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KEY POINTS
■ The current criteria for the female athlete triad include low energy availability in the presence of diminished bone health and amenorrhea or oligomenorrhea.
■ Because the female athlete triad represents a continuum, identifying the true prevalence can be difficult.
■ Clinicians should vigilantly screen female athletes to identify those at high risk.
■ A team approach is advised for management of the female athlete triad, which is a complex, multifactorial disorder. The team should consist of medical, psychiatric, and nutritional specialists and may include specialists in orthopedics and cardiology as well as a physical therapist.
Diminished bone mineral density (BMD) in the presence of amenorrhea was first documented in female athletes in 1984.1 Although regular physical activity should increase bone mineral density, young female athletes exhibited bone mineral density comparable to that of much older women. This discovery triggered exploration of the relationship between the menstrual cycle and bone health in female athletes, and nearly a decade after these original observations, the American College of Sports Medicine (ACSM) described the female athlete triad as the presence of an eating disorder (anorexia or bulimia), amenorrhea, and osteoporosis.2 Following this description, in 1997 the ACSM published the first female athlete triad position stand, which focused on educating health care providers so they could recognize the three components of the female athlete triad, treat the condition, and prevent its recurrence.3
In 2007, the ACSM published the most current position stand for the female athlete triad.4 The previous criteria of amenorrhea and osteoporosis were expanded to include menstrual dysfunction and low BMD. According to the World Health Organization (WHO), osteoporosis is defined as a T-score of -2.5 standard deviations (SDs) below the mean, while osteopenia is defined as -1.0 to -2.5 SDs (Figure 1). Additionally, the requirement for a diagnosis of anorexia or bulimia was replaced with low energy availability. The current criteria for the female athlete triad include low energy availability in the presence of diminished bone health and amenorrhea or oligomenorrhea. Thus, a female athlete currently meets the diagnostic criteria if she does not meet her current energy (calorie) requirements; she no longer needs to present with anorexia or bulimia.
The new guidance from the ACSM presents the female athlete triad as a disorder that should be evaluated as a continuum rather than as one consisting of three concise components.4 Although the definition of inadequate energy is still being clarified, researchers and clinicians agree that the presence of anorexia or bulimia is not necessary to initiate the cascade of deleterious effects that result from the female athlete triad. Athletes can certainly exhibit declining health with decreased bone mineral density and dysfunctional menstruation. Thus, the astute clinician should intervene prior to the diagnosis of osteoporosis and amenorrhea. Furthermore, if the health care provider identifies one of the female athlete triad components, the remaining two components must also be considered in female athletes.
This article reviews the three components of the female athlete triad (low energy availability, menstrual dysfunction, and diminished bone mineral density), describes the current diagnostic criteria, discusses how to identify female athletes at risk, and explains how to ensure ideal management. Since the inception of the term female athlete triad, the criteria for diagnosis have been modified; and providers must clearly understand these changes to provide the best possible care for their female athlete patients.