The bottom line: Optimal treatment of the Female Athlete Triad (Triad) must address the underlying cause of the Triad, that is, low energy availability (EA). Energy status must be normalized primarily through modifications of diet and exercise training. Restoration or normalization of body weight is the best strategy for successful resumption of menses and improved bone health.
The details: Specific treatment recommendations depend on identifying how low EA developed in the student-athlete. There may be four unique pathways to low EA, and as such, four unique treatment recommendations.
1. If the cause of low EA is inadvertent undereating, then referral for nutritional education is sufficient. Nutritional education should ideally include a sports dietitian, particularly a Board Certified Specialist in Sports Dietetics (CSSD). An exercise physiologist can also complete an assessment of energy expenditure and EA.
2. If the cause for low EA is disordered eating (DE), the referral should be to a physician, and for nutritional counseling with a sports dietitian.
3. If the cause for low EA is intentional weight loss without DE, then referral for nutritional education is sufficient.
4. If the cause for low EA involves clinical eating disorder (ED), treatment should include evaluation and management with a physician, nutritional counseling with a sports RD and referral to a mental health practitioner for psychological treatment. In this case, the reversal of low EA will not be possible without psychological treatment.
In general, the primary goal of treatment is to restore or normalize body weight, concomitant with an improvement in overall nutritional and energetic status. When DE is apparent, it must be emphasized that the treatment plan for these student-athletes must focus on the modification of unhealthy attitudes, behaviors and emotions related to food and body image that may perpetuate the DE. Weight gain is a primary concern for student-athletes with amenorrhea who are underweight and it is important to emphasize that the amount of weight gain that typically leads to resumption of menses is variable among individuals. In studies thus far, a range of approximately five percent to ten percent of body weight or one to four kilograms of weight gain has been observed.
Treatment Targets for Low EA
Treatment targets are varied and depend on individual circumstances. Specific treatment targets may include one or more of the following:
• Reversal of recent weight loss;
• Return to a body weight associated with normal menses;
• Weight gain to achieve a BMI of 18.5 kg/m2 or 90 percent of predicted weight;
• Energy intake should be set at a minimum of 2000 kcal/day; or more likely, a greater energy intake will be required, depending on exercise energy expenditure.
Recommendations should consider individual preferences and may depend on where the student-athlete is in the competitive season (reductions in training volume may not be feasible in season; acceptance of increased energy intake may be better received versus a reduction in training volume). Prescribed changes in energy intake to achieve an increased BMI and/or body weight goal should be gradual, beginning with an approximately 20 percent to 30 percent increase in caloric intake over baseline energy needs, or the amount of energy required to gain approximately 0.5 kg every 7 to 10 days. For student-athlete consuming 2000 kcal/day, this would represent a gradual increase of 200 to 600 kcal/day, accomplished over several months.
Specific Recommendations That Target Eating Disorders
The goals of treatment for exercising women with ED is to normalize pathological eating behaviors, reduce dieting attempts and alter negative emotions and beliefs associated with food and body image. A multidisciplinary team approach to care is essential. Team members should have experience in working with student-athletes affected by eating disorders. The team includes, at a minimum, a physician, sports RD and a mental health professional (e.g. clinical sports psychologist). In younger student-athletes (e.g. high school) involvement of the parents and family is often critical to success. Other members of the team may include athletic trainers, strength and conditioning coach and on a certain level, the sport coach.
Medication Use in Student-Athletes Affected by the Triad
It bears repeating that non-pharmacological measures should constitute initial management in female student-athletes with the Triad. For treatment of osteoporosis and/or in those student-athletes with a history of multiple fractures, medication is to be considered if there is a lack of response to non-pharmacological therapy for at least one year, and if new fractures occur during that time. Pharmacological management may also be necessary in the psychological treatment of eating disorders and disordered eating, especially if there are significant comorbid conditions such as depression or anxiety.
Oral Contraception and Hormone Replacement Therapy
When considering pharmacological strategies to address amenorrhea and hypoestrogenemia (low blood estrogen levels) in student-athletes and exercising women, it is essential to reiterate that combined (estrogen + progesterone) oral or non-oral routes of contraceptive therapy do not restore spontaneous menses; indeed, contraceptive therapy simply creates an exogenous ovarian steroid environment that often provides a false sense of security when induced withdrawal bleeding occurs. Moreover, oral contraceptive therapy does not normalize the metabolic factors impairing bone health, and is not consistently associated with improved bone mineral density (BMD) in amenorrheic athletes, and may in fact further compromise bone health due to the metabolic effects of oral contraceptives by the liver. Before starting any type of hormone replacement therapy in amenorrheic women it is important to fully evaluate the underlying cause of amenorrhea, which includes not only low EA, but also conditions such as pregnancy, thyroid disorders, and other endocrine and genetic disorders.
In female student-athletes affected by the Triad and amenorrhea who have a need for contraception, oral contraceptive pills are certainly a reasonable option; however, it is important that this artificial restoration of menses does not negate the need for nutritional intervention to restore adequate energy availability. Data on the impact of the Nuvaring is conflicting, as to its effect on BMD. As an effective form of contraception, it is also a reasonable choice for women affected by the Triad.
In females who meet criteria for pharmacologic intervention, but do not have a need for contraception, use of transdermal estrogen along with oral progesterone is the preferred route of administration, as it has been demonstrated to increase bone mineral density in amenorrheic adolescents affected with eating disorders.
Vitamins and Minerals
The goal is for the individual to attain necessary vitamins and minerals through dietary consumption. However, in those individuals with documented low levels of vitamin D, oral supplementation should be considered to achieve a vitamin D level between 32 to 50 ng/ml. Likewise for calcium, dietary intake of foods rich in calcium should be encouraged. In those with intolerance of dairy, supplementation can be considered. Optimal intake of calcium should be 1,000 to1,300 mg/day.
About the Female Athlete Triad Coalition
The Female Athlete Triad Coalition, a non-profit 501(c)(3) organization, represents key medical, nursing, athletic, and sports medicine groups, as well as concerned individuals who come together to promote optimal health and well-being for female athletes and active girls and women. The Coalition strives to prevent the Female Athlete Triad through advocacy, education, international leadership, public policy and research. Formed in 2002, the Female Athlete Triad Coalition is a group of national and international organizations dedicated to addressing unhealthy eating behaviors, hormonal irregularities and bone health among female athletes and active women. For more information, visit www.femaleathletetriad.org. The Consensus Paper was sponsored by the Female Athlete Triad Coalition: An International Consortium, and endorsed by Female Athlete Triad Coalition, American College of Sports Medicine and the American Medical Society for Sports Medicine.
About Elizabeth Joy, MD, MPH, FACSM
Elizabeth Joy, MD, MPH, FACSM is the Medical Director of Clinical Outcomes Research at Intermountain Healthcare, and Adjunct Professor in Family and Preventive Medicine at the University of Utah School of Medicine in Salt Lake City, Utah. She is the incoming President of the Female Athlete Triad Coalition. Dr. Joy’s clinical care, research writing, and advocacy are focused on physical activity promotion, care of women and girls with eating disorders, injury prevention, and the Female Athlete Triad.
