Expert’s Corner: Managing the Female Athlete Triad

Female Athlete Triad

The Female Athlete Triad is comprised of three, interrelated components — low energy availability with or without disordered eating, menstrual dysfunction and low bone mineral density.

According to Kathryn Ackerman, MD, MPH, medical director of Boston Children’s Female Athlete Program, patients may present with one or more of these components. However, the challenge is that sports medicine physicians and other clinicians have varied approaches to management.

In February 2014, the Female Athlete Triad Coalition published a consensus statement detailing a 12-point scale that takes into account different aspects of the triad — low energy availability, low body mass index, delayed menarche, menstrual irregularities, low bone density and history of fractures — to help physicians make more systematic decisions.

“It was important to create standardized criteria to help physicians determine which patients need a more in-depth workup and who needs to be restricted from activities,” Ackerman says.

Signs of Female Athlete TriadAccording to the consensus statement, patients scoring zero or one point can be fully cleared for sports participation, and those with six or more points should be restricted from training. However, provisional or limited clearance is recommended for patients scoring between two and five points.

“Patients scoring from two to five points represent a bit of a gray area,” says Ackerman. “The approach to sports participation and training is going to vary. Depending on individual needs, the sports medicine physician might recommend limited sports participation and follow-up with a nutritionist, physician, sport psychologist or other health professional.”

Moderate- and high-risk athletes should be referred to a sports medicine physician who can provide the expertise and multidisciplinary resources to manage more complex cases. After initial evaluation and risk assessment, primary-care providers can manage low-risk patients. However, moderate- and high-risk athletes should be referred to a sports-medicine physician who can provide the expertise and multidisciplinary resources to manage more complex cases.

Meanwhile, some colleges and universities have started to implement a related model. The International Olympic Committee (IOC) has suggested replacing the term Female Athlete Triad with Relative Energy Deficiency in Sport (RED-S). RED-S is a more inclusive term that recognizes that men and Paralympic athletes can have similar health sequalae stemming from low energy intake.

While the IOC and Female Athlete Triad Coalition refine terms and patient populations, Ackerman and colleagues at Boston Children’s and elsewhere are studying the impact of the triad guidelines. Their primary objective is to define ways to make them more user-friendly and applicable in clinical practice, particularly for moderate-risk patients.

Learn more about the Female Athlete Triad and Boston Children’s Female Athlete Program.