athletes need to understand muscle weighs more than fat. Therefore, young athletes tend to have a higher body mass index (BMI). It’s important to evaluate body composition and reinforce what a healthy athlete should look and feel like. “I encourage pediatricians to continually remind girls about the importance of strength, how it is a positive, and that people appreciate a healthy physical body that is capable of doing things, not an ultra-skinny body that is too weak to perform,” Ackerman says.


Patient Resources
To help female athletes stay at the top of their game, Boston Children’s Female Athlete Program created a suite of patient education guides.

When to refer?

Pediatricians are encouraged to refer to Boston Children’s Female Athlete Program when disordered eating patterns are suspected; athletes have sustained multiple stress fractures, or menses have become irregular in the context of training.

“At Boston Children’s, we have so many great resources for female athletes to get more informed about their health and performance,” she adds. “I love seeing our patients taking advantage of these resources and feeling empowered as they become healthier and have more successful seasons.”

Learn more about Boston Children’s Female Athlete Program


About our expert: Kathryn Ackerman, MD, MPH, is a sports medicine physician and Director of the Female Athlete Program at Boston Children’s, as well as an Assistant Professor in Medicine at Harvard Medical School. She is also a former national team rower and is currently the team physician for the U.S. National Rowing Team.